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REGIONAL MINISTERIAL CONFERENCE SANTIAGO, CHILE 2008

Government of Chile and United Nations World Food Programme (WFP) Regional Office for Latin America and the Caribbean United Nations

World Food Programme

Towards the eradication of child undernutrition in Latin America and the Caribbean

Edition by the United Nations World Food Programme (UN WFP) Regional Office for Latin America and the Caribbean Gaillard Avenue, Vicente Bonilla Street Buildings 124 & 125 Clayton, City of Knowledge P.O. Box 0819-10751, Zone 6 El Dorado, Panama Rep. of Panama Tel: (507) 317-3900 Fax: (507) 317-3903 www.wfp.org © United Nations World Food Programme (UN WFP) All rights reserved First Edition: 2008 Compiler, editor, and translator: Carlos Guevara Mann General Direction: Pedro Medrano Supervision: María Eugenia Pino Coordination: Judith Thimke, Moy de Tohá Technical Support: Eduardo Atalah, Alfredo Solari Revision: Carol Montenegro, Lisa Lomax Publicity Team: Angélica Beas, Paulina Marín, Violeta Güiraldes Design and Layout: Jhoram Moya Photography: United Nations World Food Programme (UN WFP) by Alejandro López-Chicheri, Elias Romero, David Parra Monica San Martín, Elio Rujano, Sabrina Quezada ISBN: 978-9962-8950-1-5

“Hunger is not part of humanity’s manifest destiny.” Michelle Bachelet President of Chile

“The goal of eradicating child undernutrition in our region is absolutely attainable.”” José Miguel Insulza Secretary General of the Organization of American States (OAS)

CONTENTS

PREFACE

Josette Sheeran

INTRODUCTION Pedro Medrano

PART ONE: POLITICAL COMMITMENTS IN THE FIGHT AGAINST CHILD UNDERNUTRITION IN LATIN AMERICA AND THE CARIBBEAN Michelle Bachelet: We Must do Something!

José Miguel Insulza: The Fight against Hunger and Democratic Governance

Paula Quintana: Equality: A Fundamental Factor in the Fight Against Child Undernutrition

Mirta Roses: The Fight against Undernutrition in the Health Agenda of the Americas

Rebeca Grynspan: An Urgent and Decisive Call to Action

Marcela Suazo: Equality of Opportunity to Break the Cycle of Hunger

Sheila Sisulu: High Food Prices: Crisis and Opportunities

Enrique Ganuza: Support of the United Nations System in Fighting Child Undernutrition

Cristina Lazo Vergara: Chilean Cooperation and South-South Cooperation

The Santiago Declaration

PART TWO: THE ERADICATION OF CHILD UNDERNUTRITION IN CHILE Chapter 1: Child Undernutrition in Chile: Policies and Programmes that Explain its Eradication Summary

Introduction

Demographic and Nutritional Transition

Main Features of Chile’s Child Undernutrition Eradication Policies

Main Institutional, Programmatic, and Legislative Policies

Conclusions and Policy Recommendations

References

Statistical Annex

Chapter 2: The Chilean Experience in the Eradication of Child Undernutrition: A Comprehensive Vision Summary

María Soledad Barría: The Health Sector’s Strategy in the Fight Against Child Undernutrition

Eduardo Abedrapo: The Chilean Experience in Eradicating Child Undernutrition

PART THREE: TECHNICAL APPROACHES TO CHILD UNDERNUTRITION IN LATIN AMERICA AND THE CARIBBEAN Chapter 1: Undernutrition, Poverty, and Economic Development Summary

José Graziano da Silva: Child Undernutrition in the Region: Reasons to Eradicate It

Juan Ángel Rivera Dommarco: The Lancet Series on Maternal and Child Undernutrition

Rodrigo Martínez: The Social and Economic Impact of Child Undernutrition

103

Chapter 2: Monitoring and Evaluation of Social Programmes to Combat Child Undernutrition Summary

111

Jere Behrman: Priorities in Early Childhood Nutritional Interventions

113

Juan Ángel Rivera Dommarco: Evaluating Nutritional Policies and Programmes: A Reflection

125

David Bravo: Monitoring and Evaluation of Nutrition Programmes: Twelve Important Observations

131

Chapter 3: Theoretical and Practical Frameworks for Maintaining Nutrition during Crisis Periods Summary

135

Fitzroy Henry: Preserving Nutrition in Crises: The Caribbean Experience

137

Chapter 4: A Comprehensive Approach to Efforts to Eradicate Child Undernutrition Summary

147

Onaur Ruano: A Comprehensive Approach to Efforts to Eradicate Child Undernutrition: Actions to Reduce Poverty and Income Inequality in Brazil

149

María Roquebert: A Comprehensive Approach to Eradicate Child Undernutrition in Panama

155

Chapter 5: South-South Cooperation in the Fight Against Child Undernutrition Summary

163

María Dolores Martín: Spanish Cooperation in Latin America during the Food Crisis

165

Germán Valdivia: NUTRINET.ORG: An Instrument for Strengthening South-South Cooperation and Work in Thematic Areas

167

Nils Kastberg: South-South Cooperation in the Fight against Child Undernutrition

171

Patricio Meller Bock: Food and Nutritional Security and their Impact on Equality

177

Manuel Espinoza: The Public-Private Relationship in School Feeding Programmes

183

PART FOUR: RECOGNITIONS AND ACKNOWLEDGEMENTS Summary

187

Fernando Monckeberg: Successes in the Fight against Child Undernutrition in Chile

188

Francisco Mardones Restat: Knowledge Sharing in the Fight against Child Undernutrition

189

Acknowledgements

191

PREFACE Food is so basic to human survival that its denial is a denial of life itself. I have heard it said that there are only seven meals between civilization and anarchy—at the seventh meal lost, all begins to fall apart as people are reduced to fending for survival. Ensuring access to adequate, affordable food and nutrition is one of the fundamental responsibilities of governments, and a defining characteristic of civilization itself. The global food supply system is groaning under the strain of increasing demand, the soaring cost of inputs, crop loss due to drought, floods and severe weather, and pressure on the use of food for energy and other supplies. This food crisis is a silent tsunami hitting the world’s most vulnerable, 80 percent of whom are women and children. An additional 130 million people face hunger and malnutrition as food is priced out of their reach. The consequences of high food prices are devastating. Families in many developing countries spend between fifty and eighty per cent of their money on food. As prices have risen, many have been forced to cut back on health and education expenditures. At the same time they are choosing cheaper and less nutritious food commodities. Some households are even facing the agonising prospect of cutting back on the number of meals they eat each day. At the United Nations Millennium Summit of world leaders in 2000, the international community committed in the first Millennium Development Goal (MDG) to cut the proportion of hungry in the world in half by 2015. We cannot let this become the forgotten MDG. The dramatic increase in food prices we have witnessed over the past year has raised awareness that food cannot and must not be taken for granted. The world has also awakened to the fact that the food supply chain—from imports to planting, harvesting, processing, storage and delivery, and all the supporting market structures, from access to credit, risk mitigation, commodity exchanges, crop surveys, and water access—are vital to world stability and prosperity. In this challenging environment, the Regional Ministerial Conference “Towards the Eradication of Child Undernutrition in Latin America and the Caribbean,” held in Santiago, Chile, in May 2008, offered an opportunity to emphasize the importance of national social protection programmes to fight hunger, especially among children; to underscore key interventions to protect child nutrition; and to insist on the need for safeguarding the advances already made toward the MDGs in the region. The Conference provided a forum for sharing successful experiences, promoting South-South Cooperation, strengthening networking relationships among the Latin American and Caribbean states, and developing support mechanisms for the countries in the region. The Santiago meeting, co-sponsored by the Government of Chile and the World Food Programme (WFP), was a call to action and this book follows up on that call. Indeed, as throughout the meeting, in the following chapters societies and Governments are encouraged to prioritize the fight against hunger, placing the eradication of child undernutrition at the top of the policy agenda, promoting opportunities for dialogue at the national and international level, and fostering cooperation initiatives. Successful cases of child undernutrition eradication, such as Chile, are showcased in an effort to motivate other countries towards the same goal. Key players at the international cooperation arena are invited to join efforts, catalyzing coordinated actions to eliminate hunger among children.

If national Governments and the international community act now in support of targeted interventions, Latin America and the Caribbean could be the first region not only to avoid the current crisis, but also to achieve the hunger target of the first Millennium Development Goal by 2015. Despite the global food crisis, favourable conditions still exist in the region to facilitate reaching MDG 1, especially as regards the eradication of child undernutrition. We see a fourth straight year of economic growth above 5 percent. Throughout the region, we see countries with booming agricultural industries exporting food products worth some US$55 billion in 2006. And we see democracy flourishing throughout the region. Amartya Sen has said: “No famine has ever taken place in the history of the world in a functioning democracy.” Defeating hunger is achievable, particularly in Latin America and the Caribbean. Let us make true the words of the Chilean poet Gabriela Mistral when she wrote: “El hambre es el ayer” (“Hunger is yesterday”).

Josette Sheeran

Executive Director United Nations World Food Programme (WFP)

INTRODUCTION

The fight against hunger and child undernutrition in Latin America and the Caribbean is acquiring a growing importance, particularly during the current food crisis. Although the region has access to sufficient food resources to guarantee adequate nutrition for all its inhabitants—especially its younger population—almost nine million children suffer from chronic undernutrition and four million are affected by global undernutrition. In response, the Governments of the region have begun to incorporate the struggle against child undernutrition to their agendas. This is a significant development, and as a result there is increasing emphasis on the need for guaranteeing the greatest possible effectiveness of programmes designed to eradicate hunger and undernutrition. This book seeks to contribute to the fight against child hunger through the diffusion of theories and best practices accumulated throughout many years of social programme implementation in the countries of the region. It includes the main papers given at the Regional Ministerial Conference “Towards the Eradication of Child Undernutrition in Latin America and the Caribbean,” held in Santiago, Chile, on 5-6 May 2008. The first part of the book contains political approaches to the topic, with contributions by H.E. Michelle Bachelet, President of Chile; José Miguel Insulza, Secretary-General of the Organization of American States (OAS); Paula Quintana, Minister of Planning of Chile; Mirta Roses, Director of the Pan-American Health Organization (PAHO); Rebeca Grynspan, Regional Director of the United Nations Development Programme (UNDP) for Latin America and the Caribbean; Sheila Sisulu, Deputy Executive Director of the World Food Programme (WFP); Enrique Ganuza, Resident Coordinator of the United Nations in Chile; and Cristina Lazo Vergara, Executive Director of Chile’s Agency for International Cooperation (AGCI). The second part provides a valuable analysis of the Chilean experience in eradicating child undernutrition. It contains the background paper for the Santiago conference, entitled “Policies and Programmes Explaining the Eradication of Child Undernutrition in Chile,” commissioned by the Chilean Government. Following the study are contributions by María Soledad Barría, Minister of Health and Eduardo Abedrapo Bustos, Under-Secretary for Planning and Cooperation of Chile.

Part Three includes papers by specialists in the fight against child hunger from five different perspectives. The goal is to provide the reader with a broad overview of the struggle against child undernutrition in the region, with the purpose of contributing to the dissemination of best practices to improve the quality, reach, and effectiveness of programmes designed to combat hunger and overcome the current food crisis. Part Four recognizes the pioneering contributions of physicians Fernando Monckeberg Barros and Francisco Mardones Restat in the battle against child undernutrition in Chile. Broad cooperation among the countries of Latin America and the Caribbean offers an opportunity to concentrate material and intellectual resources towards interventions that promote equitable social development, foster nutritional wellbeing, and encourage food security to overcome the current crisis. Assuring the effectiveness and efficiency of interventions designed to improve the nutritional situation of children in the region is key for achieving the desired results. To help attain these objectives, WFP is pleased to present this compilation of papers in the hope that it will provide useful guidelines for public officials, social programme administrators, and other parties interested in the eradication of child undernutrition in Latin America and the Caribbean.

Pedro Medrano

Regional Director for Latin America and the Caribbean United Nations World Food Programme (WFP)

Part one: POLITICAL APPROACHES TO THE FIGHT AGAINST CHILD UNDERNUTRITION IN LATIN AMERICA AND THE CARIBBEAN

We Must do Something! Michelle Bachelet President of the Republic of Chile

In one of his memorable verses, the Spanish poet Miguel Hernández said: “Hunger is the earliest knowledge.” Would it that no child, anywhere in the world, would have to acquire this knowledge! Would it that in our region, no child had to go through this tough lesson!

The tendency towards a rise in food prices may cruelly increase the gap between the richer and the poorer. Over the past 18 months, the average amount of food purchased by the inhabitants of rural areas in Latin America and the Caribbean has decreased by half. People thus affected have also cut their nutritional intake by half, with all the consequences this reduction implies. Experts have already revealed the drama of those nine million children who suffer from chronic undernutrition and demand a response. The question is: Can we do something? My answer is: We must do something! Because the truth is that hunger is not part of humanity’s manifest destiny. Hunger can not be treated as fate, as something that we should accept as part of the natural order of things. In many countries, hunger has become a chronic condition. With adequate policies, however, it can be defeated. Opportune decisions can eradicate hunger, even though attaining a massive effect in the struggle against hunger may take time. In this regard, it is helpful to look at the example of Chile, not to boast about statistics that might be better than those of other countries but, on the contrary—without arrogance, with pride, and, above all, with certainty—to say that it is possible to overcome undernutrition. Child undernutrition has been practically eradicated in Chile. The prevalence of global undernutrition in children under six dropped from 37 percent in 1960 to 0.7 percent in 2007. We are privileged in this respect. But this achievement did not happen by chance. Neither was it free.

Michelle Bachelet

The current global juncture further aggravates the situation. A profound concern for food prices has inserted itself on the international agenda. The rise in oil prices and transportation costs, together with an increased demand for food, a rise in basic food prices for items such as cereals, and the effects of droughts and floods have combined to produce a complex scenario. This new set of circumstances is significantly more complicated than what 189 nations envisioned in the year 2000, when they signed the Millennium Development Goals (MDGs), committing to reduce by half, by 2015, the number of people affected by hunger and poverty. All of this explains the great importance of the Regional Ministerial Conference and the excellence of its speakers.

President of the Republic of Chile

Given the prodigious advances of humanity in so many areas, it is a disgrace that hunger and—specifically—child undernutrition are far from disappearing as a problem for millions of human beings. For this reason, when Pedro Medrano invited me several months ago to participate in the Regional Ministerial Conference “Towards the Eradication of Child Undernutrition in Latin America and the Caribbean,” I felt it was important to take part in the discussion of such transcendent a topic in my capacity as President, as a woman, as a mother, and as a paediatrician with public health training.

The physicians who received recognitions during the Regional Ministerial Conference were instrumental in this process.1 Leadership is particularly important in endeavours such as combating undernutrition. The leadership of individuals such as physicians, professors, and teachers reveals itself, precisely, in their clarity and tenacity to transform policies into real accomplishments, with clear objectives. In Chile, we were able to transform this leadership into a sustained state policy that remained in place through political changes. Our first National Complementary Feeding Programme began in 1924. That was the first step in a state policy oriented to guaranteeing the satisfaction of the nutritional needs of all children. From the point of view of disease prevention, cognitive capacity, and intellectual development—as well as of future productivity—a child’s nutrition is crucial. I do not need to convince anyone about that. But its being obvious cannot allow us to forget it. Public policies for development cannot be conceived without regard for this aspect as a priority. In 1953, the Food Distribution Programme for mothers and children was initiated. As well, a President who—like me—was also a physician, introduced the memorable daily Half Litre of Milk Programme for each child in Chile. At the time there were discussions and disagreements. Some people even said: “The milk will be used to mark soccer fields.” The truth is that these initiatives, together with strong public health institutionalization and educational programmes, have been extremely successful. In addition to food delivery in clinics, the implementation of nutritional plans in schools has been crucial. Currently, 2.2 million rations are delivered free of charge every day in public schools, benefiting an important number of students.

The country has been able to overcome the scourge of child undernutrition with perseverance and effort. And that is how we attained our current statistics. But there is more: breastfeeding is an important factor in preventing malnutrition. For this reason, we have promoted breastfeeding as a fundamental component in human development. Today, exclusive breastfeeding is practiced by almost 50 percent of all mothers until the sixth month. Another central factor is the influence of the mother’s nutrition on the weight of her children. This has been clinically demonstrated and also taken into consideration in our health and nutrition plans, which include complementary feeding for pregnant and breastfeeding women and the delivery of different quantities of milk, dependDr. Fernando Monckeberg Barros and Dr. Francisco Mardones Restat (editor’s note).

ing on the needs in each case. This is considered a public good and, for that reason, is independent of whether the mothers belong to the public or private health system. I want to emphasize that although the statistics we present are encouraging, they have not been reached by accident. What I mean to say by this—perhaps my single big message—is that is possible to defeat hunger. Chile has achieved it in a little over four decades. It has been done through planning, effectiveness, endurance, and clarity in objectives. But, above all, it has been accomplished through political will and by prioritizing early childhood. Other experiences, like those of Cuba or Costa Rica, have also had excellent results. Sadly, we cannot say the same for all countries in our region, where enough food is produced, but people still suffer from hunger. This is clearly a paradox. Food production in Latin America and the Caribbean more than triples the energy needs of the population. Nonetheless, there are 53 million people who lack sufficient food. Of all children under five, 7 percent are underweight and 16 percent have low height per age. Today, the lack of access to food has less to do with scarcity than with the buying power of populations with limited resources, which is aggravated by the recent increase in food prices. Facts like these show the true impact of inequality. Inequality begins in the womb, decreasing possibilities in the life, growth, and intellectual development of a person even before birth. Disgracefully, inequality is maintained and perpetuated in the majority of societies as a detrimental cycle during a person’s entire life. In this sense, I would like to share a reflection. Pedro Medrano has made the call to confront the challenges of this moral and ethical question, whatever the cost may be. I know there are many ministers, vice-ministers, and programme directors who will have to struggle to solve this problem, especially when it comes to budgeting, based on different priorities, because countries have many necessities. But I want to tell you that the cost to a country is infinitely greater if it does not tackle this responsibility. The cost includes the loss of capacities in many people, including children, as well as the cost of associated diseases, and is much greater than the amount that would be spent to save children from hunger. Having a healthy, developed, fully capable population is a factor of competitiveness and development for countries interested in developing their economies. All of us here believe we have a fundamental moral commitment to our children. As Gabriela Mistral tells us: “The future of the chil-

All of us here believe we have a fundamental moral commitment to our children. As Gabriela Mistral tells us: “The future of the children is always today.” dren is always today.” That is, today we have to worry about having healthy children, who will become healthy young adults and eventually productive adults. But beyond that, in terms of a country’s economic development, adequate nutrition is a central element. Every five seconds, a child dies of hunger somewhere in the world. This is a dramatic reality that confronts all nations. Regrettably, this is not a distant reality. This happens here, in our region. This situation is made even more critical in the case of indigenous and afro-descendant children. In this respect, as an example, 90 percent of the 150 million afro-descendant people in Latin America and the Caribbean are poor. And, logically, the highest levels of undernutrition are also concentrated among those groups. These populations are victims of inequality and social exclusion within their countries. But, at the same time, on many occasions they remain outside international cooperation priorities, because some of these populations form part of middle-income societies. In this sense, they suffer a double exclusion. As we have seen before, lack of access to food due to a lack of money generates grave social conflicts. A population that does not have food is a population in a state of urgency and impatience, a population with justified anger and a population, furthermore, disenchanted with democracy. Faced with this situation of tremendous inequality, it is not possible to remain inactive. We must respond as a continent. We must commit ourselves to doing all that can be done to defeat this scourge.

And this implies, as has been said at the conference, a serious and sustained technical effort. This implies cooperation and solidarity, but, above all, political will. Based on its experience in combating undernutrition, what has Chile done and what is Chile doing in the international arena to contribute to stop this terrible scourge? In November 2007, during the IberoAmerican Summit held in Chile, I committed to the creation of a Fund for the Protection of Childhood in Ibero-America, which will be implemented this year. Through joint action with the United Nations Food and Agriculture Organization (FAO), we have committed to the agricultural rehabilitation and reforestation of Haiti. A high-level group of Chilean technical professionals is currently working on this project, which is fundamental for agricultural development and is improving the production and availability of food. Also in Haiti, our National Pre-School Board (Junta Nacional de Jardines Infantiles [JUNJI]) is supporting the Government in the formulation of a child protection policy. But, furthermore, we have especially undertaken the design and implementation of an education, health care, and feeding centre for 180 children from two to five years of age in southern Haiti. Through FAO we have sent a number of professionals to Guatemala, as part of a Special Programme on Food Security. Additionally, as President, I belong to the Global Network of Leaders that is attempting to significantly reduce infant and maternal mortality, Millennium 17

Development Goals (MDGs) 4 and 5. Naturally, I also strongly support MDG-1, aimed at reducing the mortality resulting, in a majority of cases, from undernutrition and a lack of minimal sanitary conditions necessary for subsistence. At the operational level, this networkâ&#x20AC;&#x2122;s counterpart is the Partnership for Maternal, Newborn, and Child Health, which works in coordination with the World Health Organization (WHO). In September of this year the regional launch of this activity will take place in Chile, an activity we are working on jointly with Norway and Brazil, as part of our interest in strengthening collaboration in the area of nutritional health. In December 2008, representatives from global leaders heading the fight against maternal and child mortality will meet in Oslo with the objective of coordinating policies that accelerate the reduction of mortality levels across the globe. These, among many other initiatives, are part of the Chilean commitment to equality, on one hand and justice, on the other.

Undernutrition and poverty are centuries-old burdens in our region. Overcoming them might take only a few decades, but we will only be successful if we maximize the capacities of all our countries. The Regional Ministerial Conference placed emphasis on protecting families integrally, strengthening social policies, and exercising a will to guarantee the basic food needs of all the inhabitants of the continent. These objectives cannot be put on hold: we need to implement measures to achieve them immediately. Chile is part of this commitment and will do what it needs to do. We want to help to the best of our abilities. We want to be part of the commitment to defeat hunger and undernutrition in the region. Nothing is more important than saving the precious lives of many children who are waiting for our solidarity. Toward this endeavour, Chile and this President can be counted on.

The fight against hunger and democratic governance JosĂŠ Miguel Insulza Secretary General of the Organization of American States (OAS)

The Regional Ministerial Conference took place during a very crucial moment, when the issue of food prices reached front pages throughout the world. Specialists are still seeking explanations for the accelerating rise in basic food prices for items such as wheat, rice, and corn. The fact, however, is that the cost of food has increased across the globe in an exaggerated way, to the degree that in the last three years prices have practically doubled. This situation is likely to condemn millions of people to stay in or return to poverty worldwide. It will not only affect possibilities for development, but also the political stability and potential for strengthening democracy in many countries. When individual desperation caused by hunger and the inability to provide food to children becomes a collective problem, it may provoke demonstrations of social discontent with potential for destabilizing governments in affected countries. In our region, this situation is already playing out in Haiti, a country we need to help in all possible forms because it is the first case in our hemisphere where the problem of food scarcity has revealed itself most critically. The President of the World Bank has recently indicated that at least 33 countries are at risk of facing social difficulties cause by a lack of food. While a majority of these countries are located in Africa, in our hemisphere we should be on alert for a phenomenon that could have negative effects on our efforts to combat poverty and strengthen democracy. The food crisis threatens to further deteriorate conditions which, having seen progressive advances, still show serious difficulties. I refer to the fact that in our region more than fifty million people still do not have access to adequate food and nutrition. Child undernutrition, with its negative biological, social, and economic consequences, today impacts nine million children.

JosĂŠ Miguel Insulza

This is a moral problem for all of humanity. In a world of wealth, abundance, and scientific advances beyond comparison, it is ethically inexcusable that nearly 25 thousand people die every day of causes related to nutritional deficiencies.

Secretary General of the Organization of American States (OAS)

The theme around which the May 2008 Regional Ministerial Conference in Santiago, Chile was convened is of the greatest importance and, sadly, of the greatest gravity. The drama of hunger and food insecurity, affecting all regions of the world in one way or another, is felt principally by the poorest countries and social segments of the global population, and, among these, in an especially cruel way by children.

The successes achieved thus far in fighting poverty may not be permanent. Based on a 2006 report from the Economic Commission for Latin America and the Caribbean (ECLAC), we know that 36.5 percent of the region’s population lives under the poverty line and 13.4 percent survives in a condition of indigence. These are, indeed, very high percentages. But, at the same time, in 2006 15 million people rose out of poverty and ten million emerged from extreme poverty. For the first time since 1990, the total number of people who live in poverty in the region is below 200 million. These advances are threatened by high food prices. ECLAC has warned that poverty and extreme poverty will increase if appropriate actions are not taken to reduce the impact of the sharp rise in food prices. According to their calculations, a 5 percent increment in food prices will increase extreme poverty levels almost one point. Given the current escalation in food prices, ten million people could be at risk of falling into extreme poverty in the region and a similar number may fall below the poverty line. This is clearly a setback, which is unacceptable in the context of efforts to create more equitable, just, and democratic societies.

But today’s crisis may also present an opportunity. We should not forget that the inequalities alluded to occur in spite of the fact that, at the global level, Latin America and the Caribbean is the region that imports the least amount of food. Latin America and the Caribbean imports 26.7 percent of the food it consumes, a level that compares favourably with other world regions: 38.6 percent in North America; 53.5 percent in Europe; 52.5 percent in Asia-Pacific; and more than 70 percent in Sub-Saharan Africa and the Middle East. Some of our countries are potential world leaders in the production and export of cereals, grains, fruit, and meat. More just and inclusive agricultural policies would give Latin America and the Caribbean a better opportunity to completely eradicate undernutrition, contribute to alleviate the hunger situation across the developing world, and improve the quality of life for its rural population, where the greatest levels of poverty have taken root. We know well that such policies do not only depend on calls to increase production. There are also internal factors that have to do with the concentration of unproductive agricultural properties, with a lack of technical assistance policies and support for small- and medium-level producers, with a protectionism that persists in the most developed countries in North America and Europe, and, naturally, with a very unjust distribution of income on a global level, that puts more than a third of humanity below the poverty line and more than a billion persons in extreme poverty. The goal of eradicating child undernutrition in our region is absolutely attainable. This is why it is important to emphasize the political commitment that exists about the need to urgently attend to 20

this scourge. The past few years have seen in the region the development of increased social and political consciousness about the necessity of confronting and combating poverty, not only for social and ethical reasons, but also because democratic governance is unsustainable if these problems are not addressed. On the other hand, the democratization and political stability achieved during the last ten years is an accomplishment also worthy of consideration in relation to this issue, given that it has provided a basis for sustained economic growth, additionally generating the institutional capacity to confront poverty, social exclusion, and its most perverse effects— such as hunger and undernutrition—in the most effective way. With this motivation and in the framework of our permanent commitment to integrated development and democratic governance, we have searched for strategic alliances that allow us to pursue more just societies. In this context, the recent Cooperation Agreement signed by the Organization of American States (OAS) and the World Food Programme (WFP) is oriented to design and execute joint projects and exchange experiences on humanitarian assistance, especially with reference to national capacity building related to eradicating hunger and undernutrition in the region. I take advantage of this opportunity to congratulate Dr. Josette Sheeran, Executive Director of the World Food Programme, for her untiring efforts to create awareness in public opinion about the food crisis—the “silent tsunami,” as she has called it—and in pushing governments and international organizations to act now to avoid what could become a global catastrophe.

Another expression of our commitment to the necessity of confronting this grave problem was the incorporation of the topics of hunger and child undernutrition as one of the four central aspects in the First OAS Meeting of Ministers and High Authorities of Social Development held in Chile on 9-10 July 2008, as part of the ministerial summits of the OAS and under the organizational responsibility of the Chilean Ministry of Planning. In addition to the traditional work done in this field by churches and civil society organizations, the health and education systems have historically been the institutional channels to reach the neediest with help and food supplements. Various programmes are being implemented in the region to address poverty from an integral perspective, such as conditional cash transfers, put into action in most cases under recently created Ministries of Social Development. The ministerial meeting in Chile provided an opportunity for analyzing pos-

sibilities for integrating feeding issues into these new programmes designed to combat poverty. I thank the Minister of Planning, Paula Quintana, for her ongoing efforts in preparing for this event. I should reiterate that the region has a lot left to do with regard to child undernutrition and hunger. This effort can be facilitated if national resources and political will partner with the technical capacity of international organizations such as WFP and the political commitment that can be obtained in forums such as the OAS, with the financial support that can be offered by international banks. Assuredly, the effort will be strengthened through agreements and permanent contact with civil society organizations, as well as alliances with the private and productive sectors, with the objective of guaranteeing the sustainability of the programmes and future income generation sources for families.

Equality: a fundamental factor in the fight against child undernutrition Paula Quintana Minister of Planning of the Republic of Chile

We have, however, an Achilles heel, and this is inequality, a factor that can definitely make a difference between a country that grows and one which crosses the threshold of development. Unending determination is needed to overcome inequality. It is necessary, additionally, to understand the origin of inequality. Inequality initially manifests itself in a person’s first years of life, continues through educational opportunities, is heightened by discrimination, and is consolidated by adversity. Inequality occurs in both opportunities and results, is reproduced on a daily basis, and broadens each time powerful particular interests are emphasized over the general interest, whether in the business sector or in the political arena. The history of our social policies and advances since the restoration of democracy gives us a solid base for confronting our next challenge: articulating in Chile a true system of social protection based on rights, capable of guaranteeing equality of opportunity and coverage for the principal risks facing families and people with scarce resources throughout their lives. Under the Governments of the Concertación alliance our social policies have transitioned from an assistance model to a social protection network based on guaranteed rights. This has been possible due to a consistent reduction in poverty, increased access to important social services, the distributive impact of social spending, and legal correction of discrimination against diverse groups in society based on ethnicity, gender, social or territorial origin, or sexual orientation. But this process has occurred in the midst of inequalities stemming from an unequal distribution of wealth, which although historically present in Chilean society, is currently unacceptable because of its incompatibility with a meritbased system and its reliance on socioeconomic and cultural criteria which translate into a lack of opportunities for many. The need for a social protection system is also based on the accelerated changes undergone by our societies that generate vulnerabilities associated with new risks, such as the surge in modern poverty and its high turnover, the existence of precarious and unstable jobs, the growing participation of 23

Paula Quintana

The desire for a greater and more equitable economic, social, and environmental development throughout our country over the long term has motivated Chilean society for many years. We have been very successful in the areas of growth, employment, and poverty reduction, among others, as well as in the reduction of child undernutrition. We have made substantial progress in health, education, social and economic infrastructure, and achieved improved indicators and recognition from international organizations.

Minister of Planning of the Republic of Chile

It was a great honour for Chile to host the Regional Ministerial Conference in May 2008, which provided a necessary and opportune discussion about the eradication of child undernutrition in Latin America and the Caribbean. The experiences and knowledge shared in this forum represent an effective contribution towards the development of our children and our region.

women in the labour force and its impact on the social structure, the ageing of the population, and changing migratory patterns. These vulnerabilities transcend the population already living in poverty and threaten some specific non-poor segments, such as children, people living with disabilities, older adults, adolescent mothers and female household heads, indigenous peoples and communities, and immigrants. A good social protection system supports people throughout their life cycle, protecting their first steps, assuring them access to opportunities for education and work, covering risks of illness and infirmity, and guaranteeing a dignified old age. A good social protection system recognizes people’s problems and allows them to maintain greater control over their own lives. The first years are crucial in the development of key skills and capacities that guide people through the rest of their lives. The stimulation and socialization that children receive during this stage of life in large part determine their abilities to confront learning opportunities later on, assure the development of healthy physical and psychological lives, and ensure their ability to construct productive work, family, and social lives during adulthood. In this context, the childhood protection programme “Chile crece contigo,” (“Chile Grows with You”) currently under implementation, represents a significant advance in the design and execution of a social protection system. This programme contributes to transform Chile into a more equitable, just, and secure country, allowing the maximization of opportunities available to individuals from their birth. The development of this programme constitutes a main challenge for our Government. Chile’s progress in the fight against child undernutrition has been significant. For that reason, in addition to maintaining results, it is also necessary to advance toward greater challenges and tackle issues such as preventing the moment of birth, socioeconomic origins, or other conditions from becoming factors of inequality, exclusion, poverty, or future vulnerability. The accomplishments of Chile’s society in addressing child undernutrition are the result of the articulation of integrated policies sustained over the long term, and designed around prevention, treatment, and control.

The Chilean experience demonstrates that a political and technical consensus dating from the 1940s, the continuity of programmes over the long term, integrated interventions, and a well-developed monitoring system have been fundamental in achieving today’s results. The objective of meeting the Millennium Development Goals related to overcoming hunger and diminishing risk factors associated with child undernutrition challenge us to articulate, in a comprehensive manner, actions that address the multiplicity of causes associated with the problems of undernutrition. “Chile crece contigo” (“Chile Grows with You”), initiated in 2007 and covering the entire country beginning in 2008, will play a central role in combating child undernutrition. The programme has as its goal to attend to the needs of and support the development of children in each stage of their early childhood. The system promotes the basic necessary conditions for childhood development, simultaneously influencing biological, physical, psychological, and social aspects of children in their entirety. Other efforts have been carried out in our region and have helped reduce undernutrition in certain countries and eradicate it in others, including Cuba, Costa Rica, Argentina, and Chile. The problem will not only continue to be a significant issue for Latin America and the Caribbean but will also, as currently, be relevant to the global food crisis. We need to be very proactive in the tasks of setting up policies and appropriate global agreements to guarantee access to food for the most vulnerable and lowest income segments of the population. This will allow us to avoid important setbacks in the area of undernutrition and in the levels of poverty and extreme poverty prevalent in the region. Meetings such as the Regional Ministerial Conference in Santiago, held in May 2008, represent important spaces for reflection and give us the opportunity to share experiences and achievements related to eradicating hunger and undernutrition in our countries and for our children, and to share the great challenge of constructing more just and unified societies.

The fight against undernutrition in the health agenda of the Americas Mirta Roses Director of the Pan-American Health Organization (PAHO)

In this regard, the Health Agenda for the Americas, approved by the PAHO member countries in 2007, establishes that the region should work to guarantee effective protection starting with prenatal care and prioritize specific actions designed to reduce maternal and infant mortality, as well as child undernutrition. The Health Agenda also calls for the reduction of health inequalities among and within countries. For this purpose, it is important to intensify South-South Cooperation in thematic areas related to health and nutrition and, additionally, to concentrate country efforts in strengthening national capacities and developing programmes to reach the most vulnerable groups. As a follow up on this Agenda and on the agreements reached in summits and ministerial meetings with heads of state, aimed at maximizing efforts to eradicate child undernutrition, it is necessary that the countries meeting in Santiago in May 2008 renew their commitment to prioritize hunger and undernutrition in their public agendas. We call on the international community to join the countries in giving priority to combating child undernutrition as part of their cooperative dialogues and in strengthening the exchange of knowledge among institutions and states.

Mirta Roses

The effects and damaging consequences of undernutrition are irreversible and can be seen from the moment of conception. Worse still, they are transmitted from generation to generation. These damages not only affect the individual human being, but also impact society as a whole, producing enormous economic losses in our health and social security systems.

Director of the Pan-American Health Organization (PAHO)

The topic addressed during the Regional Conference â&#x20AC;&#x153;Towards the Eradication of Child Undernutrition in Latin America and the Caribbeanâ&#x20AC;? is not an isolated subject. Rather, it represents one of the most visible and sensitive issues of human existence and development. Health and nutrition go hand in hand. It is unacceptable to have nine million children suffering from chronic undernutrition in a region possessing the knowledge and sufficient human, material, and financial resources for all its inhabitants.

An urgent and decisive call to action Rebeca Grynspan Regional Director of the United Nations Development Programme (UNDP) for Latin America and the Caribbean

We believe that today, more than ever, Latin America and the Caribbean are in a condition to confront this challenge and execute political, economic, and social measures that protect their most vulnerable population groups from the devastating effects of escalating prices in the basic food basket. We need programmes that increase income and access to food for vulnerable populations and also improve the supply and distribution of foods, especially by small agricultural producers. The challenge that brings us together today is not the exclusive responsibility of any one institution or Government. We must take action at the global, regional, and national levels. We will need to activate internal and external cooperation mechanisms that will facilitate addressing the problem in all its multiple dimensions. We need strong political will and firm determination to ensure that this time, unlike in the past, the economic cycles of the world economy will not place millions of Latin American citizens in desperation and extreme poverty. We cannot allow the possible effects of this crisis to impact the children of the region and deepen the perverse cycles of intergenerational transmission of poverty that convert temporary poverty into structural poverty. The region has an opportunity to prove itself at this moment and avoid the greatest injustice that plagues this continent: that children are condemned to poverty because they suffer from chron27

Rebeca Grynspan

The Santiago Conference took place at a specific and critical juncture, which requires the commitment and work of each of our organizations. Today, we are traversing one of the worst moments of our recent history, as a result of the food crisis, given the latest increases in the price of food. The Secretary-General of the United Nations has recently called for immediate measures, as well as the realization of medium- and long-terms actions to address this issue. The magnitude of this crisis may jeopardize the advances obtained in the region in the areas of poverty reduction and closely related Millennium Development Goals, such as reducing child undernutrition as well as maternal and infant mortality.

Regional Director of the United Nations Development Programme (UNDP) for Latin America and the Caribbean

The eradication of child hunger, affecting more than nine million children in our region, is, without a doubt, an issue of utmost importance for all our Governments. With greater urgency now that we are living through a cycle of large increases in the prices of food and fuel, reaching this goal requires that we refocus our efforts in the region to prevent even more children and Latin American citizens from suffering from the scourge of hunger and undernutrition. The Regional Ministerial Conference in Santiago, Chile, addressed the existing commitment to combat child undernutrition and the necessity of sharing information and experiences, as well as finding solutions and more effective paths to confront this big challenge.

ic undernutrition and, because of this—before even reaching two years of age or being capable of making decisions, before even starting school—their destinies are sealed because they were born in poor homes or—worse still—because they were born during a food price crisis that was not addressed. The Regional Ministerial Conference “Towards the Eradication of Child Undernutrition in Latin America and the Caribbean” provided

an opportunity to share valuable experiences and information that contributed to the identification of strategies for addressing this problem. An urgent and decisive call was made to concerted action and to a commitment from national and international organizations to this objective. We at the United Nations Development Programme (UNDP) reiterate our pledge to work together and continue supporting efforts in this direction.

Equal opportunities to break the cycle of hunger Marcela Suazo Regional Director of the United Nations Population Fund (UNFPA) for Latin America and the Caribbean

The United Nations Population Fund (UNFPA) is certain that the success of actions designed to address this crisis depends on taking people into account comprehensively. This includes attending to and respecting people’s rights, their conditions as women and men, and their necessities, including their reproductive health, which contributes significantly to reducing low birth weight and child undernutrition. I would like to reflect on the key role women play in breaking the cycle of hunger in their families, communities, and societies. We know that when women improve their social and economic situation, the condition of their family and children immediately improves. For this reason, improving the condition of women is important in the response to hunger, including child undernutrition. We need to adopt public policies that empower women; eradicate gender-based violence; facilitate the access of women, girls, and young people to quality health and education services; and incorporate men and young males in actions designed improve conditions for women and girls. At the United Nations System and UNFPA we renew our commitment to the countries of the region to reduce these gaps through support and technical assistance in policy formulation and national strategy implementation and, in particular, promoting the right of each woman, man, and child to enjoy a healthy life, with equal opportunities for all.

Marcela Suazo

Hunger and all its manifestations, including child undernutrition, particularly affect the poor. Hunger is “over represented” among women and their children, especially among women who live in rural or marginal urban areas with little or no education, as well as indigenous and afro descendent populations.

Regional Director of the United Nations Population Fund (UNFPA) for Latin America and the Caribbean

The world faces today the worst food crisis of recent times, due to the intense and persistent increase in the prices of food, a situation affecting the Latin American and Caribbean region, which is characterized by inequality and poverty. In Latin America and the Caribbean, some 35 million people live in extreme poverty and another 190 million live in poverty. Without taking effective action, the crisis could push into extreme poverty an estimated ten million people, who would need urgent help. An additional ten million people would fall below the poverty line and towards the limits of subsistence.

High food prices: crisis and opportunities Sheila Sisulu Deputy Executive Director of the World Food Programme (WFP)

For example, we know that undernutrition can cause irreversible mental and physical damage in children between birth and age three. We also know that this, in turn, will have a profound impact on a child’s productive life and will limit his or her contributions to society. Last year the World Food Programme (WFP) and ECLAC released a study of six Central American countries and the Dominican Republic which showed that the average cost of child undernutrition amounted to the equivalent of more than 6 per cent of Gross Domestic Product (GDP). Today’s food crisis threatens to increase that figure significantly. At the same time, we have all witnessed the social unrest sparked by higher food prices. Haiti recently joined a list of countries of the world where violent protests have erupted as a result of the food price increase. It requires no great insight to realize that many similar disturbances could ensue in the future, which in turn could have grave economic and political consequences for the countries involved as well as risk the needless loss of life. Our challenge today is to find the best means of assisting the hungry poor and to ensure that the necessary resources are devoted to this task. By this I mean that business as usual will not suffice. Not only will the international community have to play a critical role in providing financial resources to cooperation organizations like WFP, the United Nations Children’s Fund (UNICEF), the United Nations Food and Agriculture Organization (FAO) and the Pan American Health Organization (PAHO), but the nations of the region will have to take unprecedented and forceful action. If a needless tragedy is to be avoided, new policy and budget priorities will have to be adopted. Governments will face difficult 31

Sheila Sisulu

The Economic Commission for Latin America and the Caribbean (ECLAC) has already estimated that at current price levels, the region can expect to see ten million people plunged into extreme poverty or indigence. At the same time we can expect to see a comparable rise in illness and disease as the region’s poor find their bodies weakened by hunger and less able to resist, and if we are not careful we risk seeing an increase in hunger-related deaths, especially among children. In addition, another ten million people will find themselves on the knife edge of poverty, barely able to cope and threatened with hunger and undernutrition by any subsequent rise in prices. In short, not only does the food crisis threaten a catastrophe on millions of new victims, but it threatens to wipe out the important gains obtained through development efforts.

Deputy Executive Director of the World Food Programme (WFP)

We gathered in Santiago at a critical moment. The world finds itself in the opening stages of a global food crisis that threatens the wellbeing of tens of millions of the most vulnerable people on the planet. The truth is that the global institutions of the post-World War II era have never faced a humanitarian food crisis of comparable magnitude, complexity, and geographical reach. In less than two years we have seen global food prices increase on average by 83 per cent. The indications are that not only could prices still rise, but that they may well stay high for several years to come.

decisions as they assign lesser importance to some politically popular projects and give top priority to the hunger and nutritional crisis that is gradually gripping this region. Unless Governments convincingly respond to food prices in the initial phases of the crisis, they may well find themselves unable to respond to events as later stages unfold. As you may have read, WFP has requested that donor Governments contribute on urgently an additional US$756 million to help us for our current programme of work. In other words, the additional US$756 million would enable us to bridge the gap between the original estimated costs of our operations to feed 70 million people to the actual cost today. This amount excludes any additional people who will need assistance either because the high food prices leave them unable to meet a bare caloric minimum or for any new emergencies. The result is that we are currently assessing the additional needs and discussing with our partners plans for a more comprehensive response. As you also may know, the president of the World Bank, Bob Zoellick, has called for a new Marshall Plan and a coordinated response from the Bretton Woods institutions and key UN agencies. It is indeed on such a grand scale that we must respond if we are to be successful.

vides an opportunity to strengthen social safety nets, mother-child health and nutrition interventions and school feeding programmes that prioritize the nutritional well-being of vulnerable groups and renew the region’s commitment and determination to eradicate child undernutrition. According to FAO, the Organization for Economic Cooperation and Development (OECD), the US Department of Agriculture (USDA) and the World Bank, food prices will remain high in 2008 and 2009—and they are likely to remain well above the 2004 levels through 2015 for most food crops. We must ensure that in the face of this crisis the advances already made in reducing child undernutrition in the region are safeguarded and vulnerable groups receive extra protection against these shocks. The International Food Policy Research Institute (IFPRI) called for the implementation of a “comprehensive social protection and food and nutrition initiatives to meet the short- and medium-term needs of the poor” and other long-term agricultural and trade policies to face up to the challenge. Meanwhile the World Bank has stated that high priority should be given to avoiding negative nutrition impacts because the recent rise in food prices will produce in the poorest families a sudden cut in real incomes. This in turn could hit complementary feeding and reduce effective access to health care and medicines, thus further worsening nutritional outcomes.

Besides the increase in commodity prices, Latin America and the Caribbean face increasing emergencies caused by natural disasters. The latest hurricane season lasted longer than those of previous years and was particularly harsh, with two exceptional Category 5 storms starting the season and a host of other storms repeatedly hitting the region. This situation has severely damaged crops and agricultural activity, it increases food insecurity and vulnerability of more and more people—especially women and children—and is threatening development gains in the region. A Colorado State University forecast for the 2008 hurricane season predicts eight hurricanes, four of them Category 5 storms, hitting the region.

All of us have very important roles to play if we are to succeed. Each and every participant in the 2008 Santiago Ministerial Meeting needs to persuade their Governments to adopt an activist approach. We will need their support, particularly in the diplomatic arena. Forceful efforts must be made to persuade donor countries to become engaged to the fullest and at the earliest possible time. It must be clear that this will not be a one-shot deal. There will need to be sustained financial support as long as prices remain exceedingly high. At the same time, Governments will have to adopt an activist approach at the national level.

In the WFP as well as other UN agencies, our greatest concern is the impact the food price crisis is having on the deterioration of the nutritional status of children and pregnant and lactating women. As Latin American and Caribbean governments undertake immediate actions to tackle the effects of the current crisis, this situation pro-

This is a region rich in experiences in addressing child undernutrition. Many of the countries already have in place robust policies and programmes that include reaching vulnerable populations with well-targeted and effective social safety nets. The current world scenario especially highlights their importance and relevance.

During the Ministerial Meeting in Santiago we were challenged to develop an inventory of experiences and best practices derived from child undernutrition programmes undertaken to date; to establish a network of institutions and players responsible for programmes on child undernutrition in the region; to identify areas for South-South and triangular cooperation in support of national programmes to eradicate child undernutrition; and to adopt a mechanism to facilitate the sharing of knowledge, experience, and best practices.

We have also developed methodologies and tools to support Governments in eradicating child undernutrition, such as the Cost of Hunger Studies and the Hunger and Undernutrition Atlas; provided technical support to combat vitamin and mineral deficiencies; and designed with Governments and other stakeholders a knowledge management platform and networking tool to promote South-South and triangular collaboration in support of food-based and nutrition programmes.

The World Food Programme stands ready to work with the countries represented in the Santiago Ministerial Meeting. The Regional Initiative “Towards the Eradication of Child Undernutrition in Latin America and the Caribbean” has received political endorsement at the highest level, promoted technical exchanges at regional and national levels, and brought policy and programme makers together in events such as this one.

Among other things, we can help design improved emergency response mechanisms. We can also use this crisis to fast-track implementation of the regional initiative “Towards the Eradication of Child Undernutrition”. It is my hope that this conference will result in the development of an action plan for quick implementation at this moment when time is truly of the essence, as hunger waits for no one.

The United Nations system contribution to fighting child undernutrition Enrique Ganuza Resident Coordination of the United Nations in Chile

Recent studies, based on modern analytical techniques and a group of almost twenty countries (including almost all of Latin America and the Caribbean’s population and Gross Domestic Product) indicate that the region, assuming existing policies remain unchanged, appears to be on a good path towards achieving the MDGs. Additional efforts, however, are required to meet the goals (Vos et al). With the exception of Chile and Cuba, where the goals should be met with current policies and efforts, other countries need to increase their social spending between 2 and 6 percent of GDP per year until 2015 to assure the objectives are accomplished. At the same time, there needs to be more growth in employment and less inequality in order to achieve the poverty reduction objective. All cases should likely consider a combination of financial strategies, in which fiscal reforms are complemented with access to more internal and external resources. The central message to the Governments of the region is that they must persevere and increase their efforts, that it would be wise to have a perspective that goes beyond 2015, and that public policies should manage and integrate macroeconomic and social sector policies. Child undernutrition is one of the challenges we take on as a system as well as in the Declaration of the Millennium Development Goals: a priority issue in the activities of a majority of our agencies. Since the signing of the Millennium Declaration in 2000, the United Nations has worked to achieve the goal of reducing the proportion of the population that suffers from hunger by half at 2015, based on 1990 levels. Nevertheless, if special efforts are not made to attack nutritional problems among children, attainment of this MDG will be compromised. Although the countries of Latin America and the Caribbean have sufficient food to cover the needs of their population, 16 percent of all children under five suffer from chronic undernutrition, an indicator of the persisting social inequalities.

Enrique Ganuza

The United Nations System in Chile operates within the context of a strategy aimed at reaching the Millennium Development Goals (MDGs). Leaders from all the world’s countries agreed to achieve the MDGs by 2015, with the objective of creating a world with less poverty, hunger and disease; better educated children; more gender equality; better possibilities for maternal and infant survival; and a healthier environment. With less than ten years before 2015, there are still great challenges for the future, although there are signs of progress.

Resident Coordination of the United Nations in Chile

It was very important for the United Nations System in Chile, including the 15 organizations represented in Santiago, to collaborate with the Government in the organization of the Regional Ministerial Conference “Towards the Eradication of Child Undernutrition in Latin America and the Caribbean.”

Undernutrition in children increases their risk of death, inhibits their cognitive development, and affects their health for the entirety of the lives. Addressing this problem is fundamental in assuring their right to survival, as well as guaranteeing economic development for the region’s countries. Thanks to sustained health, nutrition, education, and environmental policies, Chile has effectively combated this health problem. Today, less than 2 percent of Chile’s population has some degree of undernutrition. Chile’s current malnutrition problem is, rather, overweight. The country has one of the highest levels of obesity in the world. The World Health Organization (WHO) estimates that there are currently 3.4 million obese people in Chile, a number that is expected to increase and that when added to the overweight population (almost 4.7 million people) will mean that almost 9 million Chileans are likely to be affected by problems related to excess weight at the country’s bicentennial (2010). The United Nations has worked to broach this issue, which is today becoming a public health problem, through joint work with the PanAmerican Health Organization (PAHO) and the Chilean Ministry of Health. This cooperation has permitted the creation of a Chilean Government Office for Global Strategy against Obesity, which has developed and carried out publicity campaigns related to lifestyle, nutrition, physical activity and health, among other issues. But while the principal malnutrition problem in Chile is obesity, in other countries in Latin America and the Caribbean is it chronic undernutrition. For this reason, the Regional Office of the Food and Agricultural Organization (FAO) for Latin America and the Caribbean, based in Santiago, provides technical support to national projects on food and nutrition security starting at pre-school age. FAO also supports the “Latin America and the Caribbean without Hunger Initiative,” promoting the right to food for all and the development of nutritional and educational programmes through family gardens and other initiatives. The high level participation of various United Nations agencies at the Conference “Towards the Eradication of Child Undernutrition in Latin America and the Caribbean” provides evidence not only of the interest in combating child undernutrition but also the importance of South-South Cooperation for these agencies. Indeed, the Government of Chile and the United Nations System have agreed to make South-South Cooperation one of the priority areas for its 2007-2010 work plan. This Conference (in the preparation and follow-up of which the World Food Programme has played a central role) represented a unique opportunity for exploring areas of common interest, establishing regional alliances, and sharing best practices and successful experiences in food and nutrition security applied with success in many countries in the region to eradicate child undernutrition.

An example of this is the agreement between the states attending the Conference, consisting of an inventory of countries providing and requesting support, which is being compiled by Chile’s Agency for International Cooperation (AGCI). This initiative will create a South-South Cooperation agenda and triangulation possibilities in support of countries, facilitating rapid and adequate responses. To advance towards the completion of the Millennium Development Goals, the collective and coordinated work of the United Nations agencies and national institutions is vital. This is how we respond to the call made during the Conference to the United Nations specialized agencies to support the plans and programmes formulated by the region’s Governments, as well as to back efforts in support of local production markets and the commercialization of food. Within a reasonable timeframe, comprehensive policies, joint efforts, and exchanges of experiences and lessons will succeed in overcoming malnutrition, thus improving people’s quality of life.

References Vos R, Ganuza E, Logfren H, Sánchez M, Díaz Bonilla C. Políticas Públicas para el Desarrollo Humano. Santiago de Chile: Uqbar (forthcoming).

Chilean cooperation and South-South Cooperation Cristina Lazo Vergara Executive Director of the Chile’s Agency for International Cooperation (Agencia de Cooperación Internacional [AGCI])

Thirty years after the Buenos Aires Declaration on South-South Cooperation (1978)—a historical marker, especially for our region—it is necessary to systematize and recover best practices, successful experiences, and, above all, qualified individuals in each of our countries, in an effort to share knowledge and lessons learned. This systematization and articulation is necessary because we need to utilize all the resources at our disposal and use all the experience we have accumulated in our countries. This experience includes traditional cooperation by historic donors, whose contributions have been internalized, adapted, and adopted to each specific reality. As a result, a broad resource base of capacities is available today. Child undernutrition and its terrible consequences are equivalent to mortgaging and curtailing a good proportion of the human and genetic potential in our countries. International cooperation and, especially, South-South Cooperation, because of its character grounded in solidarity and consensus, are effective support tools. South-South Cooperation is useful not only in complying with the Millennium Development Goals (MDGs) by 2015, but also in avoiding the unnecessary deaths of millions of children, not only in our region, but throughout a large part of the South-South world. Cooperation efforts need to be increasingly integrated and integrating. As an issue, child undernutrition should be the responsibility each country’s whole society, with each part contributing their respective role. As we saw during the Regional Ministerial Conference in Santiago (May 2008), undernutrition has ceased to be an isolated public health problem. It has now become linked to almost all social themes, including exclusion, marginality, women, indigenous and afro descendent groups, housing, education, employment, harmonious rural development, productivity, and school feeding, among others.

Cristina Lazo Vergara

South-South Cooperation has oftentimes been part of each country’s efforts to end, or at least attenuate, this scourge. However, actions and individual experiences have not been adequately articulated among all the actors, nor have they responded to a systematization of efforts. These appear to be more a confluence of individual wills, which are always valuable and necessary, but still not integrated or corresponding to a broader and more encompassing institutional framework. This integrated approach is needed to move beyond required, yet sporadic, interventions, to a more organized plan of cooperation, with an ability to respond with concrete and measureable results to the needs of the countries necessitating cooperation.

Executive Director of the Chile’s Agency for International Cooperation (Agencia de Cooperación Internacional [AGCI])

The magnitude of the challenges and the urgency of the measures that should be taken to eradicate child undernutrition in our region make it necessary to resort to all possibilities, capacities, and available tools.

Through its Programme for South-South Cooperation, Chile has been present in confronting these challenges. To the best of our abilities, we have tried to share our experiences in child nutrition with the rest of the countries in the region that have requested our assistance. The issue of child undernutrition has intermittently been part of requests submitted by countries associated to the Chilean Government’s South-South Cooperation Programme. This Programme was created in 1992 and is managed through the Agency for International Cooperation (Agencia de Cooperación Internacional [AGCI]). Matching the offers and requests with needs and capacities existing in the country continues to be one of AGCI’s principal tasks. Many of the actions initially provided and supported by AGCI continue to be undertaken through different cooperation mechanisms administered by the Agency. We have thus formed specialized networks in different thematic areas that currently operate as intergovernmental mechanisms. It is also pertinent and opportune for each specialized institution, whatever its nature, to assume an appropriate role in completing the transcendental effort needed to end child undernutrition. Agencies producing studies or poverty maps, with successful experiences

at the community and local levels, with cohesive programmes and policies with proven results, and with technicians, professionals, or community actors and resources at their disposal must make an effort to share these resources and articulate a Regional Cooperation System that will help us eradicate child undernutrition and form the basis for best practices in solidarity and cooperation among our countries. Through AGCI, Chile has the best intentions and desire to assume those roles that match our mission and objectives. We are available to build strong working partnerships with countries that are available for this initiative. The Chilean Agency for International Cooperation, with its 16-year presence in the region, is willing to continue providing support towards the attainment of the MDGs in our countries and our hemisphere. We have thus contributed to save the lives of many children in our region. We are investing in the biological, moral, intellectual, and productive capacity of each of the nations represented at the 2008 Santiago Meeting, and this investment deserves our best and most energetic efforts.

SANTIAGO DECLARATION Agreed to in Santiago, Chile, 6 May 2008 The Vice-President of Guatemala and the Ministers, Vice-Ministers, and official representatives of the Governments of the countries of Latin America and the Caribbean, participating in the Regional Conference â&#x20AC;&#x153;Towards the Eradication of Child Undernutrition in Latin America and the Caribbean,â&#x20AC;? held in the City of Santiago, Chile, on 5-6 May 2008,

Recognizing that: 1. Although their situation has improved over recent decades, the countries of the region still exhibit important nutritional problems: i) food and nutrition insecurity manifested in chronic child undernutrition affecting nine million children; ii) micronutrient deficiencies such as iron deficiency, prevailing in 50 percent of children under two with anaemia, and also affecting women of child-bearing age, particularly pregnant women; and iii) the growing prevalence of excess weight and obesity, beginning in childhood. 2. Inequality and the social, cultural, economic, and political exclusion of population segments such as those in rural communities, indigenous and afro descendent populations (except in the Caribbean), are among determining factors of undernutrition, with national averages hiding significant disparities.

those under three, impacts individual and collective wellbeing by significantly compromising their human development, health, learning and education, and productivity; by diminishing social cohesion and perpetuating poverty; and by slowing social development and economic growth in the countries. 4. Chronic undernutrition (stunting or low height for age) in children under three is particularly devastating, as it occurs during a critical phase of psychomotor and cognitive growth and development, for which reason prevention and control measures are needed to avoid irreversible damage for the rest of their lives. 5. Knowledge and, in some cases, necessary resources exist to reverse this situation, but limits in capacity development and targeting of the most vulnerable populations, from a nutritional point of view, reduce the effectiveness of prevention and control interventions for child undernutrition. 6. The sustained increase in the price of food during the past three years has aggravated the nutritional situation through two effects: i) the increase in poverty and extreme poverty suffered by some twenty million people per year (ECLAC); and ii) the aggravation of food and nutritional insecurity in homes with the least resources (more than half of the population).

3. Undernutrition among children under five and, particularly, among 39

7. Because this is a phenomenon responding to multiple and complex factors (commercial, environmental, financial, etc.), food price stabilization is, to a large degree, a measure escaping the unilateral possibilities of the regionâ&#x20AC;&#x2122;s Governments, for which reason a multilateral response is required, including social protection mechanisms, production stimuli, optimization of water usage, and transparent food commercialization. 8. With the purpose of meeting the Millennium Development Goals and guidelines on food and nutrition security, many countries in the region, supported by WFP, FAO, WHO, UNICEF, IDB, the World Bank,

INCAP, OAS, and other organizations, have elaborated medium- and long-term programmes for the eradication of child undernutrition. 9. Countries have established bilateral and multilateral mechanisms of South-South Cooperation as an effective tool for sharing best practices and successful experiences, which have received acknowledgement and support of international organizations, as evidenced in the recent Cooperation Agreement between the OAS and WFP, establishing a South-South and triangular cooperation agendas in support of the regionâ&#x20AC;&#x2122;s countries.

We express our determination to: 1. Continue considering food and nutrition security as a â&#x20AC;&#x153;national, regional, and universal emergencyâ&#x20AC;? that should be placed at the highest level of the policy agenda, emphasized as a major priority in national poverty reduction and social protection strategies, allocated appropriate financial resources, and articulated in diverse public policies as a base for effective intersectorial action. 2. Strengthen the fight against undernutrition from a human rights perspective, through multiple strategies: i) formulating or reinforcing comprehensive social action plans, based on scientific evidence that can be assessed and can guarantee food and nutritional security for the most vulnerable population groups, especially populations living in rural areas or marginalized ethnic groups living in extreme poverty; ii) including nutritional interventions as one of the key themes in social protection policies, above all those directed at children under three, women of child-bearing age, pregnant and breastfeeding mothers, and other groups with special nutritional needs; iii) stimulating greater food production, in particular on behalf of small farmers in rural areas, and facilitating their access to consumer markets; iv) promoting policies that assure functioning transparency in food markets at the national and international levels; v) promoting the empowerment of this nutritional and food challenge by affected families and communities, through mechanisms adopted by the countries, such as popular participation and social control of interventions, and; vi) providing social communication strategies that encourage necessary knowledge sharing and ensure that nutrition remains on the regionâ&#x20AC;&#x2122;s public agenda. 3. Take into account that, according to evidence obtained by countries in the region, effective prevention and control of child undernutrition requires: i) adopting a comprehensive care strategy for the family, with cultural sensitivity and a focus on gender that includes food and nutrition actions that are preventive and multisectoral (primary health care, promotion of breastfeeding, social development, sexual and reproductive health, family farming, basic water and sanitation services, finance, comprehensive education, etc); ii) reflecting nutritional priorities in the adoption of specific instruments, such as food and nutrition guides, epidemiological systems for nutritional

surveillance, or the specification of goals to be reached in given timeframes; iii) targeting interventions at populations, with cultural sensitivity and gender focus, especially on pregnant and breastfeeding women and children under three; iv) targeting interventions geographically, to immediately assist populations in urban and rural areas with the highest prevalence of poverty and extreme poverty; v) improving the food and nutrition situation of homes in poverty or indigence through multisectoral interventions of proven efficacy, which includes direct access to appropriate foods, nutritional education, and monetary or food transfers; vi) introducing prioritized safe water and sanitation projects. 4. Join the urgent call to the international community to intensify, in a coordinated way, support for the most vulnerable countries of the region through resource and/or food donations and their channelling through WFP to confront the new financial needs caused by the worldwide food price crisis, in support of the neediest populations. 5. Insist on joint action from the specialized agencies of the United Nations System in supporting plans and programmes formulated by Governments in the region and support the efforts of these agencies to encourage local production markets and the commercialization of food. 6. Take advantage of and support the existing knowledge management platform (NUTRINET.org) to facilitate the exchange of information, knowledge, and best practices among countries, thereby strengthening national and regional efforts towards the eradication of child undernutrition in Latin America and the Caribbean. 7. Assure South-South and triangular cooperation among countries via diverse mechanisms: i) networks of countries with similar situations that facilitate the production of rapid and adequate responses with the capacities and needs for cooperation presented at this Regional Conference; and ii) structures for the production of regional public goods, including, among others, unified support between countries in emergency situations, exchange and regulation of knowledge and information in thematic, economic, and epidemiological areas, and the joint realization of research projects, technical assistance, and human resource development.

Part two THE ERADICATION OF CHILD UNDERNUTRITION IN CHILE

Chapter 1

POLICIES AND PROGRAMMES EXPLAINING THE ERADICATION OF CHILD UNDERNUTRITION IN CHILE Paper prepared for the Regional Technical Conference “Towards the Eradication of Child Undernutrition in Latin America and the Caribbean” by Fernando Vio (Food Nutrition and Technology Institute [Instituto de Nutrición y Tecnología de los Alimentos, INTA], Chile), Gerardo Weisstaub (INTA), Eduardo Atalah (Ministry of Health [MINSAL]), Teresa Boj (MINSAL), Mónica Jiménez (MINSAL), Paulina Fernandez (Ministry for Planning and Cooperation [MIDEPLAN]), Germán Puentes (MIDEPLAN), Donatella Fuccaro (National Pre-School Board [Junta Nacional de Jardines Infantiles, JUNJI]), Juana Rojas (JUNJI), Mónica Vásquez (INTEGRA Foundation, Chile), J. Folch (INTEGRA), Graciela García (Procurement Office of the National Health Service [Central de Abastecimiento del Sistema Nacional del Servicio de Salud, CENABAST], Chile), and Gabriel Méndez (CENABAST). Support provided by Moy de Tohá (United Nations Development Programme [UNDP]), Angélica Beas (UNDP) and Hernán Acuña (MIDEPLAN) is gratefully acknowledged.

SUMMARY

Undernutrition increases the risk of death, inhibits cognitive development, and has lifetime effects on the health of children under three. Addressing this problem is a fundamental requirement to ensure the right to survival and development of children in Latin America and the Caribbean (LAC). Adequate child nutrition is directly linked to the achievement of the Millennium Development Goals (MDGs). Without special efforts to tackle the more frequent nutritional problems affecting the region’s children, the objective of meeting all MDGs could be seriously compromised. Between 1960 and 2000 Chile succeeded in eradicating child undernutrition. Prevalence of undernutrition (including mild undernutrition) in children under six dropped from 37.0 to 2.9 percent during this period. These results contrast with the incidence of child undernutrition in other LAC countries, where it remains a public health problem. Several factors combining synergistically contribute to explain Chile’s favourable performance in combating child undernutrition. The central element in achieving this result, however, was the existence of a state policy to eradicate child undernutrition, which was sustainably applied over four decades, without regard to the country’s political and economic changes. To a large extent, this result was due to a technical consensus achieved in Chile on undernutrition and the more adequate programmes to face the problem. Since the 1960s the National Health Service (Servicio Nacional de Salud [SNS]) increased its national coverage, allowing access to a national health infrastructure capable of penetrating all levels of society, especially lower income socio-economic groups. SNS services included free preventive medicine and health attention services, which increased live births, pre- and post-natal care, and child health controls with vaccination coverage and food delivery. Additionally, in 1953 SNS launched a food distribution programme for mothers and children. As the amount of milk distributed through health centres increased, child health controls and medical attention also augmented, especially among lactating children under two. In that area as well, Chile put into action successful recovery programmes for under-nourished children through closed and ambulatory strategies (at CONIN centres and through the COFADE programme, respectively). These programmes operated in close contact with the primary health network, effectively incorporating undernourished children. Alongside food and health policies, Chile implemented nutritional policies in its educational system. These included food delivery to children in nurseries, pre-schools, and grade schools throughout the country’s public school system. With regard to sanitation, since 1930 Chile had introduced policies to expand coverage of potable water and sewage services. As a result, by 1990 these services covered 97.4 and 81.8 percent, respectively, of the urban population. The proportion of the population living in urban areas rose from 75 percent in 1970 to 86.6 percent in 2000.

INTRODUCTION

Repetitive infections (diarrhoea, respiratory infections), which are frequent in undernourished children, have a negative impact on individual health status, with potential for causing a child’s death. While severely undernourished children are at a greater risk of death, it is important to emphasize that between 76 and 89 percent of all deaths from infectious diseases are attributable to moderate or mild undernutrition. For this reason, treatment for undernourishment must cover the entire undernourished population, not only children affected by severe undernourishment (Pelletier et al. 1994). The absence of complementary feeding programmes for children of vulnerable families also contributes to the emergence of undernutrition. Maternal milk by itself satisfies the nutritional needs of breastfeeding babies during the first six months. After this period, complementary foods are important to cover the nursing baby’s demand of nutrients. Retarded growth may occur if these foods are not introduced at the right moment, in adequate amounts and quality. Caloric density and frequency of meals must be considered when recommendations on adequate feeding practices are formulated. Between 1960 and 2000 Chile, succeeded in eradicating child undernutrition. Prevalence of undernutrition (including mild undernutrition) in children under six dropped from 37.0 to 2.9 percent during this period (see Table 1). At prevalence rates of 0.2 and 0.1 percent, respectively, by 1990 moderate and severe undernutrition had practically disappeared. In other words, by the end of the 1980s Chile had already achieved a virtual eradication of child malnutrition.

Table 1 Prevalence of Global Undernutrition in Children under Six Chile, 1960-2000

Year

Total

Mild

Moderate

Severe

1960

37,0

31,1

4,1

1,8

1970

19,3

15,8

2,5

1,0

1980

11,5

10,0

1,4

0,2

1990

8,0

7,7

0,2

0,1

2000

2,9

2,6

0,2

0,1

Source: Ministry of Health 2000.

Child undernutrition became a public health issue in Chile around the middle of the twentieth century. Various programmes and actions were implemented to simultaneously address the different factors impacting the emergence and maintenance of the phenomenon. These measures included water and basic sanitation programmes, family planning, increased schooling for the general population and, especially, for mothers, reduction in poverty levels, basic sanitary infrastructure expansion, etc. Together with complementary feeding programmes, these interventions explain the successes in moth-

er-and-child health achieved throughout the country, including the eradication of child undernutrition (see the Statistical Annex). The central element in achieving these results, however, was the existence of a state policy to eradicate child undernutrition, which was sustainably applied over four decades, without regard to the countryâ&#x20AC;&#x2122;s political and economic changes. To a large extent, this result was due to the technical consensus achieved in Chile on undernutrition and the more adequate programmes to face the problem.

DEMOGRAPHIC AND NUTRITIONAL TRANSITION

Demographic Transition From the mid-twentieth century onwards, Chile has undergone an important demographic and nutritional transition. Population changes have been very significant. Total population under 15 declined from 39.2 percent in 1970 to 25.7 percent in the 2002 census. Over the same period, population over 65 rose from 5 to 7.2 percent, while fertility and birth rates underwent a significant reduction, with annual population growth declining from 1.8 to 1.1 percent. The infant mortality rate also decreased dramatically from 82.2 percent in 1970 to 7.8 percent in 2002. As a result, life expectancy increased from 60.5 years (men) and 66.8 years (women) in 1970 to 73.2 and 79.5 years in 2002, respectively. Concurrently, a process of increasing urbanization has taken over the same period. In the 1970s, 75 percent of the population lived in urban areas; by 2000 the number had risen to 86.6 percent. This process has had positive effects, such as increased access to potable water and sewage, presently covering over 95 percent of the population. Literacy has also risen and access to housing and health services has improved. Among the negative aspects of urbanization are changes in diet, physical activity, and consumption of tobacco, alcohol, and drugs, together with environmental pollution and an increase in mental health problems, which relate to the increase in non-transmissible the chronic diseases (Albala et al. 2001).

Nutritional Transition The coexistence of undernutrition with obesity is the principal characteristic of the nutritional transition period. This implies that undernutrition cannot be considered in isolation from obesity, since both phenomena are intimately related and primarily affect the poorer socio-economic groups. The theory of nutritional transition refers to dietary and nutritional status changes in populations within the framework of complex interactions with demographic, socioeconomic, and environmental factors (Popkin 1994). At the pre-transition stage, occurring in developing countries, diet is based on a reduced number of vegetable foods (cereals, roots, or fruits), which explains high undernutrition and a deficit in micronutrients. This it was the case with rice in Asia; maize, beans, and bananas in Middle-America; wheat and potatoes in South America; and cassava in Africa. As they develop and per capita income rises, societies increase their consumption of processed foods with high fat, sugar, and salt content. This produces an increment in obesity, which coexists with child undernutrition. The coexistence of undernutrition with obesity is the principal characteristic of the nutritional transition period. Nutritional transition affects all socioeconomic levels, but targets the poorest (Monteiro et al. 2001). At a low socio-economic level, children are frequently undernourished and suffer from infectious diseases. As they grow, however, they may become obese from exposure to obesogenic environments, in which items with high energetic content but low nutritional quality cost less than â&#x20AC;&#x153;healthyâ&#x20AC;? foods. Evidence also indicates that fetal and child undernutrition may create a greater risk of becoming obese and developing diabetes in adulthood. Significant levels of undernutrition were evident in Chile from the 1960s through the beginning of the 1980s. These levels may have contributed to determining the higher prevalence of chronic disease subsequently observed. Strong income growth among the population since the latter 1980s contributed to higher food consumption.1 Regrettably, however, animal and processed foods with high fat, sugar, and salt content saw the largest increases. Consumption of cereals, vegetables, and other items rich in fibre and antioxidants either remained stable or declined (Crovetto 2002). An explosive growth in obesity occurred between 1987 and 2000, as a result of sedentary behaviour and the consumption of foods with high energy density. This finding is supported by annual statistics of children seen at National Pre-School Board facilities (Junta Nacional de Jardines Infantiles [JUNJI]) (Figure 1); of children entering the first grade of elementary school, as compiled by the National Scholarships Board (Junta Nacional de Auxilio Escolar y Becas [JUNAEB]) (Figure 2); and of pregnant women seen at health services. Obesity levels stabilized from 2000 onwards, with a slight increase among first grade schoolchildren Vio et al. 2008). Lamentably, a similar situation is identifiable in other Latin American countries (PeĂąa and Bacallao 2000; Kain et al. 2003). 1

It is estimated that lower income groups allocated approximately 50 percent of their income to food purchases.

Figure 1 Prevalence of Overweight and Obesity in Children from Two to Five Years Attending JUNJI Centres (%) Chile, 1995-2006

Overweight Obesity

Source: Data provided by Junta Nacional de Jardines Infantiles (JUNJI).

% obesity

Figure 2 Prevalence of Obesity in Schoolchildren Entering their First Year of Primary School at JUNAEB Centres (%) Chile, 1987-2006

Source: Data provided by Junta Nacional de Auxilio Escolar y Becas (JUNAEB)

Policy Responses Since the mid-twentieth century, Chile implemented targeted policies aimed at reducing undernutrition. These policies included a Complementary Feeding Programme (Programa Nacional de Alimentación Complementaria [PNAC]), consisting in the delivery of food to all children seen at health centres (primary prevention). It also comprised a more frequent follow-up programme based, on the one hand, on a reinforced delivery of food to mildly undernourished children or at risk of becoming undernourished (secondary prevention) and, on the other, on the hospitalization in CONIN centres of children with moderate or severe undernutrition (tertiary prevention) (Uauy and Vio 2007). Despite Chile’s nutritional transition, there was a temporary lack of adjustment in food distributed by programmes. This might have contributed to the rise in overweight and obesity (Kain et al. 1998; Uauy and Kain 2002). In 2000, Chile established sanitary targets to reduce obesity by 2010. Specifically, the aim is to reduce obesity among pre-schoolers from 10 to 7 percent; among children entering the first grade, from 16 to 12 percent; and among pregnant women, from 32 to 28 percent. These targets had not been met by 2005, for which reason obesity remains the country’s principal nutritional problem and one of the major public health issues, given its implications for the economy and society as well as the burden it places on the health system. To sum up, Chile provides important lessons regarding the relevance of timely public policy changes to adequately address the dynamics of a particular problem. Without a doubt, systems to monitor and follow up social problems, as well as sufficiently flexible institutions and public programmes, are necessary conditions to make such changes possible.

MAIN FEATURES OF CHILE’S CHILD UNDERNUTRITION ERADICATION POLICIES Broad Coverage Health and Education Programmes Beginning in the 1940s, Chile’s basic education coverage underwent continuous expansion, resulting in a drop in illiteracy and an improvement in the educational level of mothers, an important element in the decline in undernutrition and infant mortality. Health service network improvements since the 1960s increased live births, pre- and post-natal controls, and healthy child controls with vaccination coverage and conditional food transfers (linked to compliance with the control timetables established by the health system). Additionally, the health system broadened its coverage to include the entire country and set up an increasingly complex health network (including rural outposts, primary care centres, and hospitals), together with regulations that allowed adequate health care and nutritional programme implementation.

Targeted Programmes to Prevent Undernutrition

The Government also established programmes to supplement milk with iron, zinc, and copper for groups with a high deficit of these micronutrients (pregnant women and children under two) (Hertrampf et al. 2003). Targeted programmes to detect and address goitre in high prevalence areas were established. Water fluoridation and fluoride food fortification initiatives were set up in deficit regions (Pretell et al. 2004; Mariño et al. 1999). Programmes to evaluate the calcium content in the national diet assessed the prevalence of osteoporosis among women and proposed supplementation initiatives among groups affected by calcium deficit (Leiva et al. 1992; Muzzo 1996). These programmes were characterized by high targeting (reaching more than 80 percent of the target groups) and the broad nature of the interventions, ranging from universal prevention to recovery of severe undernutrition cases to avoid future effects through timely recuperation. Coverage of the full spectrum of the problem produced synergistic results and a higher impact than would have been obtained from isolated implementation of each component.

Nutritional Surveillance

The programmes implemented in Chile to prevent undernutrition covered the phenomenon from its preventive aspects to the rehabilitation of undernourished children. Primary prevention consisted of the implementation of the National Complementary Feeding Programme (the basic PNAC), the objective of which was food delivery to the country’s entire vulnerable population, i.e., all pregnant and lactating women and children under 6 receiving health care. This allowed coverage of over 1.3 million children and pregnant women. A targeted national programme (the targeted PNAC) complemented the universal PNAC. The targeted PNAC was a secondary prevention feeding programme for pregnant and lactating women with nutritional deficit and children at social risk or affected by mild undernutrition. An intensive tertiary prevention or rehabilitation programme was implemented for children affected by moderate or severe undernutrition. These children were hospitalized in special CONIN centres until their full recovery and seen in COFADE ambulatory attention centres (Monckeberg 2003; Lewin et al. 1989). Concurrently, school feeding was fortified through programmes complementing PNAC: those focused on children under six, implemented by the National Pre-School Board (Junta Nacional de Jardines Infantiles [JUNJI]) and the INTEGRA Foundation, as well as those run by the School Feeding Programme, for children between six and 14. 52

Chile has an efficient nutritional surveillance system. Since 1975, this system has recorded the nutritional status of 1.2 million children and low-weight pregnant mothers seen at health centres on a monthly basis. During the present decade, the information was broadened to include other vulnerable groups, such as older adults and, more recently, post-delivery mothers. Additionally, a low birth weight information system was set up at maternity wards. These initiatives, together with infant mortality information recorded in Chile since 1904, allowed a very close monitoring of undernutrition in the country.

Policy and Programme Continuity A relevant characteristic of the Chilean case is that the decline in child malnutrition took place under Governments having different ideological orientations. The policies leading to such decline between the 1960s and 1980s were kept in place despite the significant socio-political changes that occurred in the country over the same period. This continuity was largely the result of a technical consensus reached regarding the need to eradicate child malnutrition and the more adequate policies and programmes to face the phenomenon. Evidence from countries that had eliminated undernutrition prevailed over political barriers, contributing to consensus-formation and helping maintain programmes over time throughout various administrations.

An important effort was made to share information, experiences, and work between university faculty and Health Ministry technicians in charge of undernutrition programmes. For instance, when during the 1982 economic crisis the Complementary Feeding Programme suffered a 30 percent reduction, the nutritional surveillance system reported an immediate increase in child malnutrition. University researchers informed Health Ministry technicians and the public about this situation. The cutback was reversed, allowing a return to the declining tendency in undernutrition prevalence. In 1985, the opposition of professional and academic groups prevented the substitution of rice for milk distributed to pre-school children (Vio et al. 1992).

Institutional Framework Chileâ&#x20AC;&#x2122;s policies and programmes were backed by a solid institutional framework achieved over several decades, with adequate legal support. This allowed their continuity, given that policies and programmes should not change arbitrarily as a result of political alterations. Nutritional objectives were thus achieved with efficiency, efficacy, and very low corruption levels. This legal framework, however, has become an obstacle when reform has been necessary to adapt programmes to the countryâ&#x20AC;&#x2122;s new epidemiological and nutritional conditions.

The implementation of child nutrition policies has not been linked to the countryâ&#x20AC;&#x2122;s economic cycles. Between 1982 and 1984 Chile underwent a severe economic crisis, with gross domestic product (GDP) plunging 14 percent in 1982 and a further 2 percent in 1983. This drop caused an increase in unemployment and poverty (Tokman 1985). But child undernutrition continued its descent as a result of the impact of health and nutrition policies executed without interruption since the 1970s.

Human Resource Development Chile has prioritized human resource development in food and nutrition university programmes at the undergraduate and graduate levels. Specifically, personnel dealing with undernutrition—including physicians, paramedics, nurses, nutritionists, and midwives—have reached a very high level of knowledge and experience. To account for the country’s rapid epidemiological change, in the early years of the twenty-first century the curriculum was updated to include nutritional problems such as obesity, food quality, and innocuousness.

Research and Knowledge Development As part of a more effective response to child undernutrition, the University of Chile established the Department of Nutrition at the College of Medicine in 1969 and the Nutrition and Food Technology Institute (Instituto de Nutrición y Tecnología de los Alimentos 54

[INTA]) in 1976. These and other academic units have continuously contributed research on the causes of early nutritional deficit and its consequences for health, education, and socio-economic conditions. Additionally, they have recommended concrete solutions to undernutrition issues through public policies and programmes, participating in the formation of qualified human resources, in the design of new foods for programmes, and in evaluating the effects of interventions. INTA contributed to the establishment of the Nutrition and Food Council (Consejo para la Nutrición y Alimentación [CONPAN]), which contributed significantly to the recovery of seriously undernourished children. Together with the health sector, these academic groups have played a prominent role in monitoring the implementation of nutritional programmes, designing and evaluating new foods, assessing programme impact, and proposing changes to improve their effectiveness.

MAIN INSTITUTIONAL, PROGRAMMATIC, AND LEGISLATIVE POLICIES Programmes, Institutional Changes, and Legal Initiatives This section describes the principal programmes, institutional changes, and legal initiatives in each intervention area that explain the processes leading to the eradication of child undernutrition in Chile.

Health Policies Compulsory Worker Insurance, Mother and Child, and Preventive Medicine Laws A set of bills submitted to the National Congress by President Arturo Alessandri Palma in 1924 included the Compulsory Worker Insurance Bill (Law 4,054), which established a Medical Department to provide health assistance to the poorer workers. Female insured workers began receiving social and health support during pregnancy, at childbirth, and during rearing. This support extended to female insured workers’ children up to the age of eight months, but excluded the rest of their family and the non-insured population. In 1937, during President Alessandri Palma’s second administration, Health Minister Dr. Eduardo Cruz Coke created the National Food Council, based on the results of studies commissioned by him. This information also served as a basis for the Mother and Child and Preventive Medicine bills Dr. Cruz Coke submitted to Congress, which were approved in 1940. The Mother and Child Law initiated food delivery by the State, through the health sector, to lactating children of workers, less than two years of age, during health controls, as part of a mother-and-child plan comprising several preventive activities (Mardones Restat et al. 1986). Implementation of these laws produced increased health coverage of children, broad delivery of milk, and a large drop in infant mortality. The relationship between an increase in milk deliveries and a nearly 50 percent reduction in infant mortality became evident in the 1940s.

The National Health Service (SNS) Dr. Cruz Coke’s initiative led to the approval of an action programme including the creation of a Social Security Service (SSS) and a National Security Service, with the purpose of uniting within one entity all public and private organizations providing health services for the poor. These included, among others, the Social Security agency, the Public Welfare agency, several municipal health services, the Drop-of-Milk societies, and the National Child Protection Association (PROTINFA). In 1948, the approval of the Physician-Functionary Bill guaranteed the participation of physicians in SNS. In 1952, Health Minister Jorge Mardones Restat obtained support from the Medical College for an SNS bill, approved that year. The amalgamation of all medical services into one national health service facilitated medical treatment and health prevention through a network providing the population with free vaccination and complementary foods distribution Winter et al. 1950). The creation of SNS allowed the implementation of public health activities such as BCG vaccination for all newly-born children as well as iron and vitamin B fortification of flour used in bread making. The latter initiative received significant support from the Chilean Society of Nutrition and Bromatology and the Nutrition sections of the country’s schools of Medicine and Pharmacy. A national health infrastructure capable of penetrating all segments of society—especially the more deprived sectors—thus emerged, offering free preventive medicine and health care. Though initially the system covered only a fraction of the population, it was gradually expanded throughout the country, excluding only those individuals who were capable of financing their health care through private means (Mardones Restat 2003).

The Primary Health Care Network A policy of assigning general zone practitioners to remote areas of the country outside the reach of modern medicine began in the 1960s, during the administration of President Eduardo Frei Montalva. Small hospitals, clinics, and rural health centres were established as well, which created a genuine, broad coverage health care network. The result was an immediate decline in maternal and child mortality. In peripheral urban areas, clinics were also set up to provide care to the more vulnerable sectors, including the poor and recent rural migrants, who survived under meagre conditions in marginal settle55

ments, more often than not lacking water supply, sanitation, and electricity. Diarrhoea, bronchopneumonia, and infectious diseases were highly present among children in these areas, as were high undernutrition levels. Primary coverage increased in the early 1970s, during the administration of President Salvador Allende. Numerous peripheral clinics were established in the Santiago Metropolitan Region and other important cities, and the general zone practitioner policy was reinforced (Kaempfer and Medina 1982). Clinics and small hospitals gave priority to pre-natal and healthy child controls, institutionalized childbirth in maternity wards, and diarrhoea prevention campaigns (the principal cause of disease and death in children), together with the expansion of complementary feeding programmes. This was achieved with important community participation, through the Community Health Councils and Parity Councils in clinics and hospitals, which empowered users to demand that programmes remain in place during the military regime. At this time, medical attention and nutritional programmes were also implemented in isolated areas, through the creation of rural centres, each staffed by one health worker. A medical team visited these centres on a weekly basis. Healthy child controls were carried out at the rural centres, which also served as distribution outlets for food delivery to children under six and pregnant and lactating mothers.

Investment in public hospitals dropped drastically after the arrival of the military regime in 1973. Because of their relatively lower cost, primary attention programmes—especially mother and child health controls—were maintained. These programmes were carried out by non-medical professional staff (nurses, midwives, nutritional specialists, nurse assistants). Targeting was also included as a component in Complementary Feeding Programmes.

The National Food and Nutrition Council (CONPAN) Despite the advances in primary care coverage and food delivery achieved through PNAC in the early 1970s, in 1974 undernutrition still affected 16 percent of children under six and child mortality stood at 64 per thousand live births. It was therefore necessary to design a new, globalized strategy, which included the creation of an organization in charge of designing and coordinating food and nutrition policy. In response to this perceived need, the National Council for Food and Nutrition (Consejo Nacional para la Alimentación y Nutrición [CONPAN]) was created. CONPAN was set up as an autonomous entity for inter-ministerial coordination, with a committee consisting of the ministers of Health, Economics, Education, Agriculture, Labour, and Planning and an executive coordinator, responsible for the execution of its activities. Shortly after the establishment of CONPAN, however, various obstacles to its functioning became evident. Resources were limited, bureaucratic resistance to its operation grew,

interest group opposition emerged, and rivalries among ministries made the implementation of a comprehensive and complementary nutritional and food policy impossible. As a result, the efforts of CONPAN focused on specific interventions with the purpose of improving the nutritional conditions of the most vulnerable groups, according to age and socio-economic criteria. During the three years it operated, CONPAN was able to implement various programmes. After the organization was shut down, the food and nutrition policy continued to be assessed, especially by INTA at the University of Chile, which established direct links with the government departments involved in policy implementation. These links prospered as a result of credibility and trust based on scientific evidence. In hindsight, CONAPAN’s brief existence was decisive in the development of Chile’s nutritional policy. This organization succeeded in designing methodologies for the solution of various nutritional, health, educational, and sanitary problems, which were later reviewed and improved (Valiente and Uauy 2002).

The 1980 Health Reform In 1980, the Chilean health system underwent a major reform. The National Health Service (SNS) was replaced by the National System of Health Services (Sistema Nacional de Servicios de Salud [SNSS]), consisting of 27 theoretically autonomous services throughout the country, responsible for the population’s health care. Concurrently, a new Municipal Law transferred responsibility for the primary health clinics to the municipalities. In many cases, this reform represented a setback in comprehensive health care. It created a gap in the country’s health care network, making the hospitals dependent on the health services and the clinics reliant on the municipalities, with different reporting lines that were not always adequately coordinated. Despite these hurdles, the preventive health programmes—among them the immunization and PNAC initiatives—remained in place.

Mother and Child Coverage: Pre- and Post-Natal Health Controls

birth. The reduction in childbirth risk produced a drop in neo-natal mortality.

In over fifty years of operation, SNS and, subsequently, SNSS increased their coverage and efficiency. As a result, medical and midwife controls over pregnancy expanded to the point that currently all births take place in hospitals and are assisted by professionals (Szot Meza 2002). Additionally, 97 percent of Chileâ&#x20AC;&#x2122;s children are regularly immunized according to existing programmes. Approximately 80 percent of lactating and pre-school children attend quarterly health controls.

By the 1990s, a decline in the incidence of diarrhoea and the eradication of undernutrition had generated a drop in infant mortality to 20 per thousand live births. High infant mortality resulting from bronchopneumonia, however, persisted. To confront this problem, the health system implemented winter campaigns, including acute respiratory infection wards. This strategy produced a further diminution of infant mortality to 10 per thousand toward the end of the decade (Figure 3).

A Farming Motherâ&#x20AC;&#x2122;s Household Programme (Programa de Hogares de Madres Campesinas) was implemented to increase pregnant womenâ&#x20AC;&#x2122;s health and ensure adequate care during childbirth. In rural maternity wards, 74 housing units were set up for use by pregnant mothers. To ensure access to preventive health care before delivery and avoid subsequent complications, these units were made available to women a few days prior to and up to ten days after child-

Figure 3 Infant mortality in Chile, 1960-2000 (Number per thousand live births)

Source: INE 1960-2000

In summary, the existence of primary health care and nutritional programmes for the more vulnerable age groups (children and pregnant mothers) are the two basic factors explaining the drop in child undernutrition in Chile. Family planning, breastfeeding, healthy child and healthcare controls, vaccination, nutritional education, and PNAC food delivery programmes were implemented through the primary centre infrastructure.

Complementary Feeding Policies

As a result, resource allocation became dependent on yearly Health Ministry budget discussions, producing a decline in programme capacity.

Mother and Child Law The 1938 Mother and Child Law was the first legal instrument concerned with workers’ families. It introduced the delivery of milk from the end of breastfeeding until two years of age. This measured purported to replace the ulpo, a mixture of sugar, water, and wheatbased flour, lacking in basic amino acids and other nutrients, which children were traditionally fed and which was responsible for high child undernutrition levels. The milk delivery strategy stimulated the production of condensed and dehydrated milk to overcome seasonal and regional limitations to the production of fresh milk. Distribution at Worker Insurance clinics was financed through an additional 0.5 percent contribution on salaries. The Worker Insurance agency later replaced sweet condensed milk with powdered, partlyskim milk, which delivered twice the protein and calcium content while maintaining the same level of fat as the condensed product, at the same cost.

National Complementary Feeding Programme (PNAC) The SNS Food Distribution Programme began in 1953. Initially, the programme distributed partly-skim milk in limited amounts. Gradually, however, quantities increased until the entire population was reached in 1970. The link between health care attendance and food delivery proved that in addition to playing a nutritional role, the programme stimulated the operation of the health infrastructure throughout the country. As the quantity of milk distributed in health centres increased, healthy child controls and medical care of children—especially lactating children under two—also rose. Resources allocated to the milk plan increased in 1957, allowing SNS to promote the production of powdered milk among a dozen cooperatives. As a result, programme coverage and the amount of food deliveries rose from 2 million kilograms in 1958 to 8.4 million kg in 1964, 13.4 million in 1966, and 25.5 million in 1974. The 1980s, however, saw a reduction in the monthly amount of food distributed per beneficiary. Together with a significant drop in the birth and fecundity rates which caused a decline in infant population, this reduction produced a decline in food deliveries to nearly 17 million kg per year. In 1987, the National Complementary Feeding Programme (Programa Nacional de Alimentación Complementaria [PNAC]) was established through law, as a universal benefit for all children under six and pregnant women in the country, regardless of their individual situation. The legal provisions obliging the state to allocate resources exclusively to the purchase of milk, which guaranteed the financing of the complementary feeding programmes, were repealed in the 1980s. 60

The beginning of the 1990s saw the introduction of new measures with positive effects on mother-and-child health. Health centres began implementing specific nutritional interventions for extremely poor families having children with retarded growth. In addition to powdered milk with 26 percent fat content, these groups received rice, wheat flour, and oil. The objective of these interventions was to improve the nutritional situation of children and their families, especially among those families having more than five children (Mardones Santander et al. 1986). The product mix has changed since the early 1990s with the purpose of improving nutritional quality and expanding coverage to other specific groups. Since 1999, milk distributed to beneficiaries has been fortified with iron, zinc, copper, and vitamin C. Three new targeted products were incorporated in 2003: Mi Sopita (“My Soup”) for children with nutritional deficit, a formula for premature babies weighing less than 1,500 grams at birth and/or with less than 32 weeks of gestation (Fórmula para Prematuros); and a “Formula without Phenylalanine” (Fórmula sin Fenilalanina) for children with phenylketonuria. Without a doubt, PNAC represents the largest nutritional intervention implemented in Chile, with significant accomplishments in birth weight improvements as well as undernutrition and anaemia prevention, together with an unquestionable contribution to the notable decline in infant and maternal mortality.

Nutritional Education During the Programme’s initial years, milk delivered by PNAC was known as “mute milk,” because distribution was not accompanied by health or education interventions. This deficiency promoted poor use and sale of the product. At subsequent stages, food delivery has been considered part of mother-and-child health controls, with strong emphasis on nutritional status evaluation and food education prioritizing actions based on existing biological and social risk factors. Undernutrition prevention programmes and training in nutritional practices by nutritionists and social assistants were implemented through each health centre at clinics and households. These activities contributed to a drop in the proportion of children with low height from 19 percent in 1970 to 2.9 percent in 2000.

Nutritional Information Systems With the purpose of monitoring the impact of PNAC on the population, in the early 1970s the Consolidated Monthly Registry (Registro Mensual Consolidado [RMC]) was set up. This was a nutritional surveillance system that recorded the nutritional status of 1.2 million children and low-weight pregnant mothers seen at health centres on a monthly basis. At each health centre a real-time information system was implemented to ascertain the nutritional situation of all children under six in each of the countryâ&#x20AC;&#x2122;s regions. Together with clinical information, weight, age, and household data, including address and socio-economic conditions, were entered for each child. This system was validated by the Food and Nutrition Surveillance System (Sistema de Vigilancia Alimentaria y Nutricional [SISVAN]) starting at two health centres in 1977 and, subsequentlyâ&#x20AC;&#x201D;from 1983 to 1987â&#x20AC;&#x201D;at seventy national coverage centres. Additionally, a quarterly low birth weight information system was set up at maternity wards. These initiatives, together with infant mortality information recorded in Chile since 1904, has allowed a very close monitoring of undernutrition reduction in the country and facilitated programme adjustment, including gradual targeting, when necessary (Vio et al. 1992).

Breastfeeding Breastfeeding declined as a result of various socio-cultural factors, including migration to urban areas (the urban population rate was 75 percent in 1970). In 1940, 85 percent of lactating children were breastfed during their first six months of age. By 1974, the proportion had dropped to 19 percent. This change contributed to a rise in early undernutrition. The promotion of breastfeeding thus became an urgent necessity and the means to promote a return to this practice included media (radio, television, and magazines, among others) as well as a reinforcement of education programmes, particularly those devoted to training of health professionals (nurses, midwives, physicians, and others). Subsequently, in the early 1990s, an intensive breastfeeding campaign was launched through pre-natal controls and maternity wards. As a result, exclusive breastfeeding up to six months rose from 16 percent in 1993 to 45.8 percent in 2003 (Atalah et al. 2004). Currently, exclusive breastfeeding rates for the first 90 and 180 days are 78 and 60 percent, respectively.

Undernutrition Recovery Policies The Corporation for Child Nutrition (CONIN) Chile has implemented various undernutrition treatment strategies. The vast majority of undernourished children received ambulatory treatment at primary health centres. The more serious cases— or those presenting social risk factors (insalubrious or crowded homes)—were hospitalized. At hospitals, nutritional recovery was complicated owing to metabolic alterations produced by undernutrition and secondary infections acquired by undernourished children as a result of their immunity problems. Toward the mid-1970s, a seriously undernourished child under one required 2.8 hospitalizations, totalling four hospitalization months. This meant prolonged separations from family and high care costs. In this context, it became necessary to design alternate strategies for comprehensive treatment of undernutrition, psychomotor development stimulation, a reduction in the number of relapses, family integration in the recovery process, and cost reduction. After corroborating the success of a closed recovery centre exclusively for undernourished children, in 1976 a group of academics at the University of Chile’s Nutrition and Food Technology Institute (INTA) created the Corporation for Child Nutrition (Corporación para la Nutrición Infantil [CONIN]) as a network of recovery facilities for children affected by undernutrition.

The 33 CONIN centres built throughout the country in the late 1970s added 1,660 hospital beds to treat undernourished children in Chile. Financing came from private donations, with the Ministry of Health providing funding to cover the larger portion of operating costs (Monckeberg and Riumallo 1983, 1989-99). Each CONIN centre was under the direction of a paediatrician and a multidisciplinary team (a nutritionist, a university nurse, nurse auxiliaries, a pre-school teacher, a social worker, and an administrator) supported by community volunteers. The recovery centre system was integrated to the country’s sanitary structure. This facilitated the quick transfer to CONIN locations of children assessed at primary care clinics and hospitals. The average hospitalization period was three months. In addition to feeding, during hospitalization children received physical therapy and psycho-sensorial and affective stimulation. Additionally, mothers participated actively in treatments, learned feeding and care techniques, and joined family planning programmes. Over a 16-year period (1976-2002), 85 thousand children affected by moderate and severe undernutrition recovered at CONIN centres. The mortality rate of less than 2 percent at CONIN facilities was 26 percentage points below the rate at hospitals. Only 1 percent of children treated at CONIN centres required re-hospitalization. Daily treatment costs were 80 percent less than at hospitals (US$10 at closed CONIN centres vs. US$52 at hospitals) (Monckeberg 2003). As indicated in Table 2, follow-up showed that CONIN interventions were successful, with stable results (Table 2).

Table 2 Follow-up of 7,400 Undernourished Children Who Recovered at CONIN centres Chile, 1976-2002 Weight-Age Height-Age Weight-Height Development Quotient Age X± DE X ± DE X± DE X ± DE Release from 80,3 ± 8,0 89,6 ± 3,5 95,8 ± 1 0,9 79,1 ± 12,0 CONIN At 1 month 84,2 ± 9,2 90,0 ± 3,5 95,5 ± 11,0 88,6 ± 14,0 At 6 months

85,8 ± 10,9

90,8 ± 4,3

92,8 ± 11,5

89,6 ± 11,0

At 12 months

85,9 ± 10,0

91,6 ± 4,1

90,0 ± 10,9

95,3 ± 12,0

At 24 months

85,6 ± 10,1

91,4 ± 4,1

95,8 ± 11,3

98,5 ± 6,0

Source: Data provided by the Corporación para la Nutrición Infantil (CONIN)

Family Placement Programme for Undernourished Children (COFADE) Another form of treatment, created in 1983, was the Family Placement Programme for Undernourished Children (Colocación Familiar del Desnutrido [COFADE]). This Programme was geared toward children under two with moderate and severe protein-caloric undernutrition in cases in which ambulatory treatment had not produced good results or was impossible owing to inadequate family circumstances. Children admitted to this Programme lived three or four months with a specially-trained family in their own neighbourhoods. During this time, children could be regularly visited by their parents, who received direct training from the caretaking family. To improve family conditions, during this period social work was also carried out at the child’s original household.

Forty families providing care for fifty children per period worked in the Programme. An assessment of 291 children treated through COFADE revealed that only 10 percent had normal height per weight (h/w) when they entered the Programme. H/w had become normal in 83 percent of the cases at the time of release. Similarly, psychomotor development improved from a normality rate of 26 percent at entry to 83 percent at release (see Table 3). The Ministry of Health provided 60 percent of the Programme’s funding; the remaining 40 percent was provided by participating municipalities (Puentes et al. 1984).

Table 3 Follow-up of Undernourished Children Who Recovered through the COFADE Programme Variable

Entrance %

Release %

Age-Weight Relationship ≤ -2 SD

80,3 ± 8,0

89,6 ± 3,5

Height-Weight Relationship < -2 SD

84,2 ± 9,2

90,0 ± 3,5

Psychomotor Developmental Delay

85,8 ± 10,9

90,8 ± 4,3

Normal Psychomotor Development

85,9 ± 10,0

91,6 ± 4,1

Stable Job for Head of Household

85,6 ± 10,1

91,4 ± 4,1

17,0

64,0

Satisfactory Training of Head of Household Source: Escudero 1987.

Educational Policies National Scholarships Board (JUNAEB) Programmes Nutritional support for schoolchildren as a vulnerable group evolved from the 1930s to the 1960s. The municipal laws of the 1930s determined that municipalities should allocate 1 percent of their budgets to provide such support. In the 1960s, the law creating the National Scholarships Board (Junta Nacional de Auxilio Escolar y Becas [JUNAEB]) emphasized the need to control school desertions, stimulate regular attendance, and improve class attention and performance. Elementary instruction became obligatory in 1920, during the administration of President Juan Luis Sanfuentes. Eight years later, President Carlos Ibáñez del Campo created the Office for Elementary Education and the Community School Support Boards. These Boards became responsible for promoting and organizing school feeding and other support services for children attending public schools. In 1964, President Jorge Alessandri Rodríguez created JUNAEB. At the time, Chile had a population of eight million, of which one million were illiterate. Since its creation, JUNAEB has put together a National Student Support Network with the objective of neutralizing the negative influence of bio-psychosocial and economic factors on school performance and promoting the human development of Chilean children and youth. JUNAEB runs the School Feeding Programme (Programa de Alimentación Escolar [PAE]). The objective of PAE is to distribute daily complementary and differentiated school rations to vulnerable students at the pre-school, elementary school, middle school, and university levels throughout the academic year, with the purpose of improving attendance and preventing desertion. Rations are determined according to the needs of students of municipal and state-assisted private schools. Currently, PAE distributes 1.42 million breakfasts and 860 thousand lunches per day in four thousand schools throughout the country. PAE has also incorporated a health component, including preventive dentistry.

National Education and Social Development Foundation (INTEGRA) Programmes The National Foundation for Community Support (Fundación Nacional de Ayuda a la Comunidad [FUNACO]) was set up in 1974 to run children’s canteens created to contain child malnutrition. Of all children attending the canteens, 20.1 percent revealed some level of undernutrition, compared to the national undernutrition rate of 16 percent. The canteens distributed breakfasts, lunches, and snacks, as well as an extra meal for undernourished children. The calorie and nutrient contribution of the meals varied. On average, however, it satisfied between 70 and 80 percent of the children’s needs.

FUNACO was renamed the National Education and Social Development Foundation (Fundación Nacional de Educación y Desarrollo Social [INTEGRA]) and restructured in 1990. The change to INTEGRA represented a transformation of FUNACO from a charitable to an educational organization, requiring the professionalization of its services through staff training and the recruitment of a large number of educators. As a result, the old Open Centres gave way to the INTEGRA Foundation Pre-Schools. INTEGRA provides pre-school education to children between three months and four years of age living in poverty and socially vulnerable conditions. Children have access to a feeding programme designed in accordance with the nutritional needs of their respective age groups. The organization has offices and technical teams to supervise the education given at pre-schools and nurseries in each of the country’s regions. Currently, the foundation has 1,031 facilities serving nearly 75 thousand children. Of this total, 14,245 are lactating and 60,667 are preschoolers. An estimated 92.5 percent come from the country’s 40 percent poorest households. Most of INTEGRA’s facilities (95 percent) are located in the country’s poorest communities. INTEGRA’s curriculum incorporates specific materials to provide instruction in feeding, nutrition, and health practices leading to self-care and the formation of healthy habits. INTEGRA’s food programme provides between 60 and 75 percent of the calories and 100 percent of the protein needed by children on a daily basis. Staff receive educational material, in module format, for training in food and nutrition issues. The foundation also prepares parental guides for appropriate feeding of pre-school populations. Children presenting some type of deficit malnutrition—undernutrition or risk of undernutrition—receive at INTEGRA a caloric supplement of 100 calories, which is added to their regular rations. Staff follow up on intake, so as to guarantee appropriate consumption levels and inform families of dietary modifications and daily consumption levels at INTEGRA centres. The purpose of conveying this information is to ensure that families provide food reinforcements at home, as needed. Families are also encouraged to enrol children in extended programmes, thus allowing them access to a larger caloric intake. In the case of children presenting malnutrition due to overweight, INTEGRA coordinates with families to determine the appropriate rations to be distributed at the centre, to avoid duplicity in consumption. Parents and guardians are invited to observe the rations served so they can better ascertain the appropriate variety and quantity of food their children should receive.

Data on the nutritional situation of children receiving assistance at the INTEGRA Foundation are available since 1994. Nutritional indicators and reference standards used coincide with those provided by the Ministry of Health. Statistics are in line with the national tendency toward a drop in the prevalence of deficit malnutrition up to 1999. INTEGRA figures, however, are higher than national data and stagnate beginning in 2002. Although the age of beneficiaries is not strictly comparable, indicators of overweight malnutrition have remained at high levels during the period, surpassing the national data (Ministerio de Salud 2007).

Chart 4 Nutritional Status of Preschoolers Enrolled in the INTEGRA Foundation (According to Weight/Height) Chile 1994-2007 Year

Weight Deficit: Weight-Height < - 1 SD %

Normal %

Overweight: Weight â&#x20AC;&#x201C; Height > 1 SD %

1994

4,2

56,5

39,2

1995

2,8

57,2

40,0

1996

3,2

57,2

38,9

1997

4,1

55,9

40,0

1998

3,6

57,8

38,6

1999

3,6

57,3

39,1

2000

4,0

57,9

38,2

2001

4,8

57,7

37,5

2002

5,7

58,1

35,8

2003

5,7

59,1

34,2

2004

5,6

58,6

35,8

2005

5,3

58,8

35,9

2006

5,2

57,7

37,1

2007

5,5

58,3

36,2

Source: Data provided by the INTEGRA Foundation.

National Pre-School Board (JUNJI) Programmes The National Pre-School Board (Junta Nacional de Jardines Infantiles [JUNJI]) was established in 1970 as a de-centralized entity responsible for the creation, operation, and oversight of the country’s pre-schools. It provides care to children under six, giving priority to the poorer social segments. Its services comprise nutrition and feeding, learning, and affective environments in direct relation with family settings and the bio-psychosocial dimension. Child care is provided by pre-school educators and technicians, with the advice and supervision of nutritionists and social workers. JUNJI Programmes serve approximately 120,000 children. Of this total, nearly 25 percent are lactating children, a rising proportion (JUNJI 2002-2007). The majority of these children receive full-day care; a minority receives half-day care five days a week. Programmes benefit working mothers, especially those who are household heads. Selection criteria include poverty or social vulnerability conditions and nutritional deficit, as indicated by weight per height. JUNJI feeding programmes seek to satisfy the energy and nutrient needs required during a pre-school child’s growth period through healthy feeding; good feeding, hygiene, and health habit formation in children and their families; physical activity appropriate to the child’s development stage; recovery of children presenting nutritional alterations; and reduction of food insecurity among low-income families, thus contributing to the eradication of poverty. Additionally, JUNJI has specific programmes seeking to improve the nutritional and development situation of children exhibiting deficit in these areas (the Nutritional Intervention and Language Stimulation Centres [Centros de Intervención Nutricional y de Estimulación del Lenguaje, CADEL]). Since its inception, JUNJI has considered the family as the fundamental axis in the educational process of children. In this context, it has created opportunities for family participation in pre-schools and provided training in rearing, to ensure children are well cared for within their homes and to reinforce lessons acquired in the educational centres. Anthropometric data on JUNJI beneficiaries are available from 1988 to 1992 and from 1996 to 2005, after the establishment of the JUNJI information system. These data permit an assessment of the nutritional situation of JUNJI beneficiaries (JUNJI 1996-2005). Figure 4 shows the evolution of the nutritional deficit. A cut point of -1 standard deviation was utilized with the purpose of enhancing sensitivity to change. As can be observed, the values per height since 1999 are within the expected range, confirming an improvement in height. On the other hand, the fact that both weight per age and weight per height are below the expected range can be associated with an increase in overweight and obesity.

Figure 4 Prevalence of Deficits in Height-Age, Weight-Age, and Weight-Height <- 1 SD (%) Chile, 1988-2005

Source: Data provided by the National Pre-School Board (JUNJI).

Studies of low weight/height among undernourished children and children at risk of becoming undernourished have been conducted to assess the recovery capacity of JUNJI programmes. Findings indicate that nearly 70 percent of children at risk of becoming undernourished, in addition to a slightly lower percentage of undernourished children, recover within a year after starting the intervention.

Sanitation Policies Basic sanitation of households and the environment is an essential requirement for good health in general, especially children’s health. Adequate sanitation at homes entails access to potable water in sufficient quantity as well as sewage systems. The treatment of sewage also contributes to maintaining a clean environment, a factor directly related to human health. Adequate environmental sanitation helps prevent child undernutrition. Precarious environmental conditions affect children, particularly during their first years. Water pollution produces diseases which are often lethal for children. The lack of sewage systems contaminates the environment and facilitates the dissemination of germs and disease. Under circumstances such as these it is common for children to suffer episodes of acute diarrhoea which contribute to, or intensify, undernutrition, potentially leading to death.

Sanitation Policies and Institutions Improving the sanitary conditions of the entire population was an early concern in Chile. The nineteenth century saw the emergence of the first public sanitary initiatives (Szczaranski, 2006). The first step towards the development of an institutionalized sanitary policy materialized in 1931 through the creation of the Office of Potable Water and Sewage at the Ministry of the Interior. In 1953, the fusion of this office with the Hydraulic Department of the Ministry of Public 67

Works gave rise to the Office of Sanitary Works, responsible for designing, building, and managing potable water and sewage services with state resources throughout the country. Alongside the Office of Sanitary Works, two other state organizations involved in sanitation operated between 1953 and 1977. These were the Sanitary Services Division of the Ministry of Housing and Urban Planning, responsible for designing and building potable water and sewage networks; the Potable Water Company of Santiago (a dependency of the Municipality of Santiago), which administered the capital city’s potable water services; and the Municipal Sewage Company of Valparaíso and Viña del Mar (a dependency of the Municipality of Valparaíso). With the purpose of consolidating all sanitary entities within the state, the National Sanitary Works Service (Servicio Nacional de Obras Sanitarias [SENDOS]) was created in 1977. SENDOS acquired responsibility for operating and maintaining all sanitary systems in the country’s urban and rural areas. Towards the end of the 1980s the need for large investments in the sector, particularly in sewerage infrastructure, became apparent, together with the convenience of allowing the incorporation of private funding into the system. A decision was made to focus the public sector on regulatory and oversight matters, and to assign service provision and administration to the private sector.

As a result of these decisions, the Sanitary Services Superintendence (Superintendencia de Servicios Sanitarios [SISS]) was created in the late 1980s, with the purpose of regulating and overseeing sanitary service providers. Simultaneously, private corporations assumed the provision of sanitary services in each of the country’s regions, a process which facilitated the entry of private capital into the sector. This regulatory framework allowed the emergence of sanitary services concessionaires, private corporations under SISS oversight, responsible for providing potable water and sewage services in urban areas. At September 2005, approximately 95 percent of the sanitary services in urban areas were being provided by private concessionaires. The public sector has always had responsibility for the construction of sanitary infrastructure in rural localities, specifically through various agencies connected to the Ministry of Public Works. Since the creation of the Office of Sanitary Works (DOS) in 1957, the state has invested strongly in water and sewage infrastructure. As a result of this policy, potable water coverage in urban areas rose from 53.5 percent in 1965 to 85.6 percent in 1977. During this time period, sewage coverage in urban areas increased from 25.4 to 55.9 percent (Figure 5).

Figure 5 Potable Water and Sewage Coverage in Urban Areas (%) Chile, 1965-2005

Potable water coverage Sewage coverage

Source: Data provided by the Sanitary Services Superintendence (SISS) (www.siss.cl).

During the 1990s and the early years of the twenty-first century, the state approached the treatment of sewage as a priority area within its sanitation policy. The incorporation of private actors into the sanitary sector facilitated this approach, particularly through important private investments in sewerage facilities. The result was a speedy rise in sewage treatment coverage throughout the country, from 8 percent in 1989 to 84.3 percent in 2006 (Figure 6).

Figure 6: Sewage Treatment Coverage at the National Level (%) Chile, 1989-2006

Source: Data provided by the Sanitary Services Superintendence (SISS) (www.siss.cl).

In rural areas, it is estimated that only 6 percent of the population had access to potable water in 1960, a factor that obviously contributed to high mortality and morbidity, especially among children. Public projects carried out since then have generated important increases in coverage. Between 1990 and 2006, access to potable water through the public network increased from 35.6 to 53.4 percent of total rural households. Likewise, over the same period the proportion of rural households connected to sewage or septic tanks rose from 19 to 54.7 percent.

CONCLUSIONS AND POLICY RECOMMENDATIONS The last fifty years have seen a gradual improvement in the health and nutritional conditions of Chilean mothers and children. During this period, economic policy changed significantly, from a centrally planned to a free market, internationally-oriented economy. Additionally, two severe economic crises hit the country, in 1975 and 1982. Despite these developments, the country’s biomedical indicators continued to improve and undernutrition kept declining. Several factors combining synergistically contribute to explain Chile’s favourable performance in combating child undernutrition. The central element in achieving this result, however, was the existence of a state policy to eradicate child undernutrition, which was sustainably applied over four decades, without regard to the country’s political and economic changes. To a large extent, this result was due to the technical consensus achieved in Chile on undernutrition and the more adequate programmes to face it. Specifically, the following factors contributed to Chile’s achievements: • Broad primary health coverage, incorporating pre- and post-natal as well as healthy child controls by health professionals; • Implementation of complementary feeding programmes with national coverage (PNAC) as well as targeted initiatives (targeted PNAC, JUNJI, INTEGRA, JUNAEB); • Creation of recovery programmes for undernourished children (CONIN, COFADE) and integration of these initiatives with the health system; • A decline in birth rates resulting from the implementation of family planning programmes since the 1960s; • Education of mothers, as a result of literacy campaigns launched in the 1940s; • High potable water and basic sanitation coverage since the 1960s; Additionally, other elements facilitated the success of these policies, among them the following: • Continuity in programme implementation; • Stability in the institutional framework of programmes; • Human resources development in the field of undernutrition; • Existence of nutritional surveillance systems; • Research and knowledge development in nutrition; • Participation of health professionals and the scientific community in political decision making; • Active community participation in health services demand and complementary feeding programmes;

In the long term, the eradication and prevention of undernutrition require improving a population’s living conditions. The Chilean experience shows that in addition to seeking socio-economic development, it is vital to implement policy actions in health, nutrition, education, and environmental sanitation. Activities in these areas create synergies to improve living conditions, especially among more vulnerable and low income groups. Every strategy aspiring to alleviate child undernutrition should consider specific initiatives in each of these four areas, coordinating sectoral actions in a cross-sectoral approach avoiding programme overlap and inefficiencies in resource utilization. The Chilean experience shows that it is possible to work jointly in these four areas by: • Educating mothers to ensure that, at a minimum, they complete elementary education; • Providing potable water and basic sanitation to a large majority of the population; • Establishing regular controls for pregnant women and children under six, providing family planning information, immunizations, education, and psychomotor stimulation by professional personnel; • Treating the more frequent diseases at primary health centres; • Providing complementary feeding, especially at the end of the breastfeeding period; • Establishing adequate nutritional surveillance systems; • Creating ambulatory or closed-centre recovery programmes for undernourished children; • Developing qualified human resources in primary health care and nutrition; • Engaging the academic and technical sectors in public policy formulation to provide a scientific basis and continuity for programmes; • Empowering the community within health and nutrition programmes; • Institutionalizing programmes adequately to support implementation; • Providing a legal framework as well as juridical and financial support to the organizations responsible for the programmes.

REFERENCES Albala C, Vio F, Kain J, Uauy R. 2001. “Nutrition Transition in Chile: Determinants and Consequences” Public Health Nutrition 5: 1-7. Atalah E, Castillo C, Reyes C. 2004. “Efectividad de un programa nacional de fomento de la lactancia materna en Chile.” Archivos Latinoamericanos de Nutrición 54: 374-9. Crovetto M. 2002. “Cambios en la estructura y consumo de alimentos en hogares del Gran Santiago 1988-1997.” Revista Chilena de Nutrición 29: 24-32. Escudero PA, Puentes RR, Araos F V, Contreras AMD, Latorre, M. 1987. “El hogar sustituto como sistema de recuperación integral en lactantes desnutridos y graves.” Revista Chilena de Pediatría 58: 414-418. Hertrampf E, Cortés F, Cayazzo M, Erickson D, et al. 2003. “Consumption of Folic Acid-Fortified Bread Improves Folate Status in Women of Reproductive Age in Chile.” Journal of Nutrition 133: 3166-3169. Instituto Nacional de Estadísticas de Chile (INE).

1960-2000. Anuarios. Santiago de Chile: INE.

Junta Nacional de Jardines Infantiles de Chile (JUNJI). 1996-2005. “Sistema Informático de la Gestión del Párvulo” (GESPARVU). Santiago de Chile: JUNJI. 2002-2007. “Informe Estadístico Mensual.” Santiago de Chile: JUNJI, Departamento de Informática y Planificación. Kain J, Vio F, Albala C. 1998. “Childhood Nutrition in Chile: From Deficit to Excess.” Nutrition Research 18: 1825-1835. 2003. “Obesity Trends and Determinant Factors in Latin America.” Cadernos de Saúde Pública 19: S77-S86 (Suppl. 1). Kaempfer RA, Medina E. 1982. “La salud infantil en Chile durante la década del setenta.” Revista Chilena de Pediatría 53: 468-470. Leiva L, Burrows R, Muzzo S. 1992. “Calcium Intake of School Age Children Aged 10 to 14 Years Old.” Revista Chilena de Nutrición 20: 207-211. Lewin L, Puentes R, Saavedra R et al. 1989. “Programa Colocación Familiar en Niños Desnutridos (COFADE).” Revista Chilena de Nutrición 17 (Suplemento Nº 1): 65-76. Mardones Restat, F. 2003. “Políticas de alimentación y nutrición en planes de salud en Chile.” Revista Chilena de Nutrición 30: S195-S197. Mardones Santander F, González N, Mardones Restat F, Salinas J, Albala C. 1986. “Programa Nacional de Alimentación Complementaria en Chile en el período 1937-1982.” Revista Chilena de Nutrición 14: 173-182. Mariño R, Villa A, Guerrero S. 1999. “Milk Fluoridation Programme in Codigua, Chile: An Evaluation after Three Years.” Revista Panamericana de Salud Pública 6: 117-121. Ministerio de Salud de Chile. 2000. Informe Anual. Santiago de Chile: Ministerio de Salud. 2007. Estadísticas de salud. Santiago de Chile: Ministerio de Salud, Departamento de Estadísticas e Información de Salud. Monckeberg F. 2003. “Prevención de la desnutrición en Chile: experiencia vivida por un actor y espectador.” Revista Chilena de Nutrición 30: 160S-176S. Monckeberg F, Riumallo J. 1983. “Nutrition Recovery Centers: The Chilean Experience.” In Underwood B, ed., Nutrition Intervention Strategies in National Development. New York: Academic Press.

Monteiro CA, Conde WL, Popkin BM. 2002. “Is Obesity Replacing or Adding to Undernutrition? Evidence from Different Social Classes in Brazil.” Public Health Nutrition 5:105-112. Monteiro CA, Moura EC, Conde WL, Popkin BM. 2004. “Socioeconomic Status and Obesity in Adult Population of Developing Countries: A Review.” Bulletin of the World Health Organization 82: 940-946. Muzzo S, ed. 1996. “Normal and Pathological Bone Mineralization.” Revista Médica de Chile Supplement (8). Pelletier D, Frongillo E, Schroeder DG, Habitcht J-P. 1994. “A Methodology for Estimating the Contribution of Malnutrition to Child Mortality in Developing Countries.” Journal of Nutrition 124: 2106S-2122S. Peña M, Bacallao J, eds. 2000. Obesity and Poverty: A New Public Health Challenge. Washington: D.C.: Pan-American Health Organization Scientific Publication Nº 576. Popkin BM. 1994. “The Nutrition Transition in Low Income Countries: An Emerging Crisis.” Nutrition Reviews 52: 285-298. Pretell EA, Delange F, Hpsatalek V, Coriglianp S et al. 2004. “Iodine Nutrition Improves in Latin America.” Thyroid 14(8): 590-599. Puentes R, Escudero P, Solari M et al. 1984. “Colocación familiar de niños desnutridos severos (COFADE).” Revista Chilena de Nutrición 12: 133-137. Szot Meza J. 2002. “Reseña de la salud pública materno-infantil chilena durante los últimos 40 años: 1960-2000.” Revista Chilena de Obstetricia y Ginecología 67: 129-135. Tokman V. 1985. “Wages and Employment in International Recessions: Recent Latin American Experience.” In Kim KS, Ruccio DF, eds., Debt and Development in Latin America. Notre Dame, IN: University of Notre Dame Press. Uauy R, Kain J. 2002. “The Epidemiological Transition: Need to Incorporate Obesity Prevention into Nutrition Programmes.”· Public Health Nutrition 5: 223-229. Uauy R, Vio F. 2007. “Health and Nutrition Transition in Developing Countries: The Case of Chile.” In Kennedy E, Deckelbaum R, eds., The Nation’s Nutrition. Washington, D.C.: International Life Sciences Institute. Valiente S, Uauy R. 2002. “Evolución de la nutrición y alimentación en Chile en el siglo XX.” Revista Chilena de Nutrición 29: 54-61. Vio F, Albala C, Kain J. 2008. “Nutrition Transition in Chile Revisited: Mid-term Evaluation of Obesity Goals for the Period 2000-2010.” Public Health Nutrition 11(04): 405-412. Vio F, Kain J, Gray E. 1992. “Nutritional Surveillance: The Case of Chile.” Nutrition Research 12: 321-330. Winter EA, Amenázar RE, Molina, R. 1950. “Medicina preventiva materno infantil.” Revista Chilena de Pediatría 21: 450-457.

STATISTICAL ANNEX

Year

Table A-1 Infant Mortality, Child Undernutrition, and Low Birth Weight Chile, 1975-1993 (%) Rate of Infant Mortality Children under Six with Birth weight <2500 grams (%) (per 1000 live births) Weight-Age < - SD (%)

1975 1976 1977

55,4 54,0 47,5

15,5 15,9 14,9

11,6 11,4 10,9

1978

38,7

13,0

9,1

1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993

36,6 31,8 27,2 23,4 21,8 20,0 19,7 19,1 18,7 18,8 17,1 16,0 14,6 14,3 14,0

12,2 11,5 9,8 8,8 9,8 8,4 8,7 9,1 8,8 8,6 8,2 7,4 6,9 6,2 5,3*

9,0 8,6 7,8 6,9 6,5 6,5 7,0 6,6 6,5 6,4 6,3 5,7 5,6 5,5 5,3

* SempĂŠ Reference. In 1994, the reference was changed by WHO, interrupting the statistical series. Source: Data provided by the Ministry of Health of Chile.

Year

Table A-2 Number of Deaths in Children under One Due to Respiratory Diseases and Diarrhoea Chile, 1960-2000 Respiratory Diseases N Diarrhoea and Related Illnesses n

1960 1970 1980

4.318 2.793 502

1.365 1.476 210

1990

161

2000

Source: Ministerio de Salud 2000.

Table A-3 Socio-demographic and Maternal-Child Health Indicators Chile, 2006 Indicator

Country

Range in Regions

Urban population %

86,6

66,4 – 98,0

Unemployment rate %

7,0

2,4 – 9,8

Population below the poverty line %

14,0

6,4 – 20,9

Income Inequality Gap (5th Quintile / 1st Quintile)

13,1

7,2 – 16,2

Birth rate x 1,000 inhabitants

14,9

14,1 – 17,7

Newborns < 2.500 grams %

5,5

3,9 – 6,4

Newborns to mothers < de 20 years old %

15,7

14,9 – 20,1

Maternal mortality x 100,000 newborns

19,8

0,0 – 50,0

Neonatal mortality x 1000 newborns

5,2

3,7 – 7,0

Post neonatal mortality x 1000 newborns

2,7

0,9 – 3,3

Infant mortality x 1000 newborns

7,9

5,5 – 10,4

Source: Data provided by the National Institute of Statistics (INE) and the Ministry of Health of Chile.

Table A-4 Nutritional Status of the Population Chile, 2007 Indicator

Country

Range in Regions

Undernutrition

0,4

0,1 – 0,4

At risk nutritionally

2,3

1,0 – 3,6

Obesity

9,7

5,8 – 10,9

Chronic undernutrition

3,1

2,1 – 5,0

Obesity

19,4

16,3 – 26,2

Underweight

7,5

4,4 – 11,1

Obesity

20,0

16,9 – 25,3

Underweight

9,2

3,6 – 13,1

Obesity

23,3

17,5 – 37,2

Under Six

School-Age

Pregnant Women

Older Adults

Source: Data provided by the Ministry of Health of Chile.

Chapter 2 THE CHILEAN EXPERIENCE IN THE ERADICATION OF CHILD Monckeberg F. Prevención de la desnutrición en Chile. Rev Chil Nutr 2003; 30 (Suplemento Nº 1): 160-176. UNDERNUTRITION: A COMPREHENSIVE VISION Lewin L, Puentes R, Saavedra R et al. Programa Colocación Familiar en Niños Desnutridos (COFADE). Rev Chil Nutr 1989; 17 (Suplemento Nº 1):65-76.

SUMMARY Among the papers examining the Chilean experience against undernutrition presented at the Regional Ministerial Conference “Towards the Eradication of Child Undernutrition in Latin America and the Caribbean,” two are included in this chapter: those of María Soledad Barría, Minister of Health and Eduardo Abedrapo Bustos, Under-Secretary of Planning and Cooperation of Chile. The piece by Minister Barría explains how the Chilean State focused on guaranteeing access to health services, through primary care and a network of health centres. Among the lessons learned in Chile, the Minister first mentions the construction of a State healthcare network, major milestones of which were the establishment of the National Health Service in 1952 and the reform of the system in 2005. Other aspects worth mentioning include the emphasis on social wellbeing and free basic services; the availability of food, education, and nutrition services and resources in both rural and urban areas; the linkage of food and nutrition programmes with health and child development state initiatives; and community empowerment with regard to health rights. A distinguishing trait of the Chilean case is the political will demonstrated by leaders of all political persuasions with respect to the definition of social priorities and in meeting basic needs. Some of the features the Chilean model offers the region in the fight to eradicate child undernutrition include public policies with focused interventions and continued financing and administration; the participation of public health and nutrition specialists in diagnosing nutritional problems and designing strategies to address and evaluate them; and academic support in training nutritional professionals. Under-Secretary Abedrapo explains how child undernutrition came under control in Chile. This public health problem was addressed “as an issue of State” and has remained as such over time, “regardless of government changes.” Adequate institutionalization based on “laws, adequately articulated public and private organizations, and sustained programmes and policies” contributed to the success in the fight to reduce undernutrition. A multisectoral focus and information gathering, through studies and scientific knowledge, are crucial elements in the Chilean experience. According to Under-Secretary Abedrapo, “the quantity and quality of information we have been able to gather, obtained in primary healthcare centres as well as in more complex facilities, has been especially important in decision making and redesigning policies and programmes in this area.” After achieving the planned goals, the current public health challenge is not to neglect or reverse accomplishments. The Planning Under-Secretary concludes with a call to solidarity and activism by international organizations “to prevent the food crisis occurring in many areas from becoming a new factor of exclusion, poverty, and hunger, especially in Africa, Latin America, and the Caribbean.”

The health sector’s strategy in the fight against child undernutrition María Soledad Barría Minister of Health of Chile

According to this framework of social determinants, social structures, individual status, the socioeconomic position and ethnicity of affected groups, gender inequality, and livelihoods, work, and environmental conditions all help shape the situation. Health, then, ends up being a consequence of social policies in our countries that must be addressed. The social and economic costs of undernutrition have been more broadly analyzed in another chapter.1 Undernutrition is an ethical, social, and economic problem that affects the whole of society, and causes 50 to 60 percent of infant mortality and 61 percent of deaths from diarrhoea. In the majority of deaths caused by pneumonia, undernutrition is also an underlying factor. Low birth weight increases infant mortality 14 times, raises grade repetition by 65 percent, and reduces workforce productivity. In other words, undernutrition does not only impact in terms of money or economic resources, but also developmental capacity, illnesses, and deaths related to undernutrition. In addressing undernutrition we are simultaneously reducing maternal and child mortality. A study by the Economic Commission for Latin America and the Caribbean (ECLAC) shows how the cost impact of global undernutrition in children under five has a direct relationship to countries’ Gross Domestic Product (GDP). For a long time it has been said that we must develop countries and then dedicate ourselves to achieving good nutrition. We think these problems must be conjointly addressed, because development will be very difficult in our countries without addressing the theme of nutrition. If not addressed together, a great deal of resources will be spent on obtaining the final effects, without addressing their underlying causes, of which undernutrition is but one. We can continue to fill the hospitals to treat diarrhoea, but we must also immediately address the theme of nutrition to reduce the occurrence of diarrhoea. In Chile we have been able to significantly reduce child and maternal mortality. In only 1960—not that long ago—38 percent of our children were undernourished and we had an infant mortality rate of 120 per thousand live births. Today, we are proud to have a chronic malnutrition rate of only 1.3 percent and an infant mortality rate of 7.3 per thousand live births. These achievements were possible in forty years. Our work towards these results had to do with underlying causes, not just diseases and their final repercussions. 1

r’s note: See, in this regard, the report by Rodrigo Martinez, “The Social and Economic Impact of Child Undernutrition” in Chapter 1, Part III of this volume.

María Soledad Barría

In more modern language, from the point of view of the World Health Organization (WHO), we are talking about the social determinants of health. In other words, we are talking about how a series of social and cultural elements and inequalities come together to minimize development capacity and translate into illnesses or related conditions such as undernutrition.

Minister of Health of Chile

Undernutrition is a scourge that, in the health sector, is classically related to increases in mortality, illness, developmental delays, and other diseases. All of these, however, are consequences. If we want to seriously address and solve the undernutrition problem, we must look for its underlying causes and analyze the problem more comprehensively.

In 1975, a year in which we still had an undernutrition rate of 12 percent, we changed the patterns of measurement, always looking for greater accuracy in measurements consistent with advances in knowledge and research. Recently, in January 2007, we adopted the new WHO scheme, developed on the basis of the experiences of children growing up in various countries throughout the world under optimal living conditions: healthy, non-smoking mothers, exclusive breastfeeding, and healthy and secure environments. Is it possible to reduce or eradicate child undernutrition? In our view it is. Our history shows that even in periods when we fell behind in economic development and poverty, we were able to maintain reductions in undernutrition and infant mortality. That is to say, there are some elements that go beyond growth and development. Although it is easier to achieve progress through economic growth, we think it is possible to improve health and nutrition even in the absence of substantial progress in the economic realm. This requires 80

progress in rural and urban areas that translatesâ&#x20AC;&#x201D;and this may be the keyâ&#x20AC;&#x201D;into access to and availability of health, food, and education services and resources. This is not only a health theme. Since the 1920s, nutrition has been a concern among Chileâ&#x20AC;&#x2122;s physicians, legislators, and other social actors. Dr. Francisco Mardones Restat, a great pioneer in the public policy development to combat undernutrition, told me that in the 1930s, the first women members of Congress were key in positioning the issue and searching for appropriate measures. However, an effective system was only organized when the National Health Service was established in 1952. There had been multiple previous initiatives and complementary feeding for many years prior, but never had there been such a massive organization of services across the entire country, through which food was delivered together with sanitation. In our country, feeding is part of the services of primary care, at the first level of attention; a prioritization that was later ratified during the International Conference of Primary Healthcare in Alma Ata (1978).

tive. They monitor children’s height and weight, undertake a comprehensive nutritional survey, implement vaccination programmes, and deliver food from the National Complementary Feeding Programme (PNAC). This system includes all children under six and, as well, all pregnant women. PNAC has not been left out of health controls; rather it is profoundly linked with these services. Food is distributed across the country, in all localities and principally by the paramedic personnel. Health services are oriented around community education, preventive controls, vaccinations, and the delivery of food to select groups. The same model has been used for pregnant women, with success in achieving a high level of prenatal coverage. In this way we can distinguish pregnant women with normal weight from those who run the risk of undernutrition or are undernourished, and have determined specific policies for the different groups. The same approach is used for children under six, with a focus on the overall life cycle. Changes have been required starting this decade, as a result of our large problem with overweight malnutrition. Ensuring adequate weight is one of the focie of every traditional nutritional policy. Simultaneously, we have witnessed an increase in chronic non-infectious diseases associated with an increase in life expectancy. Our average life expectancy is now 78 years and, of course, we have different illnesses. What are other relevant elements in combating undernutrition? One of them is the promotion of breastfeeding which, with economic development and inadequate health policies, was decreasing. In the 1990s we only had 15 percent of exclusive breastfeeding through the sixth month of life, but we have been able to reverse this trend. Today we have 57 percent of breastfeeding, which is a protective factor against child undernutrition and adult obesity.

In the 1950s, the country was divided into geographic areas with defined populations. In each territory a health structure was put in place to care for those populations with outpatient centres and hospitals, reaching communities even in the most rural areas. The rural population was cared for through small health outposts that were then called—as they still are today— “rural health posts.” These posts house community health workers who today, progressively, with better education and training, are paramedical technicians. The posts were constructed—and are still constructed today—with a residential area and a separate space for providing care to the public. Community agents are also concerned with basic sanitation in the homes under their care, potable water, whether it exists or not, and education on boiling untreated water. They participate in what we call healthy child visits, that is, systematic controls not done by doctors, but by nurses or technicians with regularity and a clear objec-

For a long time we had cases of severe undernutrition, cases that were difficult to address only through community work. Specially created establishments to deal with these cases were very important. Dr. Fernando Monckeberg Barros was one of the principal promoters of these centres of the Corporation for Child Nutrition (CONIN). Children were hospitalized in these centres, which provided important support for the most severe cases of undernutrition, especially through family interventions designed to reduce the risk of relapse and death. PNAC has had a very strong impact, well beyond the mere reduction of undernutrition, because it validated the primary care model. The connection between food delivery, preventive controls, and vaccination was initially appreciated mostly because of the food. Slowly, however, the model became inserted in the culture and people began recognizing the value of health controls. Today our country can initiate campaigns with high levels of coverage—for instance, vaccination campaigns—because a preventive culture exists, and this has been very important for achieving the health goals we have accomplished today. 81

Currently, we have different types of feeding programmes with a control population of more than one million spread among children under six, premature babies, pregnant women, and breastfeeding mothers, who receive attention and products during their period of need. We also have fortification projects for high-consumption foods, to prevent specific deficits, such as iodine in salt and iron and folic acid in flour.

PNAC covers today 77 percent of the national population. According socioeconomic surveys, however, our targeting of the poorest population is almost perfect. People with higher resources are not interested in receiving two kilograms of milk, but others receive it gladly. Even though PNAC is a universal policy, it focuses almost automatically on the population with greater needs.

Another lesson we have learned is largely related to the structuring of state networks. During the reforms and important changes that we have seen over the history of our country, focus on primary care was maintained. During the time of the military government, investment in hospitals dropped almost to nil, but primary health care and rural healthcare were maintained. In fact, although there was an increase in poverty during this period, child mortality and undernutrition continued to decrease, although with less strength. The emphasis should then be in feeding as an integral part of policy. It is not simply delivery of food; it has to do with health education, basic sanitation, the possibility of access to vaccination, and other additional elements based on multisectoral work and social development. Several delegates to the Regional Ministerial Conference were part of social cabinets that are thinking more comprehensively about social policies. Additionally, a structure with an organizational dimension capable of territorial representation and presence in all communities to guarantee universal access is indispensable. This can initially be onerous, but what is saved in terms of disease prevention is much greater than the cost of creating the structure of this type of programme. Empowering the community about their health rights is also very important. This must be done through people. Another lesson from our history is the importance of policy continuity over many years. The maintenance of political will, across actors with different persuasions and over many years, is a relevant theme. How can we bring together the relevant actors in our countries? Here in Chile we created a National Council on Nutrition, with the participation of people from different schools of thought. We brought together the academic sector, whose support is very impor-

tant for monitoring and follow-up, for innovative ideas and validation, for social communication, along with legislators, national, regional, and municipal governments, and all interested actors, always emphasizing mothers and children as a social priority. It is also important to develop a structure that is able to cover the entire country to maintain these public policies. In our countries, governments change and, oftentimes, a large part of the social structure that sustains them changes as well. Only conviction and strength of common objectives, shared among different social and political forces, will allow the alignment of relevant actors to ensure programme continuity beyond governments. Today there are 213 million poor Latin Americans, 88 million living in extreme poverty, sixty million who suffer from hunger, and 2.6 million with chronic undernutrition. However, Latin America and the Caribbean produce sufficient quantities of food to feed more than 1.8 billion people. Paradoxically, not only in Chile, but also in many of our countries, obesity and overweight are increasing, along with increasing inequality. We have a great challenge as a region. Six of the Millennium Development Goals are related to hunger and undernutrition. Various agencies are committed to its eradication. All our countries have successful programme experiences, from which we can mutually learn in different areas. In meetings such as the Regional Conference â&#x20AC;&#x153;Towards the Eradication of Child Undernutrition in Latin America and the Caribbeanâ&#x20AC;? we can say we are providing political solutions to the issue that brings us together, unites us, and presents us with challenges as Latin Americans and beyond our region. In this effort, our country is willing to share its experiences.

The chilean experience in eradicating child undernutrition Eduardo Abedrapo Bustos Under-Secretary of Planning of Chile

General Background Currently, child undernutrition is a public health problem under control in Chile. In 2005, the prevalence of mild and moderate undernutrition was 2.5 and 0.3 percent, respectively (Figure 1).

At risk Undernourished Overweight Obese

Source: Data provided by the Ministry of Health of Chile.

A fundamental characteristic in the Chilean case, which is necessary for understanding current levels, is that the reduction in child undernutrition has been consistent over time. It occurred during ideologically different governments. Policies were maintained despite profound socio-political changes and through various economic cycles that affected the country from the 1950s to the 1990s.

Figure 2 Undernutrition Percentages among Children Under Six Chile, 1960-2000

Total

Slight

Moderate

Severe

Source: Data provided by the Ministry of Health of Chile.

Eduardo Abedrapo Bustos

Normal

Under-Secretary of Planning of Chile

Figure 1 Nutritional Status of Children Under Six Chile 2005

Key Elements for Understanding the Chilean Process In our opinion there are three key elements in understanding the Chilean process of eradicating child undernutrition. First was the construction of a comprehensive institutional base with adequate laws and legal backing, the generation of specialized public and private organizations, and sustained and sustainable programmes in economic and political terms. The second element relates to the multisectoral focus and coordination of different programmes to be implemented, thereby avoiding the duplication of efforts and inefficiency in resource use. The third element relates to research and knowledge generation, a task in which public agencies, academic centres, and private organizations have participated. This allowed the evaluation and systematization of best practices and the provision of adequate information needed to create new interventions and consolidate professional teams of the highest level.

Institutional Background

The National Scholarships Board (JUNAEB) was created in 1964 From its inception, JUNAEB has consolidated a National Student Support Network and administered the School Feeding Programme (PAE, acronym in Spanish), with the objective of delivering free and varied foods on a daily basis, according the needs of students in the educational establishments, through public financing.

The National Pre-School Board (JUNJI) was created in 1970 This entity is in charge of the establishment, implementation, and administration of a vast network of nurseries and day-care centres throughout the country. JUNJI offers healthy feeding programmes for the children in its care and promotes the formation of eating, hygiene, and health habits for the children and their families as well as physical activity appropriate to the childâ&#x20AC;&#x2122;s developmental level. JUNJI provides between 75 to 80 percent of childrenâ&#x20AC;&#x2122;s daily nutritional requirements.

National Education and Social Development Foundation (INTEGRA) was created in 1990

These precedents show how the expansion of an institutional base allowed the development of policies and programmes geared toward the eradication of undernutrition in Chile. The 1938 Mother and Child Law was the first legal initiative that dealt with working families, incorporating the delivery of milk from the end of breastfeeding until the child reached two years of age. At this time, the provision of childhood nutrition began to be considered as a state obligation and a right of working mothers.

This is a private foundation, whose work is financed through public resources. It complements the work of JUNJI, providing, at its nurseries and day-care centres, from 60 to 75 percent of the calories and 100 percent of the proteins needed on a daily basis by children to develop. INTEGRA also generates educational materials for staff, including training modules on food and nutrition, as well as parental feeding guides for preschool children.

Principal Policies and Programmes This section lays out the principal policies and programmes developed in different sectors associated with the phenomenon of child undernutrition.

Broad Coverage Health and Education Programmes Since the 1940s, there has been a strong impulse in Chile to create policies to improve the educational level of the population, a key factor in reducing undernutrition and child mortality. Since the 1960s, the health service network has improved substantially. Hospital births, pre- and post-natal care, and healthy child visits with vaccinations and food delivery have all increased and remain in place today. The health system also broadened its coverage to include the entire national territory and developed a health network of growing complexity: rural posts, primary care centres, and hospitals. Protocols and norms were established that allowed improvement in health care and the distribution of food in feeding programmes.

National Complementary Feeding Programme (Universal PNAC) This programme was formally created in 1953, with a focus on primary preventive care. Its objective is the provision of foods to vulnerable populations: pregnant and breastfeeding women and children under six who attend health controls.

dren, who were either hospitalized in special centres or treated as outpatients. A breastfeeding promotion programme was also implemented using various communication media as well as formal health education. This campaign was repeated with successful results in the 1990s.

Development of Information Systems Along with the execution of various programmes, a special emphasis was placed by the State on generating necessary information that would allow the evaluation of the processes, effects, and impacts of policies designed to eradicate child undernutrition. Figure 3 shows the process of generating information used in decision making.

Research and Knowledge Generation Academic centres played and continue playing a key role in the development of health and nutrition policies and programmes in Chile. In 1969, the College of Medicine of the University of Chile created a Department of Nutrition and, later, in 1970, the School of Nutrition, which had been sponsored by the National Health Service. In 1976, again from within the University of Chile, the Nutrition and Food Technology Institute (INTA) was created to respond more effectively to the problem of child undernutrition. INTA joined the efforts of other centres of study that have also generated knowledge and relevant information.

Additionally, a programme of tertiary prevention or rehabilitation was set into motion for moderately or severely undernourished chil-

Figure 3 Process of Information Generation for Decision Making Chile, 1960-2000 Population and housing censuses, as well as targeted studies on basic unmet needs permitted the quantification of demand and helped estimate the magnitude of the intervention.

Health controls through provision of milk at health centers allowed the creation of an information registry that became a central factor in achieving successes.

Data generation to measure the impact of the interventions, both quantitatively and qualitatively.

A registry system that created a health system and public hospitals network.

Undernutrition Recovery Actions

Sanitation Projects

As a result of the successes achieved with treatment in closed nutritional recovery centres, in 1976 a group of INTA academics created the Corporation for Child Nutrition (CONIN).

Since 1957, with the creation of the relevant public agencies, the state initiated strong investment in potable water and sewage systems, which were key for creating the minimum hygiene conditions needed for good development of children in their homes (see Figure 4).

This allowed possible the creation of a network of centres devoted to the recovery of undernourished children, made up of 22 CONIN units throughout Chile, which represented an increase of 1,660 treatment beds. Funding came from private sources and an agreement with the Ministry of Health, which financed most of the operating costs. Results were particularly successful, recuperating 85 thousand children with moderate or severe undernutrition. Children in the centres had a mortality rate under 2 percent, a level significantly below those treated in hospital centres.

Figure 4 Coverage by Potable Water and Sanitation Systems in Urban Areas Chile, 1965-2005

Potable water coverage Sanitation coverage (%)

Source: Data provided by the Ministry of Health of Chile.

Successes and Lessons Learned Briefly, we can mention the following successes and lessons learned from Chileâ&#x20AC;&#x2122;s fight against undernutrition:

1. The delivery of food through health clinics attracted mothers to these centres, allowing the implementation and development of a health-focused culture, through family planning programmes, the promotion of breastfeeding, and care and monitoring of childrenâ&#x20AC;&#x2122;s health, along with vaccinations and nutritional education.

2. The quantity and quality of health information existing in the country, obtained both through primary healthcare centres and more complex facilities, has been of special importance in decision making and the redesign of policies and programmes in this area.

3. Although undernutrition had been overcome as a public health problem by the end of the 1980s, feeding programmes directed at undernutrition were maintained.

4. In terms of responses to policies related to the nutritional transition in Chile, the lack of perfect timing in modifying the composition of feeding programmes may have contributed to the appearance of other problems related to malnutrition, such as excess weight and obesity, which are currently public health problems in Chile.

Current Context and Challenges Even though Chile has been successful in overcoming child undernutrition, there is full awareness that maintaining these levels is a task that cannot be overlooked. Proof of this is the current food crisis at the global level and the challenges it implies. If the necessary safeguards are not taken, this crisis may trigger an enormous setback, not only in Chile, but also globally and, especially, in those regions concentrating the higher numbers of vulnerable populations and groups with fewer resources, including children.

with food security, in addition to a speculative component, have stimulated a rapid response in food prices in recent years, generating situations of famine and undernutrition among the most vulnerable populations, including children and older adults. On a global scale, greater solidarity, combined with a very active role by international organizations, are central elements in ensuring that the food crisis does not develop into a new factor of exclusion, poverty, and hunger in the world, especially in Africa as well as in Latin America and the Caribbean.

The strong global demand for food as a consequence of economic growth in China and India, combined with changes in eating habits and the development of biological energy sources that compete

Part three TECHNICAL APPROACHES TO CHILD UNDERNUTRITION IN LATIN AMERICA AND THE CARIBBEAN

Chapter 1 UNDERNUTRITION, POVERTY, AND ECONOMIC DEVELOPMENT Monckeberg F. Prevención de la desnutrición en Chile. Rev Chil Nutr 2003; 30 (Suplemento Nº 1): 160-176. Lewin L, Puentes R, Saavedra R et al. Programa Colocación Familiar en Niños Desnutridos (COFADE). Rev Chil Nutr 1989; 17 (Suplemento Nº 1):65-76.

SUMMARY This chapter includes the papers presented at the Regional Ministerial Conference in Santiago by José Graziano da Silva, Regional Director for Latin America and the Caribbean of the United Nations Food and Agriculture Organization (FAO); Juan Ángel Rivera Dommarco, Deputy Director-General of the Centre of Research on Health and Nutrition of the National Institute of Public Health of Mexico (Instituto Nacional de Salud Pública [INSP]); and Rodrigo Martínez, of the Social Development Division of the Economic Commission for Latin America and the Caribbean (ECLAC). At the Santiago meeting, the FAO Regional Director explained how the link between access to food and citizenship provides the principal justification for eradicating undernutrition. Article 25 of the Universal Declaration of Human Rights (1948) guarantees the right to an adequate level of life assuring health, wellbeing, and food. This provision recognizes the right to special care and assistance as well as social protection for maternity, infancy. Article 11 of the International Covenant on Economic, Social, and Cultural Rights (1966) reiterates these concepts. The recent approval of a Facultative Protocol to the Covenant allows the presentation of suits for violation of these rights (including the right to food) before the Human Rights System of the United Nations, when national judicial systems have not been able to protect these rights. Director da Silva underscores the availability of FAO to work together with WFP to safeguard these rights and achieve the Millennium Development Goals by 2015. Good progress towards these goals is being made, but very slowly, especially in rural areas. In these moments of increasing food prices, it is crucially important to design simple programmes that support family agriculture to supply and empower communities, among other objectives. Dr. Rivera summarizes the findings from a series of articles published in The Lancet in early 2008, dealing with maternal and child undernutrition. The first piece gives undernutrition, micronutrient deficiencies, and inadequate breastfeeding practices responsibility for more than a third (almost 35 percent) of all deaths of children under five and 11 percent of the total illness burden across the world. More than 3.6 million children and mothers die each year as the result of undernutrition. The second article deals with the economic and educational consequences, over the long term, of undernutrition and their relationship to chronic illnesses in adults. With a basis on more recent evidence, the third article addresses the most effective interventions for reducing the effects of undernutrition and the most opportune moment to undertake them: between conception and two years of age. It systematically analyzes the efficacy of 45 interventions with a potential impact on prevention and control of maternal and child undernutrition. Among these interventions, Dr. Rivera mentioned the promotion of breastfeeding and adequate complementary feeding with or without nutritional supplements or cash transfers; the fortification of foods; the distribution of micronutrient supplements; and the clinical treatment of severe undernutrition. The fourth and fifth articles examine the expansion of interventions through national and global actions. Rodrigo Martínez addresses the “Social and Economic Impact of Child Undernutrition.” He explains that in the last decades, the countries of the region have recorded important advances in the reduction of child undernutrition. A historical tendency toward the reduction of undernutrition was observable between 1965 and 2005. In the last ten years, however, advances have decreased and, in certain cases, setbacks have been experienced. In 2006 there were 194 million poor Latin Americans, of which 71 million lived in extreme poverty. The rise in food prices means that there will be an increase of ten to 16 million people living in poverty or extreme poverty in the region. Between 2001 and 2003, almost 52 million people (9.9 percent of the population) did not have access to their minimum caloric requirements, even though agricultural production in the region well surpassed their needs. Between 2002 and 2006, 7 percent of children under five had low weight and 15.4 percent showed low height for their age. Beyond the ethical considerations, the eradication of hunger and undernutrition generates important social impacts and significant economic savings. Benefits exist for more than just the direct recipients of the goods and services delivered by the nutritional programmes. The higher costs attached to hunger correspond to lower productivity and, consequently, less development for the country. Fighting undernutrition is, in the end, “good business” generating benefits for all of society.

Child undernutition in the region: reasons to eradicate it José Graziano da Silva Regional Representative of the United Nations Food and Agriculture Organization (FAO) in Latin America and the Caribbean

Despite good economics in the region during the last four years, characterized by an average annual growth rate of 3.3 percent, there are 194 million people living in poverty (36.5 percent of the region’s population). The proportion of persons living in extreme poverty is 13.4 percent. In spite of improvements, the region has still not managed to return to 1980 levels. The number of people living in poverty was then 136 million, of which 62 million lived in extreme poverty. As a result of these advances, the region is on a positive path towards achieving its commitment to reduce 1990 extreme poverty levels by half, by 2015, in accordance with the objective laid out in the first United Nations Millennium Development Goal (MDG). Currently, with 68 percent of the time to reach MDG-1 already elapsed, the region has met 87 percent of the goal. In this regard, however, the behaviour of the region’s countries has not been uniform. One group of countries (Brazil, Chile, Ecuador, and Mexico) has already achieved the goal. Another group, consisting of Colombia, El Salvador, Panama, Peru, and Venezuela, shows greater progress than would be expected at a point when 68 percent of the completion timeframe has passed. Argentina, Bolivia, Honduras, Nicaragua, Paraguay, and Uruguay have not yet come halfway towards achieving the goal, and additionally show slow progress in reducing rural poverty. Moreover, Latin America remains the most unequal region on the planet, with high levels of inequality in resource distribution, aggravated by ineffective structures for redistributing wealth. The wealthiest 10 percent of the population in Latin America and the Caribbean appropriates 36 percent of the region’s total income, while the poorest 40 percent only gets 14 percent of that income. In other words, the median income per person in the wealthiest homes is 19 times that of the median income among the poorest 40 percent of the region’s homes.

José Graziano da Silva

After overcoming the setbacks of the end-1990s, when extreme poverty rates reached 19 percent, the region has shown an important reduction in poverty and hunger continuously since 2002. In the most recent year analyzed year, 15 million people came out of poverty and ten million left extreme poverty. In percentage terms, total poverty was reduced by 3.3 percent in 2005, while the proportion of extreme poverty decreased two percentage points.

Regional Representative of the United Nations Food and Agriculture Organization (FAO) in Latin America and the Caribbean

This paper, written for the Regional Ministerial Conference “Towards the Eradication of Child Undernutrition in Latin America and the Caribbean,” purports to offer a perspective on hunger and poverty, with a particular emphasis on Latin America and the Caribbean. It also seeks to briefly describe the favourable context that exists in the region today to eradicate child undernutrition.

The GINI index measures inequality in income distribution and consumption. According to World Bank data, from the 1970s to the 1990s inequality in Latin America and the Caribbean was ten points higher than in Asia, 17.5 points higher than in the thirty Organization for Economic Cooperation and Development (OCED) countries, and 20.4 points higher than that in Western Europe. Inequality in the regionâ&#x20AC;&#x2122;s less unequal country (Uruguay) is greater than in the most unequal country in Eastern Europe and the industrialized states. Despite broad differences within the region, levels of inequality remain basically unchanged, although countries such as Brazil, Mexico, and Chile show slight decreases in recent years. Inequality in access to land helps explain these high levels of inequity, together with tax policies that do not contribute to income redistribution. Better social inclusion in Latin America and the Caribbean requires paying more attention to rural areas.

Advances and Setbacks in the Fight Against Hunger According to preliminary data from the United Nations Food and Agriculture Organization (FAO), in 2004 the number of hungry people throughout the world was 860 million. By far, the majority of the hungry lived in developing countries (830 million). Sub-Saharan Africa is currently the region with the highest prevalence of undernutrition, where one of every three people is deprived of access to sufficient food (FAO 2007). Even though the countries in Latin America and the Caribbean have made important progress since 1990-1992 (Table 1), there still remains a long way toward completion of the MDGs and, especially, toward the goal established at the 1996 World Food Summit (WFS). These issues will be addressed in more profundity in the remainder of the text.

Table 1 Magnitude of Undernutrition in Developing Countries in Latin America and the Caribbean 1990-1992 Region / Country

2002-2004

Undernourished Population (millions)

823,1

20,0

830,0

17,0

59,4

13,0

52,1

10,0

4,6

5,0

5,3

5,0

5,0 7,7

17,0 27,0

7,5 6,8

1,0 21,0

Developing Countries Latin America and the Caribbean North America (Mexico) Central America Caribbean Source: FAO 2007 (*preliminary data for 2002-2004).

According to the most recent figures available, the region produces around 30 percent more food that is necessary to feed all its inhabitants. However, the problem of hunger continues to affect approximately 52 million people, of whom nine million are children under five. These figures confirm that hunger is not primarily a problem of supply and demand, but that it is related, above all, to income. For farmers, access to food is determined to a large extent by the price they can obtain for their products. FAO has calculated that there are sufficient natural resources and capacities to guarantee food security for 12 billion people worldwide. However, that is not where the problem lies. Hunger is in large part a consequence of structural causes. The Latin American and Caribbean region has made progress in monitoring indicators related to hunger. Undernutrition, global undernutrition (both MDG reference indicators), and chronic undernutrition have declined. However, global statistics mask enormous differences, which reflect social and economic inequalities among and within countries. In this sense, there are countries whose indicators have seen marked improvements, while the situation has deteriorated in other states. In general terms, the countries of the region, with the exception of Haiti, considerably improved during the 1970s and 1980s, but during the 1990s the rate of progress weakened. Furthermore, in many national cases there were setbacks (especially among the countries of Central America). Peru, Chile, Brazil, and Cuba, on the other hand, show notable progress in recent years. Over the last fifteen years, the number of undernourished persons in Latin America and the Caribbean dropped by seven million (3 percent), from 13 percent of the population in 1990 to 10 percent in 2004. The region thus approached completion of MDG-1 (6.7 percent of undernutrition in 2015). However, the commitment acquired by all the regionâ&#x20AC;&#x2122;s countries at the 1996 World Food Summit, of reducing by half the number of hungry people, is still far off. If current tendencies in the reduction of undernutrition and population growth are maintained, in 2015 Latin America and the Caribbean can expect roughly 41 million undernourished people, compared to a Summit target of 30 million. Some countries and sub-regions, particularly in Central America, have registered little or no progress in reducing undernutrition. The highest incidence of hunger and undernutrition is found in rural areas,1 especially in mountainous and marginal zones in Central America and the Andean region, which principally affect the most vulnerable segments (women, children, and elderly adults) of indigenous and afro descendent groups (ECLAC 2004; ECLAC/WFP 2007). A permanent insufficiency in the quantity and quality of adequate

foods needed to satisfy the energy requirements of the entire population is observable only in Haiti. This lack of access has its most serious manifestation in child undernutrition. Of the two forms it takes, low weight and low height for age, height retardation is particularly important in the region, due to its greater incidence and the irreversibility of its negative impacts on the development of individuals and societies.

A Favourable Economic Moment The region is undergoing a favourable economic moment, with sustained growth over five years in most countries. The annual average regional growth in per capita income was 3 percent. This growth was accompanied by important reductions in extreme poverty, recuperation in the social realm, a recovery of the stateâ&#x20AC;&#x2122;s role as guarantor of minimal rights for all (health, education, access to food), growing functional institutionalization, and increasing democratization. This regional context presents unique conditions to drastically reduce the profound economic and social gap affecting Latin America and the Caribbean. The last time per capita GDP showed sustained growth above 3 percent in the region was forty years ago, in the late 1960s and early 1970s. According to the Economic Commission for Latin America and the Caribbean (ECLAC), various factors have influenced economic growth in Latin America in the most recent period. Among them, those worthy of special recognition include: 1) The maintenance of a current account surplus of 0.7 percent; 2) A new improvement in commercial terms of exchange around 2.6 percent; 3) The continuity of a positive balance in fiscal accounts; 4) A decrease in unemployment to around 8 percent; and 5) The expansion of international reserves and the reduction of external debt as a percentage of GDP. In the current scenario of growth, a significant percentage of the regionâ&#x20AC;&#x2122;s economies has registered an important increase in fiscal income, with a regional average of 20 percent respective to GDP. In 2007, the region saw an annual increase of 0.4 percent. This means that Governments (with some exceptions) have been able to increase public spending considerably, with regional averages reaching 20.4 percent. Countries such as El Salvador, Mexico, and Paraguay saw a decrease in public spending. Despite increases in fiscal expenditure, the tax load in these countries and in the region continues to be low compared to developed countries.

Due to high rates of urbanization in the region, there are now more hungry people in urban areas. In some countries, the levels of undernourished people in urban areas have surpassed those of rural areas.

are: Finally, the challenge for the countries is to maintain the current dynamism in economic growth, using fiscal policy to apply policies that reduce vulnerability to extreme impacts, and translating this growth into greater efficacy in the reduction of poverty, extreme poverty, and inequality. In this way positive synergies can be created between growth and economic stability on one side, and combating hunger and undernutrition, on the other. The context of sustained growth, a renewed concern among states for rights and social guarantees, and the urgency of eradicating hunger and poverty in the region have created opportunities for work and synergies among different organizations sharing responsibility for reducing undernutrition. Proposals for joint action between FAO and WFP in the region have arisen, which could materialize given political will and effort from everyone. Some of these joint actions

1) Combining income transfers with food assistance and nutritional education; 2) Connecting family agriculture with food support programmes; 3) Creating national and local supply policies; 4) Building local capacities in response to food emergencies; 5) Monitoring and evaluation of situations; 6) Promoting the eradication of hunger as a necessary condition for obtaining social cohesion.

References Dirven M. 2004. “El empleo rural no agrícola y la diversidad rural en América Latina.” Revista de la CEPAL 83 (August): 49-69. http://www.cepal.org/publicaciones/xml/1/15451/lcg2231e.pdf#page=48, accessed 21 June 2008. Economic Commission for Latin America and the Caribbean (ECLAC). 2004. Desarrollo productivo en economías abiertas. Santiago de Chile: ECLAC. Economic Commission for Latin America and the Caribbean / World Food Programme (ECLAC/WFP). 2007. El costo del hambre: análisis del impacto social y económico de la desnutrición infantil en América Latina (resultados del estudio en Centroamérica y República Dominicana). Santiago de Chile: CEPAL. Food and Agriculture Organization of the United Nations (FAO). 2007. “Food Security Statistics.” http://www.fao.org/faostat/foodsecurity/index_en.htm, accessed 21 June 2008. Organization for Economic Cooperation and Development (OECD). 2008. “Policy Brief: Agricultural Policy Reform in Chile” (March). http://www.oecd.org/dataoecd/16/32/40268283.pdf, accessed 21 June 2008.

The Lancet series on maternal and child undernutrition Juan Ángel Rivera Dommarco Deputy Director-General of the Research Centre of the National Nutrition and Health Institute of the National Institute of Public Health (Instituto Nacional de Salud Pública [INSP]), Mexico

First Article (Black et al.): Prevalence and Short-Term Consequences of Undernutrition (Death and Illness Burden) It is estimated that 178 million children under five suffer from delays in growth, 90 percent of which live in only 36 countries. Each year, 13 million babies are born with Intrauterine Growth Restriction (IUGR) and 19 million children suffer from severe clinical undernutrition. The health consequences of a certain condition are calculated by quantifying the deaths attributable to the condition, its contribution to disease rates, and its effects on the reduction of healthy years of life due to illness and disability. The unit used is the Disability-Adjusted Life Years (DALY) or illness load, which measures the difference between the current health status of a population and the ideal health state (living to advanced age in good health). One DALY corresponds to a lost year of healthy life. Intrauterine growth restriction, the retardation of post-birth growth, and severe undernutrition are responsible for 2.2 million deaths and 91 million DALYs. From this total, 21 percent occurs in children under five, who represent 7 percent of the total global disease burden for all ages—the highest disease burden of any risk factor. Vitamin A and zinc deficiencies constitute the most important remaining disease burden, with 9.9 percent of DALY. Iron deficiency represents a maternal mortality risk factor. It is estimated that it is responsible for 115 thousand deaths per year (20 percent of all maternal deaths).

Juan Ángel Rivera Dommarco

The first article (Black et al.) deals with prevalence levels and the short-term consequences of undernutrition (death and illness burden). The second article (Victora et al.) discusses the long-term economic and education effects of early undernutrition and the relationship of these to chronic illnesses in adults. The third article (Bhutta et al.) critically examines available nutritional interventions and identifies those with proven efficacy or effectiveness based on evidence. Finally, the fourth and fifth articles (Bryce et al.; Morris et al.) deal with effective large-scale interventions through national and international actions. The following sections summarize key messages from each article.

Deputy Director-General of the Research Centre of the National Nutrition and Health Institute of the National Institute of Public Health (Instituto Nacional de Salud Pública [INSP]), Mexico

The Lancet series on maternal and child undernutrition consists of five articles coordinated by the Research Group on Maternal-Child Undernutrition, a group of investigators, researchers, academics, and nutritional professionals in public health, under the coordination of Dr. Robert Black of the Johns Hopkins University.

Inadequate breastfeeding practices increase the risk of inadequate nutrient intake, illness, and death. It is estimated inadequate breastfeeding is responsible for the deaths of 1.4 million children and 44 million (10 percent) of childhood DALYs. In addition, undernutrition, micronutrient deficiencies, and inadequate breastfeeding practices are responsible for more than a thirdâ&#x20AC;&#x201D;almost 35 percentâ&#x20AC;&#x201D;of the deaths in children under five and 11 percent of the total illness burden of the world. More than 3.6 million mothers and children die each year as a result of undernutrition.

Second Article (Victora et al.): LongTerm Economic and Educational Effects of Undernutrition

Third Article (Bhutta el al.): Evidence-Based or Proven-Efficacy Nutritional Interventions The article provides a systematic analysis of the efficacy or effectiveness of 45 interventions with potential effect on the prevention and control of maternal and child undernutrition and its consequences. Interventions with proven effectiveness to reduce growth retardation, micronutrient deficiencies, child mortality, and disabilities related to nutrition include: 1) The promotion of breastfeeding; 2) The promotion of adequate complementary feeding;

The article presents new analyses of the relationships among nutritional status indicators during pregnancy and the first years of life (maternal height; birth weight; IUGR; weight, height, and BMI at two years) and several variables for adults (height, educational level, income, BMI, glycaemia, and blood pressure) from studies of various groups. It also provides a systematic analysis of studies in middle- and low-income countries on these relationships and the relationships with other outcome variables, including blood lipids, cardiovascular disease, immune response, lung function, cancer, osteoporosis, and mental illness. Undernourished children have a greater probability of becoming low height adults. Women who were undernourished as children have a greater probability of giving birth to smaller babies. Evidence links growth delays with cognitive development, academic performance, and educational achievements. IUGR and growth delays during the first years of life are conducive to low economic productivity in adults. Height-for-age of a child under five is the best predictor of human capital development. Children with restricted growth during gestation and the first two years of life that subsequently gain weight rapidly have the highest probability of suffering from high blood pressure, diabetes, and metabolic and cardiovascular disease in adulthood. There is no evidence that rapid weight or height gain during the first two years of life increases the risk for chronic illnesses in the future. It is possible to reduce the incidence of chronic illnesses through actions designed to enhance nutrition and promote growth at the start of life. Prevention of maternal and child undernutrition is a long-term investment that benefits the current generation and their children.

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3) Vitamin A and zinc supplementation; and 4) Adequate treatment of severe undernutrition. The key messages in the article are the following: 1) There are interventions based on scientific evidence that have demonstrated efficacy in preventing and controlling undernutrition; 2) If these interventions were implemented on a large-scale basis, they would reduce the deaths of children under five by one-fourth in the short term; they would also reduce growth retardation by almost one-third, avoiding 60 million DALY. 3) Pregnancy and the first two years of life is the crucial moment for intervening to prevent IUGR and undernutrition.

Fourth Article (Bryce et al.): National Health Actions National nutrition programmes should include and effectively monitor objective populations that benefit most from interventions: pregnant women and children under two. Countries should concentrate their resources in interventions that have proven to be effective and implement them as rapidly as possible. Social development policies that address poverty, trade, agriculture, and factors associated with the nutritional status of the population should be applied. Governments should attempt to incorporate relative nutrition goals in programmes that are not directly related to health, but could benefit from these additions.

Fifth Article (Morris et al.): Actions in the International Environment The international nutrition system is fragmented and non-functional. It needs reform to improve its effectiveness. Problems are chronic and have become deeply embedded in the norms and organizational structures of institutions. It is necessary to create a new global governing structure that guarantees the appropriate reporting of accounts and programmes. Funds currently appropriated by international entities are extremely insufficient and inadequately oriented.

Conclusions Progress in the fight against undernutrition and its positive effects on health and human development are possible if nutrition is made a priority. Nutrition is a central component of human development, both social and economic. Adequate implementation of nutrition interventions of proven efficacy in countries with the highest undernutrition burden would facilitate the achievement of the first Millennium Development Goal of reducing hunger levels by half by 2015 (MDG 1) and considerably increase the probability of attaining those objectives related to mother and child mortality (MDGs 4 and 5).

References Black RE, Allen LH, Bhutta ZA, Caulfield LE, Onís M de, Ezzati M, Mathers C, Rivera J. 2008. “Maternal and Child Undernutrition: Global and Regional Exposures and Health Consequences.” The Lancet 371:9608 (19 January): 243-260. Summary at http://www.thelancet.com/journals/lancet/article/PIIS0140673607616900/abstract, accessed 8 May 2008. Victora CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L, Sachdev HPS. 2008. “Maternal and Child Undernutrition: Consequences for Adult Health and Human Capital.” The Lancet 371:9609 (26 January): 340-357. Summary at http://www.thelancet.com/journals/lancet/article/PIIS0140673607616924/abstract, accessed 9 May 2008. Bhutta Z, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, Haider BA, Kirkwood B, Morris SS. Morris, Sachdev HPS, Shekar M. 2008. “What Works? Interventions for Maternal and Child Undernutrition and Survival.” The Lancet 371:9610 (2 February): 417-440. Summary at http://www.thelancet.com/journals/lancet/article/PIIS0140673607616936/abstract, accessed 9 May 2008. Bryce J, Coitinho D, Darnton-Hill I, Pelletier D, Pinstrup-Andersen P. 2008. “Maternal and Child Undernutrition: Effective Action at National Level.” The Lancet 371:9611 (9 February): 510-526. Summary at http://www.thelancet.com/journals/lancet/article/PIIS0140673607616948/abstract, accessed 9 May 2008. Morris SS, Cogill B, Uauy R. 2008. “Effective International Action against Undernutrition: Why Has It Proven so Difficult and What Can Be Done to Accelerate Progress?” The Lancet 371:9612 (16 February): 608-621. Summary at http://www.thelancet.com/journals/lancet/article/PIIS014067360761695X/abstract, accessed 21 June 2008.

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The social and economic impact of child undernutrition Rodrigo MartĂnez Regional Advisor of the Social Development Division of the Economic Commission for Latin America and the Caribbean (ECLAC)

Child Undernutrition in Context

Figure 1 Tendency of Global Undernutrition in Latin America (13 Countries) 1965-2006

Source: ECLAC, based on demographic and health surveys from the respective countries.

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Rodrigo MartĂnez

Child undernutrition in Latin America and the Caribbean is one of the indicators of inequality in the region. Although there has been a steady reduction process over the long term, during the current decade this process has stalled in several countries and relapsed in others (Figure 1). These developments raise doubts about the capacity to reach the target set in the Millennium Development Goals (MDGs) of reducing the prevalence of child undernutrition by half between 1990 and 2015.

Regional Advisor of the Social Development Division of the Economic Commission for Latin America and the Caribbean (ECLAC)

In recent decades, the countries of Latin America and the Caribbean have made important advances in child undernutrition reduction. However, in 2006 there were 194 million poor Latin Americans, 71 million of whom lived in extreme poverty or indigence. Between 2001 and 2003, around 52 million people (9.9 percent) did not have access to sufficient food to cover their caloric requirements, although regional production far surpassed their needs. From 2002 to 2006, 4 million children under five in the region (7 percent) had low weight for their age and 8.7 million (15.4 percent) exhibited low height for their age. At the same time, problems of excess weight and obesity in the region increase daily.

The world in general—and the region in particular—are experiencing an increase in food prices, which generates a complex scenario characterized by the increase in vulnerability of the poorest populations. The Economic Commission for Latin America and the Caribbean (ECLAC) estimates that “an increase of 15 percent in food prices elevates the incidence of extreme poverty by almost three points, from 12.7 to 15.6 percent. This alteration in food prices means that 15.7 million more Latin Americans could fall into extreme poverty. In the case of poverty, increases are similar and the same quantity of people will become poor.” During the current decade, food prices have experienced a constant upward trend, beyond general inflation rates in each country. Although this has happened previously, the relevant characteristic in 2007 is that the Consumer Price Index (CPI) for food was 50 percent higher than the general CPI (Figure 2).

resources will be required to confront the problem. It will also be necessary to identify innovative alternatives with potential for increasing effectiveness and efficiency of social spending. In the 1990s, public spending as a percentage of GDP grew significantly, but—following a pro-cyclical pattern—its growth rate has decreased during the present decade. This increases the vulnerability of the poorest people in moments of crisis. The countries of Central and South America with the highest undernutrition prevalences have an average annual social spending of about 298 dollars per capita (625 dollars in purchasing power parity). The countries that allocate greater resources have lower levels of undernutrition. If the level of current social spending does not seem appropriate under historical conditions, even greater efforts are required in scenarios of higher economic vulnerability to succeed in eradicating child undernutrition.

Changes in price tendencies are not currently foreseen, so this scenario presents new challenges for social policies. As indicated by the United Nations Secretary-General, an important amount of

Figure 2 Relationship between the Food CPI and the General CPI (simple averages) Latin America and the Caribbean (24 countries), 1981-2007 CPI-Food-Caribbean CPI-Food-South America CPI-Food-Central America CPI-Food-Andean Countries CPI-Food-Latin America and the Caribbean CPI General

Source: Author’s elaboration based on data from ECLAC’s Statistical Yearbook.

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Consequences and Costs of Child Undernutrition in Latin America For the past five years, ECLAC and the World Food Programme (WFP) have worked together to build a knowledge base for identifying the populations most vulnerable to child undernutrition, analyzing tendencies, recognizing successful experiences, and estimating the social and economic impact this scourge has had on countries. On this basis, we can say today that the most vulnerable population consists of indigenous people living in poverty, whose mothers have low educational levels and often do not have access to clean water and sewage services. The highest prevalence of undernutrition is found in rural areas, but marginal urban areas have large numbers of affected families. Natural disasters often aggravate undernutrition, especially as not all countries have adequate response mechanisms. To a significant extent, however, vulnerability is also produced by political and social conflicts which, in addition to increasing risks, reduce institutional response capacities. These phenomena compound the market and food price fluctuation risks alluded to above. Addressing the problem of child undernutrition is not exclusively a moral imperative for Governments and society. It is also a social and economic necessity. Undernutrition often significantly impacts operational costs in the health and education sectors, but its greatest impact is on productivity losses. The sections that follow contain estimations of the impact decades of child undernutrition produced in 2004 in Central America (Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama) and the Dominican Republic, and in 2005 in the Andean countries (Bolivia, Colombia, Peru, Venezuela) and Paraguay.

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Effects on Health National undernutrition prevalences indicate that 856 thousand Central American and Dominican children under five, along with 1.06 million Andean and Paraguayan children, showed low weight for age in 2004 and 2005, respectively. Based on official statistics, it is estimated that these levels generated 142 thousand additional cases of chronic diarrhoeal illnesses (CDI), 77 thousand cases of anaemia, and 68 thousand acute respiratory illnesses (ARI) (Figure 3). Among the Andean countries and Paraguay, there were 24 percent more cases of global undernutrition and 22 percent more cases of associated illnesses than in Central America.

Higher rates of undernutrition also associate with a greater risk of death. Given the reduction in prevalence of global undernutrition during the last seventy years, the number of estimated deaths for the zero to four year age group is significantly less than that present among earlier generations. In Central America and the Dominican Republic, undernutrition produced 2.64 million deaths between 1940 and 2004, equivalent to 40 percent of total deaths, with 77 thousand cases in 2004 (30 percent of the total). Between 1941 and 2005, there were a total of 4.7 million deaths associated with undernutrition in the Andean countries and Paraguay (30 percent of the total), of which 105 thousand occurred in 2005 (17 percent of the total). The number of cases in South America is greater, due to its larger population, but the higher prevalence of global undernutrition in Central America (2004) makes the impact on mortality almost double that of the Andean Countries and Paraguay.

Figure 3 Number of Additional Illness Cases Caused by Undernutrition Latin America (12 countries), 2004-2005 Guatemala Venezuela Peru Honduras Bolivia Colombia Ecuador El Salvador Nicaragua Dominic Republic Panama Costa Rica

Source: ECLAC, based on the last national survey available and official information on registered cases of illness in each country.

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Thousands of Repetitions

Figure 4 School Repetitions Linked to Global Undernutrition Latin America (14 countries), 2004-2005

Repetition linked to undernutrition

% of total repetitions

Source: ECLAC, based on official information for the countries.

Effects on Education

Effects on Productivity

School repetition linked to undernutrition is estimated at 129 thousand cases in Central America and the Dominican Republic (2004), and at 75 thousand cases in the Andean countries and Paraguay (2005). Desertion created an average reduction of two years of education for children who suffered from undernutrition during their first years of life (Figure 4).

Of a total of 2.64 million deaths estimated in Central America and the Dominican Republic from 1940 to 2004, 684 thousand would have died from other causes and 262 thousand would be under fifteen years of age. But 1.7 million would be alive were it not for undernutrition and would today be part of the working-age population (WAP), including people between 15 and 64 years of age. This number is equivalent to 6 percent of the total working-age population, with a loss of 2.5 million working hours in 2004 (6.5 percent of hours worked by the economically active population [EAP]).

Central America, with less total numbers of undernourished persons, has 54 thousand more cases than the Andean countries and Paraguay. This is related to higher prevalence of undernutrition in Central America and the greater probability of repetition among the student population of that sub-region. Another striking element is that Guatemala has 40 percent of the total repetitions among the 13 countries in the study. Guatemala has more cases than the five Andean countries and Paraguay combined.

It is estimated that in the Andean countries and Paraguay, 3.6 million persons who died from causes related to undernutrition could today form part of the working-age population (4.4 percent), adding up to 5.2 billion lost work hours in 2005 (3.9 percent of the total hours worked by the WAP). With losses above 10 percent of the EAP, Bolivia, Guatemala, and Peru stand out as countries with the highest relative loss of working hours. On the opposite side are Costa Rica, Panama, Paraguay, and Venezuela, with losses between 1 and 2 percent. 107

The Costs of Child Undernutrition In analyzing total costs associated with child undernutrition in the 13 countries, it is estimated that in 2004-2005, 17 billion dollars were lost, equivalent to about 3.4 percent of the aggregate GDP.

Of this amount, 6.7 billion dollars correspond to the cost produced in Central America and the Dominican Republic, equivalent to 6.4 percent of the aggregate GDP for these seven countries (ranging from 1.7 percent of GDP in Costa Rica to 11.4 percent of GDP in Guatemala). The costs in the Andean countries and Paraguay reach a total of 10.6 billion dollars, which represent 2.3 percent of the combined GDP for these six countries (Figure 5).

Millions of dollars

Figure 5 Estimation of the Total Cost of Undernutrition in Dollars and Percentage of GDP Latin America (13 countries), 2004-2005

Total cost

% of GDP

Source: ECLAC, based on official information and registered costs of education in each country. Income and educational levels come from home surveys in each country.

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Four Central American countries and Bolivia show the highest costs in relation to GDP. The countries with the highest totals include Colombia, Guatemala, Venezuela, and Peru. While in the three South American countries population size and higher opportunity costs explain the majority of these amounts, in Guatemala the high prevalence of undernutrition plays a central role. Lost productivity represents the greatest cost in all the countries (93 percent of the total), amounting to 6.2 billion in Central America and the Dominican Republic and 9.8 billion in the Andean countries and Paraguay. Of the total, 52 percent comes from the loss of human life and 41 percent from the lower education levels of people who suffered from undernutrition. These levels do not consider the losses that could occur from potential investments that never materialized due to lower human capital of the population that suffered from child undernutrition. In Central America and the Dominican Republic, the costs for additional health care added up to 434 million dollars, while the total for the Andean countries and Paraguay was 691 million dollars, or 7 percent of total costs in both cases. In education the costs were 31 million for the first group of countries and 82 million for the second, equivalent to less than 1 percent of the total costs in both studies. If the problem of undernutrition is not addressed now, its persistence will continue to increase the costs for future generations. In fact, the costs Central America is already paying for the children who were undernourished in 2004 add up to 2.3 billion dollars, and an equivalent amount could be saved in 11 years if the eradication goal is achieved by 2015. In this way, the savings produced could finance the solution to the problem.

Conclusions The estimations from the studies presented here confirm the hypothesis that, beyond the ethical imperative, the eradication of the scourges of undernutrition and hunger, to which the region’s Governments have committed, generates important social impacts and significant economic savings. The eradication of undernutrition provides benefits to society as a whole, not just to the direct recipients of programme goods and services. In fact, most of the costs to society come from lower productivity. Clearly, fighting against hunger and undernutrition is a “good business” that generates benefits for all of society. These estimations, while significant, are conservative. In fact, micronutrient deficiencies and other similar impacts, such as those caused by social and political conflicts, along with the opportunity costs of productive investments, have not been considered due to low confidence in accurately estimating them on the basis of information currently available. Finally, international experience indicates that it is cheaper to invest in eradicating child undernutrition in the region than to suffer its social and economic consequences. Not only are resources are required to achieve this goal, but also well-defined technical policies, development models that maximize impact and efficiency, and the commitment and active participation of all sectors in society.

References Economic Commission for Latin America and the Caribbean (ECLAC). 2007. Panorama Social de América Latina 2007. Santiago, Chile: ECLAC. http://www.eclac.cl/cgi-bin/getProd.asp?xml=/publicaciones/ xml/5/30305/P30305.xml&xsl=/dds/tpl/p9f.xsl&base=/tpl/top-bottom.xsl, accessed 21 June 2008. 2008a. Anuario Estadístico de América Latina y el Caribe, 2007. Santiago, Chile: ECLAC, Statistics and Economic Projections Division. http://www.eclac.org/publicaciones/xml/8/32598/LCG2356B_contenido.pdf, accessed 21 June 2008. 2008b. “Alza de precios de alimentos aumentaría la pobreza e indigencia.” Press release, 18 April. http://www.eclac.org/cgi-bin/getProd.asp?xml=/prensa/noticias/comunicados/3/32773/P32773.xml&xsl=/prensa/tpl/p6f.xsl&base=/prensa/tpl/ top-bottom.xsl, accessed 21 June 2008. Martínez R, Fernández A. 2006. “Modelo de análisis del impacto social y económico de la desnutrición infantil en América Latina.” ECLAC-Serie Manuales #52. http://www.cepal.org/publicaciones/xml/8/27818/Serie_Manuales_52.pdf, accessed 21 June 2008. 2007. El costo del hambre: impacto social y económico de la desnutrición infantil en Centroamérica y República Dominicana. Santiago, Chile: ECLAC. http://www.eclac.cl/publicaciones/xml/3/28923/DP_CostoHambre.pdf, accessed 21 June 2008. (under preparation). El costo del hambre: impacto social y económico de la desnutrición infantil en los países andinos y Paraguay. Santiago, Chile: ECLAC.

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Chapter 2

MONITORING AND EVALUATION OF SOCIAL PROGRAMMES TO COMBAT CHILD UNDERNUTRITION

Monckeberg F. Prevención de la desnutrición en Chile. Rev Chil Nutr 2003; 30 (Suplemento Nº 1): 160-176. Lewin L, Puentes R, Saavedra R et al. Programa Colocación Familiar en Niños Desnutridos (COFADE). Rev Chil Nutr 1989; 17 (Suplemento Nº 1):65-76.

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SUMMARY The second chapter incorporates pieces by Jere Behrman, Professor of Economics at the University of Pennsylvania, and Juan Ángel Rivera Dommarco, Deputy Director-General of the Centre for Nutrition and Health Research of Mexico’s National Institute of Public Health (Instituto Nacional de Salud Pública [INSP]). This is followed by a 12-point summary of relevant issues with regard to monitoring and evaluation of social programmes designed to combat child undernutrition, presented by David Bravo, Director of the Microdata Centre of the Economics Department of the University of Chile. The report by Dr. Behrman is based on the evaluation of the long-term effects of a nutritional intervention in Guatemala, carried out by the Institute of Nutrition for Central America and Panama (INCAP) between 1969 and 1977. The intervention included the delivery of a nutritional supplement to children in four locations (two large and two small towns). One large town and one small town received Atole, a nutritional supplement based on Incaparina, milk and sugar. In the other towns Fresco, a less nutritive drink, was distributed. The impacts of the interventions were measured through total ingestion of nutrients, growth, human capital development and productivity, as well as through the intergenerational effects of the programme. Dr. Behrman’s article emphasizes the importance of estimating the impacts, costs, and cost-benefit analysis of nutritional interventions. This type of exercise is linked to proposals from the Copenhagen Consensus, which identified effective solutions for ten fundamental challenges facing humanity. Evaluations of this type are extremely useful, as they provide fundamental information that helps in decision-making relative to the continuation or modification of the programmes. In this sense, the benefits of a monitoring system appear to be superior to the costs of implementing the system. According to Dr. Rivera’s second contribution to this book, evaluation exercises should be conceived as an instrument to provide feedback to the people responsible for the execution of social programmes. There are three types of monitoring and evaluation that should be applied to judge a programme’s quality: design and consistency, process or performance, and impact or efficacy (including the cost-benefit or cost-effectiveness relationships) evaluations. Impact should not be evaluated without considering the design and consistency of the programme, and the same is true for the performance of the intervention. The first step in evaluating a programme is the revision of the conceptual framework to ensure that evidence about the possibility of attaining the desired impacts if the intervention is executed according to operating procedures. This criterion basically corresponds to design evaluations. In terms of performance evaluation, the size of sample groups and indicators needs to be checked to ensure there is room to compare and evaluate expected changes in the outcome variables. The ideal format for impact evaluations is one that allows the completion of statistical confirmations about effects attributable to the programme, through random allocation with control groups. If ethical or logistic reasons prevent a random allocation, valid alternative designs allowing plausible confirmations are available. Dr. Bravo offers a series of important points relative to programme monitoring and evaluation systems, one of the pillars in the fight against undernutrition. With the purpose of applying lessons learned as broadly as possible, harmonizing nutritional intervention monitoring and evaluation systems is convenient. These systems also represent an important accountability mechanism. The three types of evaluations addressed by Dr. Rivera should be part of one single evaluation system. Several fundamental tasks must be incorporated into evaluation processes: developing analytical capacity, including control groups, determining the most appropriate moment to plan and implement evaluations, defining the results of the indicators and temporary horizons, and obtaining baseline data and information about costs.

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Priorities in early childhood nutritional interventions Jere Behrman William R. Kenan, Jr. Professor of Economics, University of Pennsylvania

early life nutrition on later outcomes. In this article I sketch out an integrated nutrition and economic approach to attempting to indentify the causal impact of early life nutrition on subsequent outcomes and how to prioritize among possible nutritional and other interventions. First, I summarize some recent new evidence about the long-run impact of early-life nutritional supplements in Guatemala. Then I summarize some important considerations in calculating benefit-cost ratios for nutrient interventions, with some illustrations based on what seem to be the best estimates available for a stereotypical low-income developing country. Finally I conclude with some comments on why such approaches are likely to be desirable.

New Long-Run Estimates of the Impacts of Improved Early-Childhood Nutrition from the Institute of Nutrition for Central America and Panama (INCAP) Longitudinal Study The INCAP Longitudinal Study was a community-randomized supplementation trial. Two villages (one more populous, one less populous) received Atole, a nutritious supplement made from Incaparina, milk and sugar, and two villages (one more populous, one less populous) received Fresco, a less nutritive drink. All children under seven at baseline in 1969 were included as well as all children born between 1969 and 1977. Children were followed until 7 years of age or study end. Total diets of children from zero to 36 months from Atole villages were greater on average by 9 grams of protein, 100 kcal/day and in micronutrients when compared to diets of children from Fresco villages. There have been a number important studies of these children, both based on the 1969-77 data collection 113

Jere Behrman

This study presents a number of associations between maternal and infant/toddler anthropometric measures, on one hand and adult outcomes, including adult height, completed schooling attainment, labour income and birth weight for the next generation. These associations are in many cases fairly large, which suggests possibly large causal impacts of early life nutrition over the life cycle and into the next generation. While these associations are suggestive, however, they are not conclusive because the associations presented may reflect the importance of other factors (e.g., genetic endowments, family connections, parental preferences) that determine both early life nutrition and subsequent outcomesâ&#x20AC;&#x201D;and not necessarily the impact of

William R. Kenan, Jr. Professor of Economics, University of Pennsylvania

The prominent recent Lancet article by Victora et al. (2008) reviews published studies linking maternal and child undernutrition with outcomes when the children become adults in developing countries and contributes analysis of new data from five cohort studies in developing countries (two in Latin America and the Caribbean, one for Brazil and one for Guatemala) in which people have been monitored from birth into adulthood.

and on subsequent follow-ups (e.g., see Martorell 1992; Habicht, Martorell and Rivera 1995; Martorell, Habicht and Rivera 1995; Schroeder et al. 1995). For example, the length/height of children exposed to Atole in the first three years of life relative to children exposed to Fresco was increased on average by 3 cm but the differential exposure for older children did not affect length/height significantly. The 2002-4 follow-up Human Capital Study targeted the 1,855 children in the INCAP Longitudinal Study (out of the total of 2,392 children in that study of whom 274 had died, mostly in early childhood, 162 had left the country and 101 were lost to follow up) who were alive and known to be living in Guatemala in 2002-4. Of these individuals, 1,571 (84 percent) were re-interviewed (Grajeda et al. 2005). Their ages ranged from 25 to 42 years, with an average of about 32 years. Therefore these data, together with the original INCAP Longitudinal Study Data, permit the estimation of the impact of exposure (“intent to treat”) to Atole as opposed to Fresco during critical windows of opportunity of the original intervention on adult outcomes. Several studies have investigated what are these impacts and how sensitive are they to the ages of exposure to the intervention. With these data it is not possible to distinguish with confidence about whether the critical window of opportunity begins at conception or birth or whether it lasts through 24 or 36 months. However, exposure during the first 24-36 months of life did have significant and substantial impacts on outcomes over the life cycle and into the next generation though exposure at older ages did not have significant effects (e.g., Hoddinott et al. 2008; Maluccio et al. 2008):

· Schooling attainment increases of 1.2 grades (0.36 SD units) for women;

· Inter-American Reading Comprehension tests scores increases of 0.28 standard deviations for both men and women; · Cognition as measured by Raven’s Progressive Matrices increases of 0.24 standard deviations for both men and women;

Wage rates increased by US$0.67 or 0.45 standard deviations for men. These are substantial effects on outcomes related to human capital and adult income and productivity. And because the exposure to Atole versus Fresco during the critical window of opportunity was exogenous from the point of view of the children and their families (determined only by the timing of their birth and their location), they are much more persuasive about being large causal impacts of improved early-life nutrition on outcomes over the life cycle than are the associations that dominate in the literature.

Benefit-to-Cost Ratios of Nutritional Interventions Improved childhood nutrition is widely thought to be desirable intrinsically because it improves welfare of the children involved, their parents and the societies in which they live. But there are many possible resource uses that society is likely to deem intrinsically desirable, such as improving education, reducing pollution, improving the health of the increasing large aging population, and reducing global warming. Therefore, it is of interest to ask what the purely economic benefits are relative to the economic resource costs of various possible nutritional interventions. Estimates of such benefit-cost ratios are likely to be illuminating not only for prioritizing among nutritional interventions, but for comparing nutritional interventions with alternative interventions ranging from education to infrastructure. I here review quickly a number of the critical considerations that are important in calculating economic benefits and economic costs to nutritional (or other) interventions with some illustrations related to early-life nutritional interventions and then summarize some benefit-cost estimates for nutritional interventions and how they relate to benefit-cost estimates for other resource uses.

Economic Benefits The economic benefits in a nutshell are the gains in economic productivity and the savings in resources not used (e.g., because of reduced morbidity) due to the nutritional intervention. Five key aspects of economic benefits are:

1) Benefits may be multiple and may occur over the life cycle and across generations. The estimates of the impacts of the INCAP Guatemalan early-life nutritional intervention above suggests that there may be important effects not only during infancy and childhood, but much later in the life cycle (and, indeed, across generations). For a another illustration, Table 1 gives estimates of seven possible economic impacts of moving a child from below low-birth weight (LBW) status <2500 gm to above that cutoff based on the best available estimates for a low-income developing country: (a) Reduced infant mortality; (b) Reduced neonatal care; (c) Reduced costs of infant and child illnesses; (d) Productivity gains from reduced stunting; (e) Productivity gains from increased cognitive ability; (f) Reduced costs of chronic diseases; and (g) Intergenerational benefits.

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Table 1 Estimation of Discounted Present Value of Seven Important Benefits of Taking a Child Out of a Low Birth Weight Condition in a Low-Income Country (In US Dollars)

Annual Discount Rate Benefit

10%

a. Decrease in infant mortality (US$)

b. Decrease in neonatal care (US$)

36 152 367 49 92 832 163%

35 85 205 15 35 10 100%

34 25 60 1 6 257 50%

c. Reduction in infant disease costs (US$) d. Productivity earnings for less growth delays (US$) e. Productivity earnings for higher cognitive ability (US$) f. Cost reduction for chronic diseases (US$) g. Inter-generational benefits (US$) Total US$ Percentage of total relative to a 5% discount scenario Source: Alderman and Behrman 2006.

The total estimated gain for the preferred estimates in the middle column (with a 5 percent discount rate, see point 5 below) suggest a purely economic benefit of US$510. Several features of these estimates merit note. First, if one were to focus only on the early-life benefits (e.g., benefits 1-3), under the assumptions of this table one would underestimate substantially the total benefits because the first three benefits are only about a third of the total. Second, over half of the benefits (57 percent) are due to productivity gains, not due to reduced health-related costs. Third, to avoid double-counting, increased schooling is not included as a benefit per se, but is a major pathway through which improved early life nutrition affects adult productivity by increasing cognitive ability.

2) Benefits generally depend on duration of the intervention and duration of exposure to the intervention. Many evaluations of programme impacts are made as if programmes started full steam on some official start-up date and full benefits and full impacts are experienced from the start of the programme. While this may be a good approximation for some programmes, such as a very efficiently-run inoculation programme that provides long-lasting benefits that are effective immediately, for most programmes such conditions are not likely to hold. Instead programmes are likely to face delays in starting up due to delays in the availability of key inputs and learning by the providers regarding how to provide services

effectively. Perhaps working somewhat in the opposite direction the initial providers of new programmes may be energized by being â&#x20AC;&#x153;pioneersâ&#x20AC;? so that over time their efforts decline (or the efforts of others when the programme is scaled up are not so considerable). Also there may be important learning about the existence and the effectiveness of programmes on the part of the potential users of the programme. Further, for biological reasons or because there are basic nonlinearities in some of the relevant processes (e.g., thresholds in learning processes), programme impacts may require time to play out and may play out in nonlinear matters. For all these reasons attention need be paid to timing and duration effects in evaluating impacts of nutritional and other interventions (see Behrman and King 2008 and King and Behrman 2008 for further discussion and some illustrations).

3) Associations are not the same as benefits, given behavioural choices. As noted above, there may be a challenge, for example, in identifying the causal impact of stunting at 36 months on subsequent outcomes if stunting proxies in part for unobserved family background, genetic endowments and other factors. The quality of the data and the estimation methods used together determine how credible are claims of estimates of causality. Critical characteristics of the data include having baseline (i.e. pre-intervention) and longitudinal fol115

low-up data (ideally for all impacts, many years) that is representative of some relevant population (e.g., not selected by clinic use), that has sufficient sample size for power to estimate the desired effects and that has sufficient detail about the intervention and about responses to the intervention to be able to understand the timing and duration issues noted in point 2. Also critical is the establishment of treatment and control groups. Ideally one would like to compare the impacts of receiving treatment versus not receiving treatment on the same individual at the same time. But this is not possible. The best approximation for evaluating a specific intervention generally is random assignment to treatment versus control for a sufficiently large sample, though good design and implementation are necessary to avoid contamination through spill over effects or selective attrition. If many of the impacts of interest are long run, as suggested above, it may be difficult to maintain experiments long enough to ascertain their outcomes and, even if possible, costly in terms of having to wait decades before learning the results. Therefore, other means of establishing treatment versus control groups or exploring counterfactuals (e.g., variations in interventions, interventions of much greater duration than yet observed) are likely to be important, albeit with stronger assumptions required. For example, propensity score matching in which comparisons are made between individuals who received treatment and individuals who are very similar in terms of observed characteristics may be informative (e.g., Behrman, Cheng and Todd 2004 provide an illustration for an evaluation of a Bolivian early childhood development programme with a large nutritional component). Or other statistical methods may be used (e.g., Behrman et al. 2008 report the effect 116

size of pre-school stunting on adult reading comprehension scores is 0.49 standard deviations if instrumental variable methods are used to control for the behavioural determinants and measurement error in pre-school stunting, which is much larger than would appear from the association in the data). Finally, structural models in which the underlying structural relations are estimated can be used to explore counterfactual interventions not yet observed (e.g., Todd and Wolpin 2006 provide an illustration based on the well-known Mexican PROGRESA anti-poverty and human resource investment programme).

4) Combining benefits. To combine the various impacts that an early life nutritional intervention might have, it is necessary to measure them in the same metric. The most common procedure is to measure them in monetary terms (as in Table 1), which also facilitates comparisons with other nutritional and non-nutritional interventions. For some impacts (e.g., the market value of increased productivity), such valuations are relatively straightforward. For others, the valuation is more difficult. For example, how should adverted mortality be valued? For Table 1 the economic value of adverted mortality was valued at the least cost alternative way (e.g., inoculations) of adverting mortality in a society such as that being considered. But arguments can be made for using other values for adverted mortality, most of which would value it more, perhaps much more (e.g., Behrman, Alderman, and Hoddinott 2004 give some examples). Therefore, if there is an impact for which the valuation is particularly subject to question such as adverted mortality, it may be desirable to value all the other impacts and to give alternative estimates for this outcome or to note separately the impact on this outcome.

5) Present discounted value (PDV) of benefits by discounting and by adjusting for survival probabilities.

uses (opportunity costs), not the transfer of purchasing power from one group of individuals to another.

A benefit of a given monetary value (e.g., 1,000 pesos) is worth more if it is received quickly than if there is a long lag because, if it is received quickly, it can be reinvested to obtain further benefits. Therefore the benefits should be discounted by the relevant discount rate to obtain their present discounted value (PDV). The PDV may vary considerably for benefits that are received some time into the future. For instance, the PDV of 1,000 pesos received in forty years is 307 pesos with a 3 percent discount rate, 142 pesos with a 5 percent discount rate and 22 pesos with a 10 percent discount rate. This pattern reflects that with higher discount rates due to higher rates of returns on investments, more is foregone by waiting than with lower discount rates. The three columns in Table 1 illustrate not only that the total PDV changes a fair amount with the discount rate, but also that the relative contribution of the benefits changes a fair amount with the discount rates (with benefits later in the life cycle more valuable the less the discount rate, for which reason the PDV of benefits from reducing chronic illnesses late in the life cycle may not be all that large even if there are large resource costs associated with such illnesses when they occur). Because it is not clear what is the appropriate discount rate (though 5 percent is often used for the social sectors), it is desirable—as again illustrated in Table 1—to see how sensitive estimates of the benefits are to the choice of discount rates.

Second, to raise revenues for public expenditures typically involves introducing distortions that have resource costs. The estimates of this cost vary considerably (see references in Knowles and Behrman 2005), but 25 percent of the governmental revenues is the order of magnitude that often is thought to be appropriate. Third, in addition to public resource costs, most interventions have private resource costs. Perhaps the most common such cost is the opportunity cost of time that private individuals (e.g., mothers of small infants) have to devote to receiving some intervention. Fourth, time and duration are likely to enter into the cost side as in the benefit side discussed above. Fifth, typically there are initial start-up costs and subsequent costs over time, so to obtain the PDV of costs they must be discounted back to the present.

Separate from the question of discounting future benefits, there is the point that benefits at any given age will be obtained from previous human capital investments such as in early-life nutrition only if the individual survives to that age. Current World Health Organization life tables for Guatemala, for example, imply that about 87 out of every 100 infants will survive to the 40-44 year age range. This means that longer-run benefits will be less than were the survival rate higher. For the estimates with the 5 percent discount rate in Table 1, for example, the PDV of the benefits would be overestimated by about 14 percent if they had not been adjusted for survival probabilities.

Economic Costs The economic costs are the additional resource costs due to the intervention. Five points are important to emphasize about such costs. First, the economic costs are not the same as the governmental budgetary expenditures even though often there is reference to such expenditures in discussions of costs of interventions. Indeed, these expenditures do not even necessarily represent well the public sector resource costs of interventions, particularly if the interventions include transfer components (as, for example, in well-known conditional cash transfer programmes such as PROGRESA/Oportunidades in Mexico). The public sector resource costs are just the use of resources such as personnel and supplies that have alternative

Some Illustrative Benefit-Cost Ratios for Nutritional Interventions Good estimates of large benefits of a nutritional intervention do not constitute a sufficient basis for arguing that the programme should be instituted, maintained or expanded. There are at least two further questions that should be addressed beyond whether the programme has a significant benefit. First, what are the benefits relative to the costs. Second, do the social rates of returns exceed the private rates of returns to investing in this nutritional intervention so that there is an efficiency motive for such investments beyond any distributional motive (see Knowles and Behrman 2005 for further discussion of this point). Unfortunately, there is little evidence with regard to the second point, though the possibilities of “market failures” for information and for capital suggest that there may be an efficiency argument favouring some nutritional interventions, particularly those directed effectively towards the poorer members of society who are likely to be most affected by these market failures. There also are relatively few estimates of the benefit-cost ratios for nutritional interventions. Too often advocates of such interventions implicitly seem to assume that if the benefits are large that is sufficient justification for the intervention. However not only the benefits but also the costs are relevant for judging society’s decisions about allocating resources. If the benefit-cost ratio exceeds one, then there is a case for using scarce resources for that intervention. Table 2 provides what the authors maintain are conservative estimates of the benefitcost ratios for selected nutritional interventions, primary related to early life or pregnant women, with ranges to reflect alternative underlying assumptions such as for the discount rates (see Behrman, Alderman and Hoddinott 2004 for details). Generally these estimates are greater than one, often much greater than one, suggesting that the benefits to using scarce resources for these interventions greatly exceeds the resource costs of the interventions.

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These estimates also effectively made the case that such nutritional interventions should be high priority in comparison with many other possibly high priority interventions in developing countries in the 2004 Copenhagen Consensus. At the Copenhagen Consensus, a panel of eight internationally prominent economists (four of whom have received Nobel prizes) prioritized up to five projects each in ten great global challenges (selected from a wider set of issues identified by the United Nations) based in part on such benefit-cost calculations for the alternative projects: 1) Civil conflicts; 2) Climate change; 3) Communicable diseases; 4) Education; 5) Financial stability; 6) Governance; 7) Hunger and malnutrition; 8) Migration; 9) Trade reform; and 10) Water and sanitation. Comparisons among projects in such disparate areas, of course, are challenging. But, subject to a number of caveats, benefit-cost ra-

118

tios give a metre stick with which to make such comparisons and to establish priorities even though from some perspective each of the issues is viewed as important on its own. Table 3 gives the 2004 Copenhagen Consensus expert ranking. Nutritional interventions ranked quite high in these priorities. Thus the use of the benefitcost estimates apparently was instrumented in persuading this expert group of non-nutritionists what many in the nutritional community believed, but were not always able to articulate sufficiently persuasively to policy makers (or ministries of finance): that certain nutritional interventions should be given very high priority.

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1,3-10,7 4,1-35,2

1b. Treatments for women presumably with sexually-transmitted diseases

1c. Drugs for pregnant women with poor obstetric history

4,3-43 176-200 6,1-14

3b. Vitamin A (children under 6)

3c. Iron (per capita)

3d. Iron (pregnant women)

Source: Behrman, Alderman and Hoddinott 2004

15-520

3a. Iodine (women with infant children)

1,4-2,9

9,4-16,2

2b. Comprehensive child care programmes

2c. Intensive pre-school programme with considerable nutrition for poor families 3. Reduction in micronutrient deficiencies in populations where they are prevalent

4,8-7,4

2a. Promotion of breastfeeding in hospitals normally promoting formulas

2. Improvement in infant and child nutrition in populations with high malnutrition prevalence (widespread among poor populations)

0,6-4,9

Benefits / Costs

1a. Treatments for women with asymptomatic bacterial infections

1. Reduction in low birth weight (LBW) in pregnancies with high LBW probability (especially in South Asia)

Target Opportunities and Populations

TamaTarget Population Size

2 billion persons with iodine deficiency 128 mill. pre-schoolers 3.5 billion, including 67 million pregnant women

0-5 years

162 million children with growth retardation

12 million LBW births per year

Table 2 Estimation of the Benefit/Cost Coefficient for Selected Nutritional Interventions

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Table 3 PProject Ranking in Copenhagen Consensus

Project Rating 1 Very Good

2 3 4 5 6

Good

7 8 9 10 11

Fair 12 13 14 15 Bad 16 17

Challenge

Opportunity

Diseases

Control of HIV/AIDS

Malnutrition

Providing micro nutrients

Subsidies and Trade

Trace liberalization

Diseases

Control of Malaria

Malnutrition

Development of new agricultural technologies

Sanitation and Water

Small scale water technology for livelihoods

Sanitation and Water

Community-managed water supply and sanitation

Sanitation and Water

Research on water productivity in food production

Government

Lowering the cost of starting a new business

Migration

Lowering the barriers to migration for skilled workers

Malnutrition

Improving infant and child nutrition

Malnutrition

Reducing the prevalence of low birth weight

Diseases

Scaled up basic health services

Migration

Guest worker programs for the unskilled

Climate

Optimal carbon tax

Climate

The Kyoto Protocal

Climate

"value-at-risk" carbon tax Source: Lomborg 2004

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Conclusions There is increasing evidence that there are strong associations between improved early life nutrition and subsequent outcomes. A few studies, such as the Guatemalan INCAP study summarized above, provide strong evidence that there are strong causal long-run effects. To interpret such results for the purpose of prioritizing allocations of resources to nutritional interventions versus other possibly important use, it is very useful to carefully evaluate both the impacts and costs of nutritional programmes over time and in different contexts. Such evaluations are demanding in terms of the data requirements and the analytical methods used. But they are likely to lead to important insights regarding whether programmes can be improved and whether they should be maintained, as well as whether they should be replicated in other contexts and what priorities they should have in comparison with other uses of scarce resources. Quite often the benefits from more systematic evaluation of nutritional programmes appear to exceed substantially the costs (as appears to be the case, for example, for the Mexican PROGRESA/Oportunidades programme that has an important nutritional component, see Behrman 2007).

References Alderman H, Behrman JR. 2006. “Reducing the Incidence of Low Birth Weight in Low-Income Countries has Substantial Economic Benefits.” World Bank Research Observer 21(1): 25-48. Behrman JR. 2007. “Policy-oriented Research Impact Assessment (PORIA) Case Study on the International Food Policy Research Institute (IFPRI) and the Mexican PROGRESA Anti-poverty and Human Resource Investment Conditional Cash Transfer Programme.” Washington, DC: IFPRI Impact Assessment Discussion Paper #27. Behrman JR, Alderman H, Hoddinott J. 2004. “Hunger and Malnutrition”. In Bjørn Lomborg, ed., Global Crises, Global Solutions. Cambridge, UK: Cambridge University Press. Behrman JR, Hoddinott J, Maluccio JA, Soler-Hampejsek E, Behrman EL, Martorell R, Ramírez M, Stein AD. 2008. “What Determines Adult Skills? Impacts of Pre-School, School-Years and Post-School Experiences in Guatemala.” Philadelphia, PA: University of Pennsylvania, mimeo. Behrman JR, King EM. 2008. “Programme Impact and Variation in Duration of Exposure”. In Amin S, Das J, Goldstein M, eds., Are You Being Served: New Tools for Measuring Service Delivery. Washington, DC: World Bank. Grajeda R, Behrman JR, Flores R, Maluccio JA, Martorell R, Stein AD. 2005. “The Human Capital Study 2002-04: Tracking, Data Collection, Coverage and Attrition.” Food and Nutrition Bulletin 26(S2): S15-S24. Habicht J-P, Martorell R, Rivera JA. 1995. “Nutritional Impact of Supplementation in the INCAP Longitudinal Study: Analytic Strategies and Inferences.” Journal of Nutrition 125 (Suppl. 4S): 1042S-1050S. Hoddinott J, Maluccio JA, Behrman JR, Flores R, Martorell R. 2008. “The Impact of Nutrition During Early Childhood on Income, Hours Worked, and Wages of Guatemalan Adults.” The Lancet 371 (February), 411-416). King EM, Behrman JR. 2008. “Timing and Duration of Exposure in Evaluations of Social Programmes.” World Bank Research Observer (forthcoming). Knowles JC, Behrman JR. 2005. “Economic Returns to Investing in Youth”. In Behrman JR, Cohen B, Lloyd C, Stromquist N, eds., The Transition to Adulthood in Developing Countries: Selected Studies. Washington, DC: National Academy of Science-National Research Council.

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Lomborg B, ed. 2004. Global Crises, Global Solutions. Cambridge, UK: Cambridge University Press. Maluccio J, Hoddinott J, Behrman JR, Martorell R, Quisumbing A, Stein A. 2008. “The Impact of Improving Nutrition during Early Childhood on Education among Guatemalan Adults.” Economic Journal (forthcoming). Martorell R. 1992. “Overview of Long-Term Nutrition Intervention Studies Carried Out in Guatemala (1968-1989).” Food and Nutrition Bulletin 14(3): 270-277. Martorell R, Habicht J-P, Rivera JA. 1995. “History and Design of the INCAP Longitudinal Study (1969-77) and Its Follow-Up (1988-89).” Journal of Nutrition 125 (Suppl. 4S): 1027S1041S. Schroeder DG, Martorell R, Rivera JA, Ruel MT, Habicht J-P. 1995. “Age Differences in the Impact of Nutritional Supplementation on Growth.” Journal of Nutrition 125 (Suppl. 4S): 1051S-1059S. Todd PE, Wolpin KI. 2006. “Using a Social Experiment to Validate a Dynamic Behavioral Model of Child Schooling and Fertility: Assessing the Impact of a School Subsidy Programme in Mexico.” American Economics Review 96(5): 1384-1417. Victora CG , Adair L, Fall C, Hallal PC, Martorell R, Richter L, Sachdev HS, for the “Maternal and Child Undernutrition Study Group”. 2008. “Undernutrition 2: Maternal and Child Undernutrition: Consequences for Adult Health and Human Capital.” The Lancet 371 (Issue 9609): 340357.

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Evaluating nutritional policies and programmes: a reflection Juan Ángel Rivera Dommarco Deputy Director-General of the Research Centre of the National Nutrition and Health Institute of the National Institute of Public Health (Instituto Nacional de Salud Pública [INSP]), Mexico

Key elements exist to guarantee that the evaluation exercise is efficient, transparent, effective, and useful. Some of these elements are listed below: 1. The evaluation of programmes and policies should be undertaken by independent organizations with technical, logistical, and operational capacities. Evaluations undertaken by the organization operating the programme run the risk of not being objective and failing to generate credibility and certainty. Moreover, it is not sufficient that the evaluating institution be independent. Evaluations must be carried out by organizations possessing the technical, logistical, and operational capacity to design an evaluation, the ability to ask for and obtain the necessary information, and the capacity to analyze and interpret the data and create reports, using scientifically sustained techniques and methodologies. 2. Resorting to a high level entity that can serve as an intermediary between evaluators and those being evaluated is recommendable to ensure greater objectivity in the evaluations and to create a mediating agency in case the persons responsible for the programme disagree with the evaluators’ conclusions or recommendations. This mediating agency can also be useful to reduce the possibility that evaluations will be overly complacent or insufficiently critical and, therefore, fail to provide useful observations or recommendations that could improve an inadequately functioning programme. Chile and Mexico have public organizations in charge of establishing evaluation guidelines, coordinating evaluations, and acting as mediators between programmes and evaluators.

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Juan Ángel Rivera Dommarco

There are at least three objectives in evaluating policies and programmes, the recognition of which is crucial in order to maximize the utility of the exercise. First, evaluations should be considered an instrument for providing feedback to those responsible for programmes and policies on their performance, results, and impacts and proposing recommendations to improve their functioning and effects. In second place, evaluations should be considered an accountability instrument for public and private resources used in the implementation of policies and programmes. Evaluations should be thought of as useful tools to ensure resource management that is transparent, responsible, efficient, and effective and to facilitate the development of public goods. Finally, evaluations, in their broadest manifestation, should take into consideration the totality of programmes and actions that form a State or Government policy. Policy evaluation is, therefore, an exercise that goes beyond the addition of individual evaluations of programmes and actions, and should identify interactions, complementary actions, and synergies among them to produce coherent and effective policies that attain their purposes.

Deputy Director-General of the Research Centre of the National Nutrition and Health Institute of the National Institute of Public Health (Instituto Nacional de Salud Pública [INSP]), Mexico

The reflections that follow refer specifically to the evaluation of nutrition policies and programmes of a country or region, but generally apply to social programmes and policies, including social development, agriculture, health, and feeding programmes.

3. The evaluation of programmes and policies has a technical-scientific aspect and a political component. The evaluator should recognize both components and communicate the results in an adequate way to technical and political audiences. Ensuring that those in charge have the vision and experience to recognize and distinguish between both components is important in selecting evaluators. Adequate evaluation of a programme rests on three types of evaluation exercises: a) design and consistency evaluations, b) process or performance evaluations, and c) impact or effectiveness evaluations (including cost-benefit and cost-effectiveness relationships). The following sections elaborate on each type.

Design and Consistency Evaluations The first step in programme evaluation is revising the conceptual framework to ensure that there is evidence that it is possible to achieve the desired effects if the programme is applied in accordance with the established operating procedures. The pertinence and effectiveness of actions or services provided to the beneficiary population must be identified to ensure that these actions are adequate given the necessities, goals, and objectives of the programme. Targeting the benefits and services offered to the most vulnerable population and the population with the highest probability of achieving the desired results should also be ensured. Design and consistency evaluations are, perhaps, the least valued and utilized types of evaluation, which is paradoxical, given its utility and low cost. An example of lack of effectiveness in a food distribution policy, resulting from an absence of design and consistency evaluations, occurred in Mexico in the 1980s. Mexico has a long history of executing policies and programmes designed to improve the nutrition of vulnerable groups. Undernutrition, however, has remained one of the country’s most important public health challenges. Various publications by the National Institute of Public (INSP) have taken a historical approach to analyzing the principal strategies, programmes, and policies that have been put into place in Mexico, examining their design and implementation, along with some of their results. In the analysis we have conducted it is evident that Mexico has made large investments in food assistance programmes. For example, in 1993 the Mexican government spent more than 2 million dollars a day on food assistance programmes, including consumer subsidy programmes. This amount is superior to the minimum level of food assistance recommended by various organizations to improve the population’s nutrition. However, the prevalence of undernutrition, anaemia, and micronutrient deficiencies was still high. Additionally, despite increased investment in food assistance programmes, the rate of reduction of low height prevalence (an indicator of chronic undernutrition) was inferior to that expected during the 1990s.

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These observations led to the examination of several aspects of the food assistance provided by the Government in 1988, using survey data collected that year, and of the magnitude and distribution of this help, compared to the nutrition needs of the population. The fact that the programme was not targeted to the population mostly in need of the assistance was one of the reasons for low effectiveness. Of almost two million children with low height, nearly 45 percent lived in the southern area of the country, the poorest region. Less than 9 percent lived in Mexico City, where 51 percent of the beneficiary families were located. Only 15 percent lived in the south, the region with the greatest nutritional vulnerability. The probability of receiving food assistance was 0.47 for families in rural versus urban areas; 0.24 for indigenous families relative to non-indigenous families; 0.42 for families in the low conditions tercile vs. the high living conditions tercile; 0.87 for families with children under two versus families with children from two to four years of age; and 0.65 for families with low-height children relative to families without low-height children. In addition to the urban emphasis and the lack of geographic targeting of marginal areas, the examination also discovered that the distributed foods and subsidies were not adequate for children from six to 24 months. Furthermore, there was a lack of coordination among programmes, resulting in the duplication of efforts and benefits. The education component of the programme was also weak. These results were very useful in modifying the fundamentals of nutrition policies and programmes during the late 1990s. The final reflection is that high costs failing to produce corresponding benefits could have been avoided by undertaking a design and consistency evaluation of Mexico’s food distribution programmes in the 1980s.

Impact Evaluations Impact and effectiveness evaluations allow us to assign causality and make statistical assertions about a programme’s effects. The ideal impact evaluation design is based on random allocation, including a control group. This design, however, is not always possible for logistic, political, or ethical reasons. For example, if a small country decides to implement actions of proven efficacy to improve children’s nutrition and has the resources to apply the programme immediately, it may not be justifiable, from an ethical point of view, to deprive a group of the benefits or services the programme will distribute. In this case, it is probably not possible to use a design with a randomly allocated control group. On the other hand, if a large country does not have the resources or logistic capacity to initiate a universal coverage programme, the programme will probably begin in certain regions, and—gradually—

expand to the entire target population. In this case, a design with randomly allocated control groups, which can later be integrated into the programme, is justified. When random allocation is not possible, there are alternative designs allowing the formulation of valid plausibility assertions. For example, using several variables it is possible to select units (communities, homes, or individuals) that share characteristics with the beneficiary groups but not receiving the programme benefits. There are various methodologies for choosing pairing units. To assure that the results of impact evaluations and their interpretations are adequate, precautions must be taken to assure the validity of the design, including the following:

路 Assuring that the time elapsed between the baseline measurement and the final evaluation is sufficiently long to document changes in selected variables, given the intervention. 路 Incorporating proximal (intermediate) variables that explain, if needed, a lack in distal (final outcome) variables. This is fundamental, given that evaluation design is often modified for political reasons. 路 Ensuring that the sample size of the comparison groups allows an evaluation of the expected changes in the outcome variables.

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Process or Performance Evaluations The impact or effectiveness of a programme should not be assessed without evaluating design and consistency as well as process or performance. These types of evaluations should not be separated. An impact evaluation that does not include information on design and intermediate variables is equivalent to a black box, in which the inputs and effects are known but the mechanisms remain unidentified. In the absence of a programmeâ&#x20AC;&#x2122;s impact, a lack of information about performance or process and of intermediate variables does not allow the identification of causes of lack of effectiveness. Is the lack of efficacy a result of the application of interventions, ineffective ac-

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tions, or the incorrect application of measures or effective interventions? The two principal areas of interest in process or performance evaluations are the system of delivering benefits or services and the utilization of these services on the part of the population.

Performance of Delivery Systems All programmes should assure that benefits arrive to the target population in the quantity and quality established by the programmesâ&#x20AC;&#x2122; operating procedures. Any failure in the benefits or service delivery system is sufficient to negate the expected effects. A performance evaluation should study the delivery programme, identify its failures, and provide feedback to those in charge of the programme.

Utilization of Services or Benefits Even if the benefits and service delivery is adequate, it is possible that the target population will not demand or utilize benefits and services appropriately. In general, nutritional programmes require the adoption of new behaviours and practices among the beneficiary population to achieve the desired effects. For example, the “Opportunities” Programme in Mexico delivers, among other benefits, free food fortified with micronutrients for children aged between six and 23 months. In this case, delivery of food to the mother when she attends her health care appointments is not enough. It is also necessary that the mother adequately prepare the foods, adding the appropriate amount of water, and give the food to the targeted child and not older children or other family members. An educational communication component is required to attain adequate food preparation and administration to generate new behavioural patterns. From its design, the “Opportunities” Programme included an educational component consisting of talks by health personnel (physicians or nurses) to beneficiary mothers with children under two. On behalf of the Programme, INSP evaluated its performance and found that the talks did not successfully achieve the objective of implementing those behavioural patterns needed to ensure that children consumed the delivered products in the expected amounts and with the required frequency. A problem was identified with educational techniques. Talks used traditional methodologies, based on long presentations by health care professionals, with support material that was inadequate for

the target population’s culture. Messages and content were not centered on behavioural changes and mothers only listened, instead of participating as well. Talks were also held at inadequate places. Frequently, there were not enough chairs for all attendants. Mothers attended with their children, who often cried during the talks and interfered with the learning process. Through formative research and social marketing, INSP developed a programme of education communication, directed towards the adoption of key behaviours to achieve the desired changes. Various means were employed, including posters; workshops with demonstrations on the preparation of foods, in which mothers and children participated and children consumed the food that was prepared; mass media announcements; videos for physicians and health care professionals to motivate them to consider fortified foods as an effective instrument for improving children’s nutrition and quality of life; and videos for benefiting mothers in the Programme. This strategy was implemented on a small scale and evaluated. The evaluation was very positive, demonstrating that changes in the behaviour of the families related to improved preparation and utilization of fortified foods. This led to the adoption of the system, which is currently being implemented on a full scale. This is an example of the usefulness of process evaluations as instruments for improving the operation of a programme or the design of certain components. These reflections jointly refer to the evaluation exercise as an instrument for improving the design and implementation of programmes and policies and for rendering the use of public and private resources in programme implementation accountable. The final objective of these evaluations is to achieve the proposed effects at the lowest costs possible.

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Monitoring and evaluation of nutrition programmes: Twelve important observations David Bravo Director of the Microdata Centre of the Department of Economics of the University of Chile

2. When dealing with regional-level objectives in Latin America, challenges associated with the necessary harmonization of monitoring and evaluation systems immediately emerge. This harmonization is essential because: a) It provides impact lessons that are generalizable to other countries; and b) It takes advantage of the public good dimension of evaluations. Given that evaluations are expensive, it is not necessary to evaluate the impact of all types of programmes in every country. A harmonized system allows all countries to take advantage of a few well-designed evaluations in each country. In this context, the framework pursued by WFP within the initiative to eradicate child undernutrition in Central America and the Dominican Republic, developed by the Microdata Centre at the University of Chile, is worthy of note (Atalah et al. 2007). 3. Monitoring and evaluation are fundamental for: a) Providing feedback on the functioning of programmes; b) Assuring continuity of State efforts over time (even under different Governments); c) Assuring transparency and accountability. 4. Three types of evaluation can be identified. These evaluations should be incorporated within a monitoring and evaluation system. a) Programme design evaluations are important to determine which strategies or programmes are capable of accomplishing the stated objectives; b) Process evaluations help determine whether or not interventions have been implemented 131

David Bravo

1. A monitoring and evaluation system is one of the pillars of any initiative designed to eradicate child undernutrition in the region. Without such a system, it would not be possible to follow up on the achievement of proposed objectives at the regional, country, and domestic programme levels. The World Food Programme (WFP) understands this and has led and promoted the incorporation of monitoring and evaluation programmes within country agendas.

Director of the Microdata Centre of the Department of Economics of the University of Chile

The following twelve points relate to the contributions by doctors Behrman and Rivera on monitoring and evaluation:

according to plans, in addition to providing information about a programme’s institutionalization and the context in which it was implemented; and

that can face different problems related to the political aspects of programmes; and b) Developing local level capacities to implement evaluations.

c) Impact evaluations help establish the causal effects of the nutrition intervention on target indicators. 5. The foundations of a monitoring and evaluation system are provided by a nutritional surveillance system that permits the monitoring, among mothers and children, on an individual level, of anthropometric and other indicators. 6. The implementation of a monitoring and evaluation system implies the necessity of developing institutional capacities, which requires: a) A mechanism that assures the independence of evaluations and 132

7. In designing impact evaluations for child undernutrition eradication programmes, it is fundamental to use a control group. Causal relationships cannot be established—and whether or not a programme has met its objectives cannot be determined—without an adequate control group. For the selection of control groups, the golden rule is random allocation of treatment status. When this is not possible, other methods—which should be analyzed on a caseby-case basis—can be utilized. If ethical dilemmas prevent random allocation of a control group, other strategies can be employed for implementation, such as taking advantage of gradual programme implementation for budgetary reasons or using pilot programmes. A significant ethical dilemma occurs if a country is not able to esta-

in the design of a strategy to use control groups, identify appropriate sample sizes, plan the application of surveys, etc. 9. A monitoring and evaluation system relies on defined results and indicators that can be used to measure them. Professor Behrman’s piece demonstrated that there is a broad range of indicators that can be used to evaluate policies. Basing monitoring and evaluation systems on logical framework matrices, which allow the construction of outcome indicators at various levels corresponding to each policy or programme objective, is recommendable and useful. 10. An evaluation system should clearly define its timeline. Depending on when the impact of the indicators is expected, the distribution of surveys and data in the administrative or monitoring system should be planned to construct indicators for appropriate times. 11. A system of impact follow-up, monitoring, and evaluation should be based on data collection. For this purpose, it is fundamental to: a) Plan the implementation of baselines in such a way that allows a configuration of the situation preceding the implementation of the interventions that are to be evaluated; b) Plan the surveys it will be necessary to apply, understanding that this requires gathering longitudinal data—in other words, that the same individuals must be followed up (even at the sample level) over time; and c) Ensure that the surveys are conducted by competent organizations to ensure the quality of the data.

blish the impact of millions of dollars invested in programmes because there was not an adequate control group. 8. When should monitoring and evaluation be planned? Early on, ideally along with the programme design. This allows more options

12. Finally, it has been emphasized that the follow-up, monitoring, and evaluation system should collect information about the costs of programmes and interventions, in such a way that cost-benefit or cost-effectiveness analyses might be implemented, so that benefits derive from implemented impact evaluations. This analysis is fundamental to rank the most effective interventions, in terms of cost, as well as to compile evidence that can demonstrate the impact relative to costs of nutritional interventions, as has already been corroborated by international studies.

References Atalah E, Bravo D, Pizarro M, Yepes M. 2007. “Monitoreo y evaluación de impacto: herramientas claves en el combate a la desnutrición infantil en Centroamérica y la República Dominicana.” Department of Economics Microdata Centre, University of Chile and World Food Programme (WFP).

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Chapter 3

THEORETICAL AND PRACTICAL FRAMEWORKS FOR PRESERVING NUTRITION IN CRISIS MOMENTS Monckeberg F. Prevención de la desnutrición en Chile. Rev Chil Nutr 2003; 30 (Suplemento Nº 1): 160-176. Lewin L, Puentes R, Saavedra R et al. Programa Colocación Familiar en Niños Desnutridos (COFADE). Rev Chil Nutr 1989; 17 (Suplemento Nº 1):65-76.

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SUMMARY This chapter contains the paper submitted at the Regional Ministerial Conference in Santiago by Fitzroy Henry, Director of the Caribbean Food and Nutrition Institute (CFNI). Dr. Henry presents a typology of critical situations that affect the states of the Caribbean, including environmental disasters (droughts, floods, earthquakes, hurricanes, volcanic eruptions), economic crises (depressions or price inflation), epidemics (hoof and mouth disease, locusts, HIV/AIDS), political crises (violence, internal displacement), and social problems (breakdown of safety networks, collapse of informal support networks). These crises negatively impact the nutritional condition of the population because they alter the availability of and access to foods, feeding practices and habits, the distribution and preparation of food, breastfeeding practices. They interrupt the care and feeding of children, generate infections and disease, and cause micronutrient deficiencies and undernutrition. Dr. Henry emphasizes the necessity of relying on solid programmes, targeted to the most vulnerable groups, to preserve nutrition during the traumatic episodes that follow crises. Many solid programmes have the possibility of resisting annual hurricanes and other crises. These programmes include mother-and-child health initiatives (including breastfeeding and iron supplementation), school feeding, and food fortification programmes. Food price inflation, however, has the potential to reverse the nutritional accomplishments achieved in some Caribbean countries.

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Preserving nutrition in crises: The caribbean experience Fitzroy J. Henry Director of the Caribbean Food and Nutrition Institute (PAHO/WHO)

Crises and Nutrition The Effect of Crises on Nutritional Status and Development

The recent history of the Caribbean has shown some spectacular gains in health and the improvement of nutritional status was critical to that achievement. Every year, compelling scientific evidence shows the growing importance of nutrition to both wellness and illness in our lives. In the Caribbean nutrition has crucial roles to play in poverty alleviation and safety net programmes; the health sector reform processes; the global food trade issues; and human rights entitlements. The importance of nutrition therefore goes well beyond the MDG targets and has an even more profound role in health for all and other aspects of national and regional development. This concept of nutrition and national development also needs to consider the additional shocks from crises created by natural and man-made disasters. Figure 1 shows that both slow-onset and suddenonset disasters can influence nutritional status. But the effects are quite different. Hurricanes and floods directly affect food availability but not all sudden-onset disasters produce food shortages severe enough to cause harmful changes in nutritional status. Sudden-onset disasters, however, cause disruption of transportation and communication systems and distortions in social and economic activities. Countries that have food stocks may find them inaccessible due to the disruptions in the distribution system or loss of income with which to buy food. In the Caribbean the destruction of food cropsâ&#x20AC;&#x201D;particularly bananas, sugar and riceâ&#x20AC;&#x201D;affect the economic viability of the family and the country.

Crises and Childhood Nutrition In the Caribbean, prolonged crises affect the availability and access to food through the erosion of livelihoods resulting from crop failure, depletion of food stocks, market failure, among others. This in turn affects how the limited food is allocated within the family (see coping strategies below). Breastfeeding and complementary feeding practices are usually maintained during Caribbean crises and young children are given priority at feeding time. 137

Fitzroy J. Henry

The nutritional status of individuals in turn has an effect on the development of individuals, communities and nations. There is a false perception that nutrition is related only to Millennium Development Goal (MDG) 1â&#x20AC;&#x201D;extreme poverty and hunger. But nutrition has a crucial role to play directly or indirectly in attaining the development outcomes embodied in the first six of the MDGs, and much more.

Director of the Caribbean Food and Nutrition Institute (PAHO/WHO)

Before looking at crises we should first examine the non-crisis relationship between nutrition and development. Figure 1 shows that the major forces that affect nutritional status are economic, sociocultural, environmental and political. In various ways these forces combine to affect the health status and food intake of individuals through different intermediary factors. These factors separately and collectively influence the nutritional status of individuals.

The major threat to child nutrition comes from infection and ill health. Because of poor environmental infrastructure and the inadequate provisions or access to materials for personal hygiene such as clean water, many children are exposed to the risk of diarrhoea and other water/food borne illnesses during the crisis.

The Caribbean Experience Nutritional Status and Trends Undernutrition exists in the region but not as severe as in other parts of the world. For most countries in the Caribbean for which data are available the rates of undernourished children under five years old have been decreasing over the past decade (Table 1). Low and decreasing rates are observed for Trinidad, St. Kitts-Nevis, Dominica and Antigua-Barbuda, while Jamaica and Grenada show moderate rates. Undernutrition in St. Vincent and the Grenadines is relatively high, with the latest data showing an increasing trend Guyanaâ&#x20AC;&#x2122;s undernutrition rate has been decreasing in recent years but it is the highest compared to the other countries. Recent surveys in Guyana indicate that undernutrition is prevalent in rural communities, but especially among the indigenous population, most of whom live in the interior parts of the country where lack of economic opportunities and poor transportation network constrain access to adequate food and health care. A discussion on causes of malnutrition will be vacuous without considering poverty. Table 1 therefore reports on poverty rates in several Caribbean countries. Despite considerable economic progress in post-independence Caribbean, poverty and inequalities in income and access to resources are at unacceptably high levels, and continue to be major challenges in this region. Carlson (1999) identifies these twin problems as key factors that have constrained growth and development in the Caribbean. The estimates of indigence poverty1 in Table 1 show a wide range among the countries. Closely related to poverty is the issue of inequality. Recent research shows that reducing inequality can actually reduce the number of households in poverty but that efforts to achieve this goal through growth must be complemented by policies to reduce inequality (Cornea and Court, 2001). A standard measure of inequality is the Gini coefficient, which ranges between 0 (absolute equality) and 1 (one person/household receives all the income). The Gini coefficients reported in Table 1 indicate relatively high levels of income inequality. These levels of inequalities are among the highest in the world (Thomas and Wint (2002). It is instructive to note that although there is not a strongly consistent relationship, some of the countries with the highest undernutrition rates also have the most poverty and large inequities. Among the micronutrient deficiencies, iron deficiency anaemia is the most common in the Caribbean. Poor dietary intake and utilization are possible reasons for this. During prolonged crises many families cope by altering the quality of the diet and consequently, anaemia could be severely affected. In most countries of the region, anaemia prevention and control programmes do exist, however, young children are often not among those targeted in public clinics. The programmes are invariably constrained by scarce financial resources, which prevent both broad coverage and expansion of the programme. The indigence poverty line (IPL) is a culturally accepted and nutritionally adequate diet for a family of four, based on the lowest market cost for a 2400 caloric requirement for adults and 720 calories for children under 12. The poverty line (APL) = IPL plus other basic non-food requirements (e.g., education, health, transportation, housing, etc.). A household is considered poor if its expenditure is less than the APL.

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Table 1 Nutritional Trends in Relation to Poverty and Inequity in the Caribbean 1994-1996, 2000-2003

COUNTRIES

1994-1996 (Maln <5)

2000-2003 (Maln <5)

TREND

Indigence Poverty (%)

Gini Coefficient

0,43

Guyana

19,0

HIGH RATES 8,0

Belize St. Vincent

15,0 5,7

7,3 5,9

È Ç

13 26

0,51 0,56

Jamaica

5,6

MODERATE 3,6

0,38

Grenada

1,5

3,4

0,45

Trinidad

3,4

LOW RATES 2,5

0,41

St. Kitts Dominica

4,4 2,3

2,0 1,6

È È

17 15

0,37 0,35

Antigua

1,8

1,2

0,48

Source: (i) Undernutrition—country clinic data; (ii) Poverty data and Gini coefficient—Country Poverty Assessments and Poverty Reduction Strategy Papers conducted by the Caribbean Development Band and the World Bank, respectively.

Impact of Natural Disasters The Caribbean is prone to natural disasters, particularly hurricanes. Between June and November each year the West Indian islands are threatened by several tropical storms which often bring with them floods and land slides. The region also experiences regular periods of drought and, less frequently, earthquakes. Hurricanes, floods and drought often devastate the crops and the agriculture base of the Caribbean economies. This has a direct effect on domestic food supplies and also foreign exchange earnings which are required to buy food, among other needs. Table 2 shows the top ten recent disasters ranked by monetary loss. Note that some countries were hit twice in the same (Bahamas) or consecutive (Grenada) years. Also, the same hurricane (Ivan) can devastate several countries in just a few days. The effects of a disaster usually depend on the existing infrastructure in the country and the resources available to adequately prepare for it. The economic indicators presented in Table 3 are a proxy for the readiness of countries to absorb the effects of a disaster. Note that most countries are experiencing modest economic growth and the countries with the largest percent of vulnerable populations (Guyana and Haiti) are the ones with negative economic growth. To compound these fragile economies with natural disasters can therefore be catastrophic.

The information in Figure 2 is therefore instructive. It shows that despite the repeated assaults of hurricanes and floods the undernutrition rates in the region still showed a declining trend. Interestingly, the percentage of overweight children increased. Clearly other factors drive the overweight trend upwards. But why did the underweight population continue to decline despite these repeated shocks? It is contended here that three fundamental and robust programmes act as a buffer to these crises. 1) Maternal and Child Health programmes that protect the health and wellbeing of women, particularly pregnant and lactating women; family planning; breast feeding and complementary feeding programmes, child health and immunization; and iron and food supplementation of mothers and young children; 2) School feeding programmes that alleviate short-term hunger in undernourished and well-nourished schools children and avoid micronutrient deficiencies. There are also other benefits. In Jamaica, providing breakfast to primary school students significantly increased attendance and arithmetic scores; 3) Fortified foods are currently available across the Caribbean. With the exception of iron, micronutrient deficiency is low. The Caribbean population is currently being targeted through the fortification of flour with iron and vitamins. The flour products are widely eaten 139

Table 2 The Top Ten Recent Caribbean Disasters 1980-2005 #

1 2 3 4 5 6 7 8 9 10

DATE

COUNTRY

Dec 20, 2005 Sep 7, 2004 Sep 9, 2004 Sep 2, 2004 Sep 25, 2004 Aug 4, 1980 Sep 9, 1994 Jul 14, 2005 Nov 21, 2004 Nov 12, 2004

EVENT

GUYANA GRENADA JAMAICA BAHAMAS BAHAMAS ST. LUCIA ST. LUCIA GRENADA DOMINICA TRINIDAD

LOSSES (US$ MIL)

FLOOD HURRICANE (IVAN) HURRICANE (IVAN) HURRICANE (FRANCES) HURRICANE (JEANE) HURRICANE (ALLEN) HURRICANE (DEBBY) HURRICANE (EMILY) EARTHQUAKE MUDSLIDE

2,674 895 592 356 350 92 85 75 45 33

by the adult population and the challenge is to ensure that the iron level is monitored so that standards are adhered to. Another challenge is to ensure that suitable fortified flour products are eaten widely by young children as well. There is much scope to encourage this in promoting improved young child feeding practices.

Impact of Food Price Inflation The soaring prices in food commodities present another type of crisis which can have devastating consequences on attempts to preserve nutritional status, particularly in children. But to truly assess the impact of this crisis, these food price increases should be related to the purchasing power of those most vulnerable in society. To assess this impact we used the method of a “nutrient cost analysis” which specifies the minimum cost of obtaining a nutritious basket of commodities for a family of given size. The basket of commodities reflects foods that are currently available in local markets and with considerations to cultural preferences. The analysis requires a list of foods and their respective prices and computer software then generates the minimum cost nutritious basket of commodities.

Table 3 Economic Indicators of selected CARICOM countries c. 2003 STATES

Bahamas Belize Dominica Grenada Guyana Haiti Jamaica St. Kitts St. Lucia Trinidad

POP(000)

321 283 72 106 750 8.400 2.600 46 167 1.300

GDP/CAPUT (US$)

15.000 3.460 3.670 3.770 1.040 410 3.300 7.750 4.410 9.070 140

GDP/GROWTH (%)

POVERTY (%)

FOOD DEPRIVED (%) 2003

1,3 3,4 1,8 4,3 -0,3 -2,4 1,1 3,3 4,4 8,4

8 33 39 29 36 78 15 30 29 21

7 5 8 7 12 47 10 11 5 11

We prefer this method because:

• Fisher Folk

1) It provides guidance to consumers on how to allocate their food purchases under prevailing food prices while simultaneously meeting minimum nutrition criteria;

• Subsistence farmers

2) The cost of the basket of food can be expressed as a proportion of the minimum wage and tracked over time to gauge the purchasing power of low income earners;

• Inner city poor

3) It can be used in poverty analysis to estimate the number of persons below some given poverty threshold;

• Rice farmers

• Sugar cane workers

• Banana farmers

• Unskilled hotel and construction workers 4) It can be used as a policy tool (e.g., to set wages) by governments, trade unions and the private sector. In Figure 3, the cost of this basket in several Caribbean countries is related to their minimum wage to assess nutritional vulnerability, i.e., the ability of the lowest paid individuals to access a balanced diet.

These livelihoods are all characterized by very limited resources which reduce the capacity to achieve food security. Moreover, limited assets restrict choices and constrain the livelihoods’ resilience to situation of stress. Focused public policies and actions are therefore required to enhance the food security status in these vulnerable livelihoods.

Social Safety Net Programmes in the Caribbean The figure revealed that in 2008 all Caribbean countries (except Grenada) showed increased vulnerability because a larger portion of the minimum wage was required to obtain a balanced diet. With the minimum wage constantly increasing, the graphs show that food price inflation had outstripped the minimum wage increase in most countries.

Protecting the Vulnerable Who Are the Vulnerable in the Caribbean? It is well known that the poor, rural and unskilled groups in the Caribbean are the most vulnerable. To target interventions in a practical way we used a “sustainable livelihood approach” to food security to assess vulnerability. A livelihood comprises the capabilities, assets and activities required for a means of living; a livelihood is sustainable when it can cope with and recover from stress and shocks, maintain or enhance its capabilities and assets, and provide sustainable livelihood opportunities for the next generation, in the short and long term. A livelihood system is classified as vulnerable when the system is exposed to various factors that create risk for most people belonging to that system. Within any livelihood-based vulnerable group some people will be more vulnerable than others. Those most likely to be food insecure are those who are economically dependent or otherwise socially marginalized. Based on this the groups classified as most vulnerable in the Caribbean are:

Social safety net programmes are designed to provide benefits for the poor and vulnerable through mitigating the effects of poverty or crises. These social programmes have a long history in the region, dating as far back to the “Poor Law” in the nineteenth century (Public Assistance, Old Age pension). The generalized economic crisis in the region in the 1970s followed by the structural adjustment programmes in the late 1980s generated more interest in social safety net programmes as means of cushioning the effects of austerity measures undertaken by governments. Natural disasters also pose a continuing threat to nutritional status of the vulnerable groups, particularly the children. Social programmes typically combine three components: 1) Social assistance (typically for persons whose incomes fall below a specified threshold); 2) Social insurance (e.g., a pension); and 3) Categorical transfers (support to “deserving” groups through some means-test). Social safety nets in the Caribbean consist of a combination of these types of transfers, the main ones are: • Social Assistance • Public works • Small business development

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• National insurance pension

school feeding programmes and provide benefits in kind to beneficiaries. (Table 4 programmes can be compared with the undernutrition rates in Table 1.)

• Homes residential care

Important lessons from social safety net programmes are:

• Travel to school, books and other related assistance

1) Need to minimize administrative costs and leakages of benefits of programmes;

• Non-contributory pension

• Unemployment benefits (Barbados only) Perhaps the most significant development in social safety nets is the current attempt to place conditions on the cash transfers (e.g. school feeding programmes in which children must record 85 percent school attendance, receive vaccination, and parents must attend PTA meetings) and to integrate several areas—such as health and education. Jamaica’s PATH (Programme of Advancement through Health and Education) and Guyana’s SIMAP (Social Impact Amelioration Programme) are good examples. Table 4 lists those social programmes that are most likely to impact directly on food access. In this regard, most countries have on-going 142

2) “Conditional transfers” appear to have greater outcome effects compared to unconditional transfers; 3) Need for effective targeting; 4) Ultimately, Governments need to create the structural underpinnings of the economy that will eliminate the need for many social safety net programmes.

Coping Strategies of the Vulnerable

Table 4 Programmes that Impact Directly on Food Available to Beneficiaries

Country

School Feeding

Benefits in kind

Guyana

St. Vincent

Jamaica

Grenada

Trinidad

St. Kitts

Dominica

Barbados

Bahamas

Belice

St. Lucia

Supplemental Feeding (Clinic)

Micronutrient Supplementation

ü ü

Table 5 shows the percentage of households that use various coping strategies during crises. Regarding nutrition, it is important to note that the quality of meals is compromise by many (44 percent). However the restriction of meals to children is only in a relatively few households (7 percent) compared with that of adults (30 percent). Perhaps these coping strategies help to explain why the nutritional status of children is not severely affected during the repeated crises shown in Figure 2.

Table 5 Crisis Coping Strategies of the Vulnerable in the Caribbean Coping strategy

% of households

Use up savings Borrow from Friend/Relative Reduced quality of meals Fewer adult meals Relatives abroad Sell livestock/assets Sell jewellery/valuables Fewer child meals Welfare organizations Beg Loan from bank

72 57 44 30 26 15 10 7 5 3 1

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Conclusion This paper shows that nutrition can be preserved even in crises if the foundations of good nutrition are robust and protected. Prolonged crises need strategies and actions directed at satisfying immediate needs but they should be matched by longer term interventions to sustain optimal nutrition. Addressing undernutrition, even in crises, provides the inescapable need for sectors such as health, education, agriculture, trade, among others to coordinate actions that target the underlying causes.

Referencias

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Carlson B (ed.) 1999. Social Dimensions of Economic Development and Productivity: Inequality and Social Performance. Geneva: United Nations. Cornea G, Court J. 2001. “Inequality, Growth and Poverty in the Era of Liberalization and Globalization.” Policy Brief No. 4. Helsinki: The United Nations University/World Institute for Development Economics Research (UNU/WIDER). Thomas M, Wint E. 2002. “Inequality and Poverty in the Eastern Caribbean.” Paper presented at the Eastern Caribbean Central Bank Seventh Annual Development Conference, St. Kitts, 21-22 November.

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Chapter 4

A COMPREHENSIVE APPROACH TO EFFORTS TO ERADICATE CHILD UNDERNUTRITION Monckeberg F. Prevención de la desnutrición en Chile. Rev Chil Nutr 2003; 30 (Suplemento Nº 1): 160-176. Lewin L, Puentes R, Saavedra R et al. Programa Colocación Familiar en Niños Desnutridos (COFADE). Rev Chil Nutr 1989; 17 (Suplemento Nº 1):65-76.

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SUMMARY This fourth chapter includes contributions by Onaur Ruano, National Secretary of Food and Nutritional Security in Brazil’s Ministry of Social Development and the Fight against Hunger, and María Roquebert, Minister of Social Development of Panama. Secretary Ruano emphasizes the impact of the “Zero Hunger” (Fome Zero) Programme, a strategy of the Brazilian Government in its attempt to guarantee the human right to adequate food, particularly among people with difficulty accessing food. The principal ideas, programmes, and interventions of “Zero Hunger” converge around four priority areas: access to food, salary generation, strengthening family agriculture, and social articulation. With regard to access to food, “Zero Hunger” administers programmes of family food baskets (Bolsa Família), school feeding (Programa Nacional de Alimentação Escolar [PNAE]), cistern construction, food storage, food baskets, food for specific groups, urban agriculture and community gardens, nutritional education, promotion of eating habits, food for workers (Programa de Alimentação do Trabalhador [PAT]), and basic feeding. Salary generation initiatives include programmes of social and professional training, economic solidarity and productive inclusion, productive organization of marginal communities (Organização Produtiva de Comunidades [PRODUZIR]), development of cooperative models and productive targeted micro financing. Such initiatives as the National Programme for Strengthening Family Agriculture (Programa Nacional de Fortalecimento da Agricultura Familiar [PRONAF]), harvest protection, insurance for family agriculture, and the Food Acquisition Programme contribute to achieving the third objective. Social articulation is promoted through the activities of the Reference Centre for Social Assistance (Centros de Referência da Assistência Social [CRAS]), and the Comprehensive Family Attention Programme (Programa de Atenção Integral à Família [PAIF]), as well as citizen education, training of public agents, collection of funds and donations, and strategic alliances with businesses and individuals, among others. Minister Roquebert describes the Panamanian social strategy for the 2004-2009 period, based on three fundamental pillars: combating poverty and indigence, promoting human development and social inclusion, and assuring the institutionalization of the social measures. The principal entities in charge of executing this strategy are the Ministry of Social Development, the Ministry of Health, and the National Food Plan Secretariat. Panamanian Government programmes focus principally in the areas of social development, health, and rural development. Family care initiatives, subsidies to non-governmental organizations (NGOs), and conditional cash transfers (family vouchers) are in place to promote social development. Cash transfers are distributed through the “Opportunities Network” (Red de Oportunidades), which provides fixed family benefits of 35 dollars a month, delivered to the mothers in families living in extreme poverty, especially in indigenous areas. Health initiatives include complementary feeding, micronutrient supplementation (iron and Vitamin A), vaccination, growth, and development programmes. Rural development is encouraged through agricultural vouchers and subsidies to NGOs.

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A comprehensive approach to efforts to eradicate child undernutrition: Actions to reduce poverty and income inequality in Brazil Onaur Ruano National Secretary of Food and Nutritional Security of the Ministry of Social

Poverty and economic and social inequality are recognized as determinants of the lack of regular access to food, in sufficient quantity and quality, for people and families in these conditions. Therefore, public policies designed to reduce poverty and inequality are fundamental, in conjunction with measures that contribute to the reduction and eradication of mortality and child undernutrition. Despite important advances, hunger and, particularly, child undernutrition, still represent challenges that need to be overcome in Brazil, above all due to a lack of access to food, caused by the low buying power of millions of Brazilians. Brazil is a federal republic with a population of 184 million people in a territory of 8.5 million square kilometres, organized in 5,564 municipalities located in 26 states and the Federal District (IBGE 2007). Its Gross Domestic Product (GDP) is approximately US$1.2 trillion, with a per capita income of 8,020 dollars (IMF 2006). From a structural point of view, economic stability with inflation control and real value recuperation of minimum salaries are extremely important factors for maintaining buying power. These factors facilitate the improvement of a family’s total income, promoting an increase in quantity and variation of consumed foods. From public policy viewpoint, results obtained after implementing the “Zero Hunger” Strategy of the Brazilian Government since 2003 have effectively contributed to the comprehensive effort in the fight against child undernutrition. Data from 2006 show 36 million people (19.3 percent of the population) existing below the poverty line. This measure comprises all families receiving a per capita monthly income under a minimum salary (71 dollars). If per capita income is considered to be under 149

Onaur Ruano

A family’s social and economic environment is an important factor for evaluating the conditions of child nutrition. Precarious life conditions that worsen health and nutrition are associated with low family incomes, which determine a limited buying power for food (Assis et al. 2007), the absence of adequate conditions for basic sanitation (Blakely et al. 2005), and limited and unequal access to effective health services (Makinen et al, 2000).

National Secretary of Food and Nutritional Security of the Ministry of Social Development and the Fight against Hunger of Brazil

Development and the Fight against Hunger of Brazil

a dollar/day PPP (Purchasing Power Parity), the proportion of the population living in extreme poverty is about 4.2 percent of the population. Recent data indicates improvement in Brazil’s human development index, which has increased to 0.8. Inequality, measured by the Gini index, has diminished to 0.562 (Neri 2007). The food security situation in Brazil was evaluated in a 2004 census by the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística [IBGE]). A National Survey of Homes (Pesquisa Nacional por Amostra de Domicílios [PNAD]) on food security has been held for the first time, using the Brazilian Scale of Food Insecurity (Escala Brasileira de Insegurança Alimentar [EBIA]). This scale is the result of the adaptation and validation of the scale used by the Department of Agriculture in the United States (Bickel et al. 2000) and was validated by Brazil after some modifications (Segall-Corrêa et al. 2004; Pérez Escamilla et al. 2004). Survey results indicated that people were living in a situation of food security in 65.2 percent of the nearly 52 million separate homes examined by PNAD. In other words, in the ninety days prior to the survey date, the persons living in these homes had access to food in adequate quantity and quality and did not feel they were at risk of suffering, in the near future, restrictions to this access. In the remaining 34.8 percent of homes that were in a situation of food insecurity, people lived in states of slight food insecurity (16 percent), moderate food insecurity (12.3 percent), or severe food insecurity (6.5 percent). It is necessary to emphasize that this situation is, in measurable form, related to the absence of resources in the homes to acquire food. The indicators show that child undernutrition in Brazil is diminishing. In 19741975, among the group of children under five, 18.4 percent had low weight for age. This proportion decreased in the following decades to 7.1 percent in 1989, 5.7 percent in 1996, and 2.6 percent in 2002-2003. In the height for age index, which shows accumulated alterations over the longer term in the nutrition and health situation of children, a diminishing trend is also observed between 1975 and 1996.1 Similarly, data from the Basic Attention Information System (Sistema de Informação da Atenção Básica [SIAB]) involving almost 45 percent of the low-income Brazilian population, indicate that undernutrition, measured by weight for age in children under one has diminished from 10.1 percent in 1999 to 2.4 percent in 2006, despite the persistence of important regional differences. In the Northeast, considered the country’s poorest region, acute undernutrition has decreased from 11.5 percent in 1999 to 3.3 percent in 2006. In the South—the most developed area—acute undernutrition declined from 6.3 to 1.2 percent over the same period (Presidency 2007). Brazil has achieved this gradual and constant reduction in child undernutrition for over more than two decades, but more prominently in recent years, due to a number of actions designed to improve the quality of life and health of the population, with priority for the most poor, especially with regard to reducing poverty and income inequality. This phenomenon is, above all, the result of urbanization occurring during the period and the adoption of policies in education, health, sanitation, and food access.

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Since 2003, with the beginning of President Lula’s first administration, the fight against hunger, undernutrition, and poverty has been considered a government priority. A structure and mechanisms were created with the objective of eradicating both problems. The first positive point in the “Zero Hunger” Strategy was prioritizing the issue of hunger on Brazil’s policy agenda, with repercussions for the global scenario in addition to reinforcing the participation and motivation of society. Accordingly, the Lula Administration created an Extraordinary Ministry of Food Security and the Fight against Hunger (Ministério Extraordinário de Segurança Alimentar e Combate à Fome [MESA]), which in 2004 became the Ministry for Social Development and the Fight against Hunger (Ministério do Desenvolvimento Social e Combate à Fome [MDS]). These initial actions became consolidated with the launching of the “Zero Hunger” Strategy, a set of programmes and actions implemented by the Federal Government to guarantee the human right to adequate food for people with difficulties accessing food. The strategy was inserted within the overall objective of promoting food and nutrition security, with the purpose of generating social inclusion and citizenship acquisition by the population most vulnerable to hunger (MDS 2005). Currently, “Zero Hunger” articulates actions in 19 Ministries of the Federal Government—in addition to activities through state and municipal governments, as well as civil society—along four axes: access to food, income generation, strengthening family agriculture, and articulation, mobilization, and social control. The guidelines of the “Zero Hunger” Strategy facilitate planned action in implementing policies with the greatest possibilities of guaranteeing access to food; the expansion of production and consumption of healthy foods; the generation of work and income; and the improvement of education, health conditions, and access to water, all from the perspective of citizenship rights. The first results of these policies can already be quantified, such as, for example, in the reduction of extreme poverty in Brazil. Data show that between 1995 and 2002, the percentage of people in the income group receiving less than one dollar per day (adjusted for purchasing power parity [PPP]) remained practically unchanged, with a median value of 7.4 percent. However, between 2003 and 2006 reduction in extreme poverty was 36 percent, decreasing from 7.4 percent of the population in 2003 to 4.7 percent in 2006. This reduction raised more than 8.4 million Brazilians out of misery and placed 7 million in the middle class. In 2006, Brazil thus reached the first objective of the Millennium Development Goals (MDGs) referring to the reduction of extreme poverty by 50 percent in 25 years. Between 1992 and 2006, there was an accumulated reduction of 58.5 percent.

Per capita income inequality in Brazil, measured by the Gini index, remained between 0.59 and 0.60 during the period of stability (19952001). During this time there was no important reduction in inequality. The Gini index, however, began to decline in 2001 and by 2006 reached a value of 0.56. An important component of the “Zero Hunger” Strategy is the “Family Basket” Programme (Programa Bolsa Família [PBF]), a direct conditional cash transfer programme benefiting families in situations of poverty (with per capita monthly income between 60 and 120 reales) and extreme poverty (with monthly income under 60 reales).2 PBF seeks to guarantee the human right to adequate food, promoting food and nutritional security and contributing to the eradication of extreme poverty. The programme is based on the articulation of three essential dimensions in overcoming hunger and poverty: 1) Promoting of the immediate alleviation of poverty, through direct income transfers families; 2) Reinforcing the exercise of basic social rights in health and education by meeting conditions, in a way that contributes to families breaking the cycle of poverty between generations; and 3) Coordinating complementary programmes seeking family development, in such a way that the beneficiaries of Bolsa Família might emerge from poverty and vulnerability. Some examples of complementary programmes include: work and income generation initiatives, adult literacy programmes, and initiatives for the provision of civil registry and other documents. Families that join PBF commit to completing the conditions of the programme in health and education. These include maintaining adolescent children of school age in school and following the basic health care schedule—in terms of vaccinations—for children under six and the prenatal and postnatal schedule for pregnant and breastfeeding women. PBF has increased its national coverage from 3.6 million participating families in 2003 (representing an investment of 570.1 million reales that year) to 11.1 million families in 2007 (representing an investment of 9.2 billion reales). In 2006 a PBF beneficiary survey was undertaken, relating to conditions of food and nutrition security. Of all respondents, 54 and 58 percent considered that the quantity of food consumed by children and young people and adults, respectively, was sufficient. Among the surveyed families, money received from the programme was spent, in the first place, on feeding (76.4 percent) followed by school supplies (11.1 percent) and shoes and clothing (5.4 percent).

According to Law #10,836 of 9 January 2004 and Decree #5, 749 of 11 April 2006.

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The research project “Nutritional Journey: A Study of the Nutritional Situation of Children in Brazil’s Semiarid Region”, implemented in collaboration with the Ministry of Health (MS) during the second phase of the 2005 National Vaccination Campaign, carried out anthropometric evaluations (weight and height) in 17,544 children under five, of whom 43.8 were among the beneficiary families of Bolsa Família. For the total number of children under five, adjusted prevalences indicate that participation in the programme led to a reduction in undernutrition frequency of almost 30 percent (6.8 percent without the programme and 4.8 percent with the programme). For children between zero and five months, the adjusted prevalences indicated a virtual absence of difference in the problem in children enrolled in the programme versus those not enrolled in the programme (2.4 and 2.5 percent, respectively) which is a consequence of the lower vulnerability to undernutrition at this age, probably—among other reasons—owing to the benefits of breastfeeding.

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Everything indicates that the greatest beneficiaries of the programme have been children between six and 11 months, among which the reduction in the prevalence of undernutrition due to the programme was 62.3 percent (5.3 percent to 2.0 percent). More modest benefits were observed among children of greater age: reduction in undernutrition of 28.2 percent for children between 12 and 35 months (8.5 percent to 6.1 percent) and reduction of 25.8 percent for children between 36 and 59 months (from 6.2 percent to 4.6 percent). The lower benefits of the programme for older children could be a consequence of the fact that they did not achieve the benefits in the first two years of life, the age at which the reversion of growth retardation is possible. Regrettably, lack of information about the time elapsed before registration in the programme prevents a more definitive response.

References Assis A, Barreto ML, Santos N et al. 2007. “Desigualdade, pobreza e condições de saúde e nutrição na infância no Nordeste brasileiro.” Cadernos de Saúde Pública 23(10):2337-2350. http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2007001000009&lng=en&nrm=iso, accessed 21 June 2008. Blakely T, Hales S, Kieft C, Wilson N, Woodward A. 2005. “The Global Distribution of Risk Factors by Poverty Level.” Bulletin of the World Health Organization 83:11826. Bickel G, Nord M, Price C, Hamilton W, Cook J. Guide to Measuring Household Food Security (Rev. 2000). 2000. Alexandria, VA: U.S. Department of Agriculture, Food and Nutrition Service. http://www.fns.usda.gov/fsec/ files/fsguide.pdf, accessed 21 June 2008. Instituto Brasileiro de Geografia e Estadistica (IBGE). 2004. Pesquisa Nacional por Amostra de Domicílios: Segurança Alimentar, 2004. Rio de Janeiro: IBGE, Coordenação de Trabalho e Rendimento. 2007. Censos 2007. Brasília: IBGE. http://censos2007.ibge.gov.br/, accessed 21 June 2008. International Monetary Fund (IMF). 2006. World Economic Outlook Database. Washington, D.C.: FMI. Makinen M, Waters H, Rauch M, Almagambetova N, Bitran R, Gilson L et al. 2000. “Inequalities in Health Care Use and Expenditures: Empirical Data from Eight Developing Countries and Countries in Transition.” Bulletin of the World Health Organization 78:55-65. Ministry for Social Development and the Fight against Hunger of Brazil (MDS). 2005. Cidadania: o principal Ingrediente do Fome Zero. Brasília: MDS. www.fomezero.gov.br/publicacoes/arquivos/livreto_fome_zero.pdf, accessed 21 June 2008. 2006. Cadernos de Estudos Desenvolvimento Social em Debate #4. Brasília: MDS, Secretaria de Avaliação e Gestão da Informação. Neri M (coordinator). 2007. Miséria, desigualdade e políticas de renda: o real do Lula. Río de Janeiro: Centro de Políticas Sociáis / Instituto Brasileiro de Economia / Fundação Getulio Vargas. http://www3.fgv.br/ibrecps/RET3/index.htm, accessed 21 June 2008 Presidency of the Federative Republic of Brazil. 2007. Objetivos de desenvolvimento do milenio: relatório nacional de acompanhamento. Brasília: Instituto de Pesquisa Econômica Aplicada / Ministério do Planejamento, Orçamento e Gestão / Secretaria de Planejamento e Investimentos Estratégicos. http://www.ipea.gov.br/sites/000/2/download/TerceiroRelatorioNacionalODM.pdf, accessed 21 June 2008 Segall-Corrêa AM et al. 2004. Acompanhamento e avaliação da segurança alimentar de famílias brasileiras: validação de metodologia e de instrumento de coleta de informação: urbano/rural. Campinas: Universidade Estadual de Campinas. http://www.opas.org.br/sistema/arquivos/vru_unic.pdf, accessed 21 June 2008.

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A comprehensive approach to efforts to eradicate child undernutrition in Panama María Roquebert Minister of Social Development of Panama

The problem is so sensitive that various organizations and international institutions have devoted enormous endeavours to fight and eradicate it. One of the most obvious efforts is the inclusion of the eradication of hunger as the first Millennium Development Goal (MDG), agreed to in 2000 by 150 countries in the framework of the United Nations. The most serious and worrying dimension of undernutrition is its effect on the younger population, especially children under five. In Panama, child undernutrition is present, in its moderate and severe forms, among 20 percent of the population in the above-mentioned age range. Child undernutrition is worrying since it compromises the future of children and their possibilities for personal development. Various specialists argue that there is an important association between this condition and poverty, which must be taken into account in programme and project design to influence and transform the situation. For example, in the Panamanian case official figures show that 39.5 percent of children under five living in extreme poverty show chronic undernutrition, a situation which is alarming to the degree that resources and measures to adequately confront it are not in place. If the problem is not solved, however, over the next years these children will become adults with limited human capacities, complicating their integration towards national development. Like poverty, undernutrition is a phenomenon with multiple causes associated with a lack of income, cultural feeding patterns, agricultural production, lack of access, weakness or inexistence of state services, etc, which ultimately requires interdisciplinary policy actions. Nutrition problems have many relevant consequences for children living in extreme poverty. Nutrition is a basic condition for good health, continuing education, and taking advantage of opportunities. As a result of their oftentimes remote locations, a large part of the population living in extreme poverty—especially indigent populations—suffer from a lack of basic social

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María Roquebert

The causes and characteristics of undernutrition can vary from region to region. For example, in urban areas the problem revolves around consumption patterns or a lack of income to buy food, while in rural areas, there is a combination of food scarcity caused by deficits in agricultural production, lack of income, and cultural consumption patterns.

Minister of Social Development of Panama

Undernutrition is a multidimensional problem affecting millions of human beings throughout the world. This occurs despite the fact that humanity has produced food in industrial quantities for more than 150 years, a situation which evidences that the problem cannot be simplified as a technological issue. Social and political measures are necessary to overcome it.

services such as access to health, potable water, and education and lack of access to existing feeding programmes. All of these factors contribute to greater levels of child undernutrition. The unavailability and inaccessibility of state services complicates nutritional attention and food distribution to populations in these areas. The low agricultural capacity soil in many places, together with a lack of resources to buy agricultural inputs for production and food for consumption compound the problem. There are considerable impacts for the whole of society when child undernutrition prevents a country from not taking full advantage of its human resources. At the local level, this negatively impacts the efforts that the inhabitants of regions and communities are making in conjunction with the State to generate development for the population’s wellbeing. Undoubtedly, the State must establish short-, medium-, and longterm nutritional policies that guarantee nutrition and food for the population, especially the population under five, which is the most vulnerable. This is possible only through the prioritization of concrete actions and the execution of programmes and projects designed to comprehensively meet the needs of the population. Nevertheless, a nutritional policy and all it entails, requires integrated institutionalization, and a firm a robust capacity to execute and sustain it. This is possible to the degree that a State decision exists to institutionalize the articulation of targeted actions based on administrative, financial, and operational sustainability.

The Diagnostic: Undernutrition in Panama1 Official studies and data indicate that undernutrition manifests in different intensities and forms, depending on the social group that is affected. For example, the phenomenon is most intense among people living in situations of extreme poverty and more acute for children under five living in extreme poverty. The following data shows the social aspect of undernutrition in Panama from a quantitative perspective. According to the results of the 2003 Living Standards Survey (Encuesta de Niveles de Vida [ENV]), chronic undernutrition affects an estimated 20.6 percent of Panama’s population under five. These

children are stunted or show low height for their age. Global undernutrition, weight deficiency, or low weight per age affects 6.8 percent of the population under five. Acute undernutrition, measured by the relationship between height and weight, affects 1.3 percent of the population under five. At the national level, 39.6 percent of all children under five living in extreme poverty suffer from chronic undernutrition, a proportion that decreases to 19.1 percent in the population living in poverty and 10.2 percent for children who are not poor. Indigenous children under five are the group most affected by chronic undernutrition (56.6 percent). Indigenous children living in extreme poverty are particularly more affected than indigenous children living in poverty (57.9 percent versus 41 percent). Studying chronic undernutrition by geographic area shows that urban areas have a lower prevalence (13.8 percent) than rural nonindigenous areas (18.5 percent). The provinces with the highest chronic undernutrition prevalences are Bocas del Toro (32.1 percent), Darién (30.0 percent), Veraguas (29.6 percent), and Coclé (23.4 percent), which are above the national average. The prevalence of growth retardation in the group from six to nine years of age is also higher in indigenous areas (61.8 percent). According to the weight-for-age indicator, the presence of global undernutrition at the national level is about 6.8 percent, although it is higher for children living in extreme poverty, with 16.3 percent, versus only 2.1 percent among non-poor children. At the provincial level, global undernutrition is concentrated in indigenous areas, where 21.5 percent of all children under five show weight below that expected for their age. Acute undernutrition (weight for height), however, is relatively low in Panama (1.3 percent), although it tends to be higher for children living in extreme poverty (who have prevalences of up to 6.9 percent among children 12 to 17 months of age. The presence of indigenous populations in a given geographic area influences the high level of the area’s undernutrition prevalence. For example, if the indigenous population in Darien were not considered, the undernutrition rate would fall from 30 to 12.5 percent. The Complementary Feeding Programme (Programa de Alimentación Complementaria [PAC]) is one of the Government’s strategies for preventing and treating undernutrition. According to ENV 2003, poor children are the principal beneficiaries of PAC. Of all children receiving PAC’s nutritional cream, 79 percent lived in poverty.

Data in this section come from Ministry and Economy and Finance of Panama (MEF), Poverty and Inequality in Panama: A Challenge that Cannot be Delayed (Panama: MEF, 2006), accessed at https://www.mef.gob.pa/Portal/DirPoliticas-Informes02.html, downloaded 20 June 2008).

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Bases of a Comprehensive Policy The right to food and good nutrition is a basic human right that has been recognized by all nations as a fundamental part of the international social agenda. Within this agenda it is important to emphasize the agreements reached at the 1996 World Food Summit, the 2000 Millennium Development Goals, and the 2004 Joint Declaration on Hunger and Poverty. Analysis and discussion about policies and programmes to fight undernutrition and hunger have produced declarations from the international community on the need to position actions and mobilize resources from all actors and sectors. For States, the nutritional situation of a countryâ&#x20AC;&#x201D;especially of its children under fiveâ&#x20AC;&#x201D;is a pillar within its policies for social development, particularly for the development of human capital. Although studies show gradual improvement in health and nutrition for all the Central American countries, setbacks have been experienced and important gaps persist. Child undernutrition in some Central American countries is, without a doubt, one of the most serious public health problems. In the early 2000s global undernutrition, measured as low weight per height, affected almost 24.2 percent of all children under five in Guatemala (24.2 percent), 16.6 percent in Honduras, 11.8 percent in El Salvador, and 7.3 percent in Belize.

Today we know that the nutritional situation of countries is closely related to access to the goods and services that determine the availability and consumption of the foods necessary for growth and health maintenance. The Central American States have recognized it in their public policies. Recent studies in some countries of the Central American isthmus have revealed that some of the highest risks faced by families living in poverty are the low consumption of food and, consequently, undernutrition and hunger. Such deficits come from insufficient income to cover the cost of an adequate caloric intake and this, in turn, is produced by limited access to the labour market for household heads in poor families. Numerous studies confirm the relationship among malnutrition from a lack of protein, energy, and micronutrients and infectious and chronic non-contagious diseases, mortality, physical growth, mental development, educational performance, reproductive health, and productivity of adults. All of the above serves to establish the existence of a vicious circle of human, social, economic, and political underdevelopment, of which a major component is food and nutrition insecurity. Given that their nutrient requirements are significant, there is consensus that children and women of childbearing age are especially susceptible to undernutrition, which makes them particularly vulnerable populations. As a result, nutritional policies are being focused on young children, since these are the areas of greatest nutritional vulnerabilities and, therefore, are the stages where nutritional interventions have the greatest effect.

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Programmes developed for the States in the region, within the framework of social protection networks in Central America, have made important contributions to poverty reduction and, therefore, by necessity, undernutrition and hunger. Interventions of these programmes include a series of components that focus on improving nutritional status. Generally, these programmes have had positive and significant impacts on the nutritional status of their beneficiaries, particularly relating to improvements in diets. The programmes have also played an important role in poverty and undernutrition reduction strategies in many countries. In Central America and other countries in the region there is evidence that data on the geographic distribution of poverty can be appropriately used to target children with the highest risk of undernutrition. Interpreting the dynamics of undernutrition and its distribution through various age, socioeconomic, ethnic, cultural, gender, and geographical groups is essential to achieve effective targeting. Studies in Central America have also proven the necessity of nutrition policies that provide incentives for improving the nutritional and health status of mothers before, during, and after pregnancy, using conditional cash transfers, whereby beneficiary mothers commit to receiving regular health care in exchange for economic support. These transfers can be complemented with educational materials and in-kind donations of highly nutritious foods, which ensure adequate intake during the periods of gestation and breastfeeding. Additionally, these studies have documented the existence of a vicious circle, which perpetuates itself from generation to generation. Mothers who suffer from protein-energy undernutrition and micronutrient deficiencies, as well as those who have higher infection rates, are likely to have premature babies with low birth weight. If these babies survive, they may suffer multiple infections and grow and develop inadequately. At school age, these children might be shorter than others and have limited educational performance. During adolescence and adulthood they may show signs of undernutrition, as well as reproductive health problems, low productivity, and reduced intellectual development. The ECLAC and World Food Programme study on â&#x20AC;&#x153;The Cost of Hunger: The Socioeconomic and Social Impact of Child Undernutritionâ&#x20AC;? highlights these problems. This study constitutes, without a doubt, a reference framework that offers Governments, decision makers, national and regional technical teams, and cooperating agencies an analytical tool that supports the design and implementation of national and regional policies, the alignment of international cooperation funds, and the increase in public budgets for strengthening the institutionalization needed to combat hunger and undernutrition in the Central American region.

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The study provides information based on the construction of future scenarios for 2015 related to the Millennium Development Goals (MDGs), which contemplate the reduction by half of 1990 undernutrition levels and, eventually, the eradication of undernutrition. This prospective analysis allows us to approach the possible costs and impacts that can be generated in health, education, and productivity from child undernutrition. The study also provides a retrospective look at the effects and impacts produced over the last decades, in the same areas for the population of each country, in 2004. Studies relating to ethnic and cultural variables allow the observation of important changes over the last decades. The Central American population was principally rural and routinely exposed to moderate or heavy physical activity. Currently the situation is completely different: the population is primarily urban and highly sedentary. This situation results in the increase in indicators relating to excess weight and obesity in schoolchildren. One of the points of this study inviting reflection is that States need to develop a capacity for deepening the analysis of the relationship between investment in nutritional programmes in the face of incidental costs and the efficiency represented by global investment in public social spending. Although Panama allocates a lower percentage of its social spending to nutrition (in relation to the rest of the Central American countries), its lower incidental costs indicate higher efficiency in public social spending on nutrition. The current complexity of nutritional problems in Central America is, without doubt, significantly greater than that found thirty or forty years ago. Therefore, all Central American Governments recognize that child undernutrition does not only affect the physical development of undernourished children: it also impacts the economic development of countries, their health, the formation of human capital, and productivity.

Strategies and Actions With the purpose of combating undernutrition affecting infant populations, principally among those living in extreme poverty, Panamaâ&#x20AC;&#x2122;s social policy actions converge around three axes. First is the fight against poverty and extreme poverty. The Government has developed a strategy for this, including a series of specific actions in social protection as a systematic intervention axis. These actions include the implementation of conditional cash transfer programmes among households living in extreme poverty, a systematic intervention seeking to guarantee social rights. The second strategy focuses on human development and the social inclusion of the population, attempting to connect marginal populations with services provided by the State, so as to transform them into beneficiaries of these services. Social institutionalization, the third fundamental axis, is crucial for the sustainability and effective execution of designed programmes and actions. This implies institutionally consolidating aspects of inter-institutional coordination, realignment of operating, administrative, and financial processes, and comprehensive actions for the population. These strategies combine with decisions and actions for strengthening the social sector of the State, through an effective reorganization, that has as its fundamental objectives optimizing coordination and effectiveness of interventions in society. Strengthening of the social sector is one of the concrete actions undertaken by the Government. To achieve this objective, the support and technical assistance of international institutions such as the World Bank (WB), Inter-American Development Bank (IDB), and United Nations Development Programme (UNDP) have been crucial.

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A Social Cabinet has been created to act as a technico-political arena for the discussion of the social agenda and the coordination of the Government’s social policy among various departments. This is a body with the capacity to bring together ministers of State to coordinate and make political decisions, with technical support from a Multisectoral Commission made up of technical teams from involved the implementing departments. In second place, the transformation of the Ministry of Childhood, Youth, Women, and Family into the Ministry of Social Development (Ministerio de Desarrollo Social [MIDES]) placed responsibility for the coordination of social policies in a specific institution. This implied strengthening the capacity of the Ministry to coordinate actions, provide follow-up, and evaluate programmes. A third element in the strategy for strengthening the social sector rests on the Ministry of Health (Ministerio de Salud [MINSA]), which is being strengthened to improve service coverage and quality. A fourth actor in this scheme, the National Food Plan Secretariat (Secretaría del Plan Alimentario Nacional [SENAPAN]), coordinates institutional actions for food and nutrition security. These reorganizations undoubtedly have an organizational basis resting on agreements between the appropriate departments. Those having greatest relevance include the agreements between MIDES and MINSA to benefit households in extreme poverty; MINSA’s comprehensive health and nutrition care package for households in extreme poverty (PAISS+N); technical assistance and training provided by the Ministry of Agricultural Development (Ministerio de Desarrollo Agropecuario [MIDA]) and the National Institute for Human Development Training (Instituto Nacional de Formación y Capacitación para el Desarrollo Humano [INADEH]) to promote food security; the offer of basic foods at low cost through the Agricultural Marketing Institute (Instituto de Mercadeo Agropecuario [IMA]); and subsidies to non-governmental organizations to generate food sustainability and community participation in the transport, stock, and food preparation in complementary feeding programmes. Programmes designed to improve the nutritional situation should place more emphasis on issues relating to creating consciousness in the population with respect to the importance of using foods for good nutrition. Likewise, pregnant women should receive information on feeding and its importance, during and after pregnancy. It is important to highlight that these programmes—even when they are targeted at regions with high levels of undernutrition—should

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also set in motion other policies and programmes designed to care for populations at risk, including risk of obesity. Our programmes allude to excess weight—a problem that impacts young populations today, with great frequency—but do not provide recommendations on how to handle it. The quality of breast milk is related to women’s nutrition during pregnancy. As a result, it is necessary to develop sensitivity campaigns that explain the importance of good nutrition in women of childbearing age as well as among those who are pregnant or in puerperium. The comparison between people who are poor and those who are not is relevant with respect to low weight and excess weight/obesity. Poor people do not show a high prevalence of overweight, but they do show the highest indices of low weight, above all among people in extreme poverty. Programmes to combat undernutrition should explain to target communities the importance of the foods they eat as well as the link between the quality of foods that are consumed, on one hand, and good health and the ability to confront illnesses, on the other. The contribution of other programmes to combat undernutrition is important. In this regard, the Government is making investments through the Ministry of Education (Ministerio de Educación [MEDUCA]) and MINSA. Programmes designed to improve nutritional quality for the population should be established from a preventive and curative perspective, in addition to involving the private sector in the most systematic and effective manner. Ideally, a single entity should be placed in charge of coordinating the execution of programmes designed to assure nutritional security. These functions should not be allocated among various departments. Consolidating them in one agency will save in costs (e.g., administrative costs). In this way a larger amount of resources might be allotted to combating extreme poverty and undernutrition. Conditional transfers coordinated by MIDES as part of the Social Protection System, through the “Opportunities Network” programme, seek to ensure that beneficiaries bring children to health centres, that pregnant and post-delivery women undergo regular medical controls, and that children between four and 17 years of age attend school. In transfer programmes channelled through MIDES, health and education services are provided by the relevant departments.

Intervention The Government of Panama is advancing in the design and implementation of a Social Protection System (Sistema de Protección Social [SPS]) that will be supported by an Inter-American Development Bank (IDB) loan and a World Bank credit facility. The strategy behind the System of Social Protection has as its objective to strengthen human capital and reduce the social exclusion and vulnerability of families living in extreme poverty. The operational objectives of the SPS include promoting the attendance and educational advancement of children in schools and improving the maternal-child health and nutrition situation. Interventions targeted at food security are channelled through three governmental sectors: social development, health, and rural development. From an operational perspective, the Government has implemented targeted programmes in comprehensive care for children and women as well as complementary food for pregnant women, children under five, and school children enrolled in the basic general education system. Interventions for pregnant women and children under five are carried out with the objective of controlling growth and development from conception. In this way, timely health and nutrition interventions can help guarantee a productive and healthy population. Feeding programmes for children from four to 17 years are designed to provide higher quality support to help them perform better. In more depressed areas where the availability of food in the home is minimal for people, the programme becomes a motivation to increase school attendance and reduce desertion. Another useful alternative—especially for rural and indigenous areas where the availability of food is scarce, as a result of either poor access or low production—is to provide incentives to help families invest part of their work in the production of foods for self-consumption, particularly products with short growing periods and high nutritional content, such as cereals and other grains.

Conclusion Undernutrition—mainly child undernutrition—remains a global health problem. In spite of the fact that food production is sufficient, not all of the population has access to the same quantity and quality of food. On this basis, within the framework of the MDGs, countries have adopted a policy of eradicating extreme poverty and hunger. This includes ensuring the population has access to good quality foods. In Latin America, the situation is no different. Various studies have shown that undernutrition—especially chronic undernutrition in children under five—is an unresolved issue that requires a solution. Transfer programmes implemented in countries in the region have advanced towards reducing the risk of critical populations with limited access to food and food insecurity. Panama’s strategy has been to execute a multisectoral intervention with the participation of social, health, and rural development programmes, targeted to the most vulnerable populations. The objective is to provide care for the most vulnerable populations, including those at risk of undernutrition or those suffering from some degree of undernutrition as a result of access and availability problems, in an opportune and direct way.

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Chapter 5

SOUTH-SOUTH COOPERATION IN THE FIGHT AGAINST CHILD UDNERNUTRITION Monckeberg F. Prevención de la desnutrición en Chile. Rev Chil Nutr 2003; 30 (Suplemento Nº 1): 160-176. Lewin L, Puentes R, Saavedra R et al. Programa Colocación Familiar en Niños Desnutridos (COFADE). Rev Chil Nutr 1989; 17 (Suplemento Nº 1):65-76.

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SUMMARY Chapter 5 includes contributions by María Dolores Martín, Director of the Technical Cabinet of the Spanish Agency for International Cooperation for Development (Agencia Española de Cooperación Internacional para el Desarrollo [AECID]); Germán Valdivia, Regional Coordinator of the Knowledge Management Initiative of the World Food Programme (WFP); Nils Kastberg, Regional Director of the United Nations Children’s Fund (UNICEF-TACRO); Patricio Meller Bock, President of the “Work and Equity” Advisory Council of Chile; and Manuel Espinoza, Executive Director of the Latin American and Caribbean School Feeding Network (LA-RAE). In her article, María Dolores Martín alludes to the current food crisis, which might be long-lasting and has the potential for causing major political disruptions. To contribute to improving the food situation, Spain works closely with the United Nations Food and Agriculture Organization (FAO) and the World Food Programme (WFP). The Spanish Government has committed to making a voluntary contribution of eight million euros to WFP. The efforts of WFP and the countries in the region against undernutrition can rely on Spain’s support. Spain sees in these efforts a new window for cooperation. Germán Valdivia presents the NUTRINET.ORG platform as an instrument for strengthening South-South Cooperation and working in thematic areas and networks. NUTRINET has been developed by WFP in response to requests from governments in the region to generate a means for information and knowledge exchange and strengthen South-South cooperation. The platform will make a broad range of resources available to users, including news; consultations into programme databases, projects, experts, and institutions; tools with various manuals and methodologies; statistics; a digital library; forums; distance education; digital photo galleries; videos and clips; a “Kid’s Zone” with educational games, art contests, literature, and educational songs; an editorial fund for promoting research and the development of knowledge in priority themes; technical glossaries; and recipes for the production of healthy food. Dr. Kastberg holds that hunger is an attack on health, life, and therefore on liberty, which justifies an active policy oriented to legalizing the right to food until it becomes reality and ensuring that the poor can achieve their own autonomy. In 2005, the region had approximately nine million children under five with chronic undernutrition (measured by low height for age) and four million children with global undernutrition (measured by low weight for age). In comparison with other regions of the developed world, a series of comparative advantages exist in Latin America and the Caribbean that policymakers should bear in mind in the design of policies, plans, and programmes. These advantages can be shared among countries to strengthen and accelerate their response to hunger. South-South Cooperation for combating hunger in Latin America should be centred on improving statistics, developing human resources, mobilizing community leadership, and strengthening governmental leadership, with the firm support of the United Nations System and other organizations. Professor Meller alludes to a significant concern over the inequality that exists in Chile and the proposed measures from the “Work and Equity” Presidential Advisory Council to mitigate it, among other measures by increasing income through improving competitiveness. The key for this radical improvement is the training of workers. Although obligatory education in Chile currently extends for 12 years, half of the labour force has not completed secondary education. This gap can be understood as a social debt, which the Government seeks to cancel, among other initiatives, through the creation of a “training voucher” that will allow employees to obtain skills in the area of their preference. The goal is to train one million workers over a six- to eight-year period. The aspiration for the longer term is to allow workers to retrain every five years, so as to help them maintain their competitiveness. In the area of traditional education, the plan is to promote learning through a programme recognizing the most talented students. Manuel Espinoza, Executive Director of LA-RAE, explains that the contractual relationship is the most relevant aspect of the participation of the private sector in food-related programmes. Through these programmes, 2.4 million services are delivered on a daily basis, demonstrating the project’s complexity. A total of 35 private-sector entities, including micro, small, medium, and large businesses participate in the delivery of services by the National Scholarships Board (Junta Nacional de Auxilio Escolar y Becas [JUNAEB]). All fulfil important functions in the implementation of JUNAEB’s interventions. The system’s response capacity is another area that reveals the importance of private sector participation. In a little more than a year, this capacity increased from 1.3 to 2.2 million daily services. Proximity to basic food production systems and the demand for these generate possibilities for the development of cottage production, with significant economic impact for the communities. 163

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Spanish cooperation in Latin America during the food crisis María Dolores Martín Director of the Technical Cabinet of the Spanish Agency for International Cooperation for Development (Agencia Española de Cooperación Internacional para el Desarrollo [AECID])

This is, without a doubt, a difficult moment. The food price crisis is already causing social conflicts and the World Bank has alerted that revolts could occur in at least 33 countries. Over the past few weeks, institutions of every type, world leaders, and societies have been paying increased attention to the issue, indicating that we find ourselves before a problematic juncture that will no doubt affect low income countries most dramatically (82 countries, according to the United Nations Food and Agricultural Organization [FAO]). Additionally, in this context we must advance towards fulfilment of the World Food Summit objective of reducing by half the number of hungry people at 1990. Such objective will only be met by 2015 if the number of undernourished people decreases by 50 million each year. This seems to be a very difficult puzzle to tackle and for that reason this is the moment to consolidate firm commitments into much more rapid progress in the fight against hunger, combining all the financial and technical instruments at our disposal in a generous and imaginative way, and placing the issue at the top of the international development agenda. We hope that Spain can at least contribute to this outcome. We are dealing with a complex crisis, one that can only be addressed in a comprehensive way. We need to encapsulate the measures used to confront the crisis in a long-term framework that allows follow up and provides coverage for a crisis that could last a long time, and promotes structural solutions to problems. In the short term, there are a series of measures that Spain has been implementing with its two closest partners in this area over the past two years: the World Food Programme (WFP) and FAO. In the case of FAO—and in addition to the 19 million dollar fiduciary fund that Spain placed with that organization—the Department of State and International Cooperation has decided to support the initiative launched in December 2007 to counter the steep rise in food prices. This decision involves a new contribution of 8.5 million dollars and additional financial support for the High-Level Conference on “World Food Security: The Challenges of Climate Change and Bioenergy,” held in June 2008.

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María Dolores Martín

The Conference, additionally, took place at an extremely opportune moment, coinciding with the food price crisis. It gave us an opportunity to transmit to the country representatives in attendance our political commitment to continue accompanying the efforts that have been made over the years in the design and execution of social cohesion and anti-poverty policies.

Director of the Technical Cabinet of the Spanish Agency for International Cooperation for Development (Agencia Española de Cooperación Internacional para el Desarrollo [AECID])

It was important for the Spanish Agency for International Cooperation for Development (AECID) to be present at the Regional Ministerial Conference held in Chile in May 2008. Our participation in this event gave us a better understanding of the state of child undernutrition in the region and witness the exchange of experiences and lessons learned. All of this contributes to orienting our bilateral programmes in the region as well our more general multilateral activities.

We also maintain our technical and financial commitment to FAO’s initiative “Latin America and the Caribbean without Hunger,” which for us is the clearest example of South-South cooperation and provides the possibility to design triangular operations. Additionally, this year we have generated a special Spain-FAO fund for assistance in humanitarian contexts, which allows us to jointly distribute assistance in emergencies, in the most effective form, to populations affected by natural and man-made disasters. We have already provided seven million euros to this fund. As pertains to WFP, Spain has made a six million euro donation this year, on top of the additional contribution made when the organization called for help to address the food crisis and we responded with

an additional seven million dollars. Simultaneously, we have supported WFP-backed initiatives to eradicate child undernutrition and reduce micronutrient deficiencies with five million euros. Finally, the agency has renewed its permanent line of work with WFP has—the international food reserve—for 15 million euros. Over the past years, this reserve has allowed us to provide assistance during humanitarian crises, not only in Latin America but across the world, in the most rapid and efficient way. The Department of State and International Cooperation is studying the possibility of opening a new thematic window in financing, oriented to specific issues of childhood, nutrition, and food security, within the Spain-UNDP Fund for the achievement of the Millennium Development Goals (MDGs), thereby reinforcing our response to this crisis. In the medium and long term, we hope to act in a coordinated way with partner countries and other bilateral and multilateral development donors. This will allow us to remain in coordination with other actors with which the Spanish Cooperation Agency 166

is very active, such as our own regions, autonomous communities, municipalities, civil society, specialized NGOs, and anyone capable of providing some support for food and nutrition. Maintaining Spanish public opinion informed on a permanent basis is an additional challenge. Meeting this challenge allows us to take advantage of the potential that exists in the private sector for advancing towards and consolidating public-private partnerships that help us work effectively in rural development in the region. Given the multitude of factors at the root of the crisis, however, it will be totally essential to work toward better policy consistency, not only in Spain, but elsewhere as well. This implies our continued positioning in a clear way on agricultural, commercial, and energy policies

within the framework of the European Union and supporting the decision to strengthen agricultural, fishing, and food research in the countries of Latin America and the Caribbean, strengthening networks of scientific-technical exchange and supporting regional development entities and the fight against rural poverty. These are, in synthesis, the broad details of our possible measures in the short and medium terms. Spain has been active in recent years and has tried to accompany and promote social cohesion policies under implementation in the region. I think the political commitment to maintain this companionship is beyond doubt. It would be truly obscene to not confront this crisis in a comprehensive way with all available financial and technical tools, knowledge exchanges, North-South cooperation, and South-South cooperation. We cannot permit any setbacks to nutritional advances. Indeed, it is not permissible to allow the most vulnerable to remain at the mercy of speculatory interests and market variations, leaving them with the only safeguard of basic social assistance measures that we have tried to overcome.

Nutrinet.org: An instrument for strengthening South-South Cooperation and work in thematic areas Germรกn Valdivia Regional Coordinator of the Knowledge Management Initiative of the Regional Office of the World Food Programme (WFP) in Latin America and the Caribbean

Information about hunger and undernutrition is dispersed, which makes it difficult to access and hard to consult for adequate decision-making, sharing lessons, and transferring knowledge. Therefore, the need exists to promote and facilitate the design of programmes and projects based on evidence and on the operational exercise of effective programmes among countries. This situation encouraged the United Nations World Food Programme (WFP) to develop a mechanism to facilitate knowledge management in relation to hunger and undernutrition, as a response to the problems the region is suffering and can be overcome in a cooperative way by taking advantage of the advantages of the Internet.

Political Backing Obtained for the Creation of NUTRINET To this effect, at more than 16 regional conferences and high-level meetings, participants backed the creation and development of NUTRINET.ORG and its national platforms. For this, NUTRINET.ORG was born as an instrument to help countries strengthen cooperation between them and consolidate cooperation networks; to share information within and outside the countries and maintain the eradication of hunger and undernutrition as a priority issue on the policy agenda.

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Germรกn Valdivia

Currently, we are facing great challenges to implement initiatives with effective impacts. The efforts of experts and those in charge of formulating policies in the region are limited by a lack of opportunities to learn from the successful experiences of others.

Regional Coordinator of the Knowledge Management Initiative of the Regional Office of the World Food Programme (WFP) in Latin America and the Caribbean

Some countries have achieved important goals within the frameworks of well-established policies and national programmes designed to meet the first Millennium Development Goal (MDG) in relation to the eradication of hunger. However, advances have been unequal in the region.

NUTRINET Provides and Promotes

Thematic Areas Receiving Priority

· Strategic contributions on information and knowledge for management within the countries;

To facilitate the achievement of NUTRINET’s objectives and use its advantages, the information and knowledge available was classified in five thematic areas:

· Support for the formulation of public policies and the design and implementation of programmes and projects designed for the eradication of hunger and undernutrition; · Support for the creation of a solid documentation base on programmes and projects as well as a solid database and digital library by thematic areas; · A database of successful experiences to share within and among countries in the region; · Tools for improved development and execution of programmes and projects;

· Maternal-child nutrition: in programmes of child nutrition and health that improve the general health and nutrition of the youngest children, pregnant women, and breastfeeding mothers; · School feeding: in food for education programmes that improve attendance and achievement in school and that, at the same time, reduce hunger in the short term for pre-school and primary school children; · Vitamin and mineral initiatives: to combat the more important micronutrient deficiencies or hidden hunger in a sustainable way; · HIV/AIDS and nutrition: interventions in the field of nutrition and HIV/AIDS that improve treatment compliance, improve the results of treatment, and mitigate the impact of AIDS on the family’s food insecurity;

· Innovative initiatives; · Cooperation among experts; · Consciousness and attitude changes about both issues in children through a “Kid’s Zone”;

· Food and nutritional security: in the preparation and response to emergencies, with the purpose of saving lives and recovering livelihoods.

· Resource mobilization for the fight against hunger and child undernutrition as well as for knowledge development.

NUTRINET is a great contributio 168

Services Offered by NUTRINET

Countries Associated to NUTRINET

NUTRINET offers an array of services, including:

Currently there are 11 associated countries: Bolivia, Ecuador, Cuba, Colombia, the Dominican Republic, El Salvador, Guatemala, Honduras, Nicaragua, Panama, and Peru. In these states, the national knowledge management teams have developed their respective national platforms.

· Information about the nutritional situation and impact results of strategies, plans, programmes, and projects; · Relevant news in the global, regional, and country environments; · National and international meetings designed to share research results, updates, and advances; · A database of programmes, national projects, institutions, and experts; · Statistics on the nutritional situation by thematic areas; · Successful experiences in the search for the eradication of hunger and child undernutrition in an effective and sustainable manner; · Publications of books, essays, magazines, documents, declarations, laws, and decrees; · A “Kid’s Zone” to raise awareness about healthy eating; · Simple recipes that are easy to understand for healthy eating; · Distance education.

The country platforms show the creative diversity and appropriation on the part of actors (governments, NGOs, and private sector) of the development of the platform and its networks. The current platform already shows several countries’ strengths as well as the information and knowledge available for sharing. Member countries have actively participated in the collection of extant information for the database. They have provided content and available materials on the web through our platform. They have undertaken research on the existence of successful cases. They have used tools, manuals, and various valuable materials, which are now available more easily on the web. In general, lessons learned in each country have been systematized and are now available on the platform. This platform of platforms is an instrument that has been developed in response to urgent requests for having it available immediately and has been constructed in a participatory format under the leadership of those requesting it: the region’s Governments. International and national NGOs, as well as the private sector, have also participated in its development.

on to knowledge management 169

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South-South Cooperation in the fight against child undernutrition Nils Kastberg Regional Director for Latin America and the Caribbean of the United Nations Children’s Fund (UNCEF-TACRO)

Bilateral Cooperation with the North For various decades, bilateral international cooperation was dominated, both in thinking and in modalities of assistance, by patterns established by and developed in industrialized countries, within the framework of the Organization for Economic Cooperation and Development (OCED) and its Development Assistance Committee (DAC), which determined how assistance and international cooperation were defined. Although there were many variations, behaviour patterns were principally governed by the “north’s” vision for assistance and cooperation towards the “south.”

Multilateral Cooperation Multilateral cooperation, primarily through global or regional financial institutions (in particular though loans) or United Nations System agencies or organizations (especially via donations) opened greater possibilities to countries in the “south” to shape international cooperation. Development banks do not apply the “one person, one vote” principle. On the contrary, the value of contributions is the determining factor in decision making. In the United Nations, the “south” has more possibilities for participation in establishing development frameworks. Increasingly, the importance of the “receiving” or “programme” country has been emphasized, as it should be, allowing the country to have ownership and act as an actor which determines the type of development desired. South-South Cooperation addresses a number of factors such as respect for sovereignty; pre-eminence of democratic processes for establishing development that benefits the many on the margins of progress and not the few who are already rich, as well as those minorities (and sometimes majorities) that experience discrimination; respect for human rights; and capacity building so the State can effectively exercise its responsibility for its citizens and determine priorities in development, to cite a few examples. However, this is not the time to tackle these issues.

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Nils Kastberg

Approaches to South-South Cooperation

Regional Director for Latin America and the Caribbean of the United Nations Children’s Fund (UNCEF-TACRO)

In developing concepts relating to South-South Cooperation as an instrument for eradicating child undernutrition—in particular the “hunger of the mind,” chronic undernutrition—it is important to address the modalities of cooperation, including South-South Cooperation. It is necessary to analyze which forms cooperation is taking in order to finally address the central issue: how to apply this form of cooperation towards the fight against undernutrition, particularly against chronic undernutrition.

Other Forms of Cooperation: Solidarity of the People

South-South Horizontal Cooperation as Public Policy

Alongside the above-mentioned types of international cooperation, new forms have been developing for many years.

Raising this form of solidarity to public policy in our region and formulating it as South-South or horizontal cooperation is also fairly recent development. In 1979, Argentina hosted the first International Conference on Horizontal Technical Cooperation, which has since emerged as South-South or horizontal cooperation, distinct from the traditional bilateral, “North-South” cooperation. At the time, a militaristic perspective prevailed in the region, which has now been replaced by an environment of human and social development: changing swords to ploughs!

Since the end of the 1970s, the number of refugees at the global level has increased dramatically. The rich countries of the “north” did not receive large numbers of refugees; rather, neighbouring countries allowed them in, received them, and, in many cases, permitted them to become locally integrated. Although supported by international cooperation, Governments, non-governmental organizations (NGOs)—and, through the United Nations System, the Office of the High Commissioner for Human Rights (UNHCR) and the World Food Programme (WFP)—the added value provided by the countries taking in the refugees greatly exceeded the value of the support provided by the “international community.” In natural disasters, more than 90 to 95 percent of the assistance received by affected populations is estimated to have been provided by the affected country. In the case of refugees or natural disasters, the population itself plays a fundamental role in cooperation, receiving and supporting in solidarity those affected and displaced by the calamity. This form of collaboration is not new, and is much broader than that supplied in emergency situations. It has been provided throughout the world for many years. It refers to solidarity with empathy, and, often, without self-interestedness, as well as to important features of community support—reaching across country lines, often to populations of similar ethnicities or those with old links, additionally cemented by cross-border marriages that erase nationalisms promoted by capital. The new feature is that in the 1980s this “solidarity” began to be quantified in relation to the international cooperation that frequently broadcasted its contributions loudly. Oftentimes, however, this cooperation amounted to less than what receiving countries or their societies provided.

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Latin America and the Caribbean is now developing what can be called the new frontiers of international cooperation: South-South Cooperation. As differences grow between countries in the region—some are “middle-income” societies with sister nations not yet reaching this economic level—this type of cooperation is evolving, and is now gaining acceptance as public policy. In this sense, the origin of this cooperation is not very different from that of North-South Cooperation. First there were affinities and cooperation among people that created the precedents on which State policies for cooperation were established. Although South-South Cooperation is being formed and developed as a State policy in middle-income countries such as Argentina, Brazil, Chile, or Venezuela, countries such as Cuba (without being a middle-income country) also contribute in a very important way to this form of cooperation, as does Mexico, a member of the Organization for Economic Cooperation and Development (OECD) and the region’s second country in economic and population terms.

The Inspiration and Soul of South-South Cooperation Before addressing some examples of South-South Cooperation in our region, a word of caution is in order. South-South Cooperation is essentially inspired by solidarity, horizontality, a desire to learn from one another, mutual respect, brotherhood, and collaboration that attempts to reduce differences. There is less emphasis on the development of theoretical models of cooperation and more on sharing what has been learned. Practical and immediate cooperation is emphasized over that which requires long elaborations of programmes and projects to be studied “ad infinitum” before becoming reality. This type of cooperation requires that all parties desire the collaboration, not that one decide to assist another. This is collaboration among officials and experts from those State institutions involved in the relationship, more than the creation of structures of project implementation financed by one of the groups.

Triangular and Quadrangular Cooperation There are countries in the North that approach this type of cooperation. The hope is that South-South Cooperation will gain recognition and more firm establishment within the OECD framework. This involves a form of triangulation, in which South-South cooperation is supported in a flexible way. As countries make it to the middle-income group, the role of the United Nations is changing. The character of its cooperation for assistance and development is mutating, becoming the source of knowledge for effective public policy making; contributing to the generation, documentation, and sharing of knowledge, practices, and experiences; articulating collaboration; advocating public policies that better protect and include the excluded; and influencing the attitudes of the citizenry, to mention some examples. In this context, the organizations and agencies of the United Nations System can be facilitators for South-South Cooperation through their ample presence in our region. In the case of chronic undernutrition, agencies such as WFP, the United Nations Population Fund (UNFPA), the Pan-American Health Organization (PAHO), and the United Nations Children’s Fund (UNICEF) can contribute to establish links and articulate contacts among countries, documenting practices, and contributing to measure the impacts and results in an impartial way that generates evidence. The possibility of bilateral donations, with the help of the United Nations in facilitating this type of collaboration among countries, can become a very strong “quadrangular” cooperation, such as that provided by Spain in supporting the United Nations to facilitate South-South Cooperation between Chile and Paraguay for birth registry. Other donors support the collaboration between UNICEF and Brazil through the Laços Sul-Sul (South-South Links) in the area of HIV/AIDS, through which Brazil supports eight countries on three

continents. In both examples, the United Nations agencies are a facilitating element, and neither Chile nor Brazil established their own costly structures, but instead utilized the capacity for international cooperation installed and present in their countries, through the United Nations.

South-South Cooperation Practices in Latin America and the Caribbean Argentina, Brazil, and Chile are involved in collaboration with Haiti, not only on the issues of democracy promotion, peace, and security but also in initiatives supporting human development. Argentina is collaborating with UNICEF to articulate their cooperation in sectors of mutual interest and in other areas through the signing of a Cooperation Agreement. Chile has established South-South Cooperation as one of its priority areas in the Framework for Development Cooperation with the United Nations, seeking to use the existing capacity to promote its growing cooperation efforts in the region. In the Regional Conference on Birth Registration and the Right to Identity, co-sponsored by the United Nations, the Organization of American States (OAS), and the Inter-American Development Bank (IDB), and with Paraguay as the host country, Chile and Paraguay signed a cooperation agreement to collaborate in overcoming the birth registry deficit in Paraguay. At the same time, the Paraguayan system of monitoring the situation children under 18 deprived of freedom in Paraguayan jails was of interest to the Chileans, who are now establishing a similar programme in legislation and are in the process of implementing it. This is an excellent example of horizontal cooperation between countries. In recent years, Argentina has introduced legislation extending education and health services as a right to all who have access, regardless of migratory status. This represents a great form of solidarity and cooperation with nearly three million immigrants from neighbouring countries, many of whom have not regularized their migratory status. Similarly, in the south of Chile there are areas where many Chileans have access to Argentine health services, particularly services for childbirth. For decades, Costa Rica has had similar provisions in place in health and education for Nicaraguan immigrants. In the 1980s the right to health and education was established due to the interest of the Ministry of the Interior in obtaining data on the immigrant population accessing these health services, for example. We all know that in a European country not long ago, a President suggested locating undocumented immigrants through their children in schools! Mexico served for a time as temporary refuge for millions of refugees along its southern border, with the collaboration of UNHCR and WFP, among other UN agencies. 173

Venezuela has expanded its collaboration in diverse ways, and its collaboration with Cuba has been particularly highlighted as an action that has brought health and education to many who thought this was inconceivable. Cuba’s cooperation with its technical personnel, particularly those in the health sector, covers not only an important number of countries in this region, but in other continents as well. Pursuant to an agreement signed on August 28, 2004, Brazil and UNICEF are collaborating to end vertical transmission of HIV/AIDS from mother to child and promoting transmission prevention in adolescents and young people in eight countries: Paraguay, Bolivia, and Nicaragua in our region; Timor Leste in Asia; and Guinea-Bissau, Cape Verde, and Sao-Tomé and Príncipe in Africa. The extraordinary results achieved in these countries are witness to what can be achieved through a form of collaboration inspired by human solidarity, combined with technical proficiency and a willingness to learn from one another.

Application of South-South Cooperation as a Form of Work in the Fight against Child Undernutrition Upon reviewing these few examples a large array of possibilities emerge for applying the rising South-South Cooperation to eradicate child undernutrition. Additional examples can illustrate these possibilities. Cuba has placed its technical personnel (many of which are physicians) at the disposal of programmes focused on the fight against undernutrition,

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provided the receiving country defines this as a priority. Based on the example of Guatemala, actions like this can reinforce monitoring at the municipal level and train and develop awareness of the importance of this follow up. If we want to reduce the terrible trio of maternal mortality, mortality of children under five, and chronic undernutrition, we must combine “the nine months before, 36 months after” methodology. Many countries in the region are at the moment reinforcing decentralization and looking for ways to improve capacities at the subnational and, particularly, municipal level. Through various agencies the United Nations is contributing to reinforce mobilization towards the Millennium Development Goals (MDGs) among nearly a fourth of some 16 thousand municipalities in Latin America. Including and developing awareness about chronic undernutrition is fundamental, since many people are unaware of its importance, or confuse it with global undernutrition. Programmatic responses—for example, “distributing food or milk”—often show this confusion, as interventions for pregnant women, in support of breastfeeding, or for the first years of a child’s life fail to arrive on time. In agreement with the receiving Government, the Cuban personnel can reinforce training and knowledge building at the local level, and this could be a factor in accelerating the fight against undernutrition. Argentina has programmes in its northeast and northwest areas to provide better prenatal care, which also benefits populations in neighbouring countries that cross the border to take advantage of them. However, it would not be very difficult to extend these programmes to the other side of the border, to be used by Paraguay or Bolivia. Training of healthcare personnel in community service, prenatal care, and cultural and ethnic aspects is only an example of the many experiences that can be shared on both sides of a border that

does not stop people from coming and going. This emphasis on prenatal care and monitoring during early childhood, as in the Nacer (“Birth”) programme, can be part of a shared and common investment among the countries, in which those with the most resources have the privilege of contributing more, but in which both can learn and share in a spirit of brotherhood. One of Brazil’s many programmes of horizontal collaboration is its support of eight countries in the fight against AIDS. This work, which has pregnant women as a central axis, offers an opportunity to provide additional services to pregnant women, contributing the fight against undernutrition in countries involved in this South-South Cooperation. Other variations of South-South Cooperation, previously mentioned, are positive practices in the reception of immigrant populations, whether they have regularized their situation or not. Countries such as Costa Rica and Argentina implement the rights to health and education as rights in themselves, not linked to the regularization of migratory status. This also represents a form of South-South Cooperation and contributes to prevent levels of chronic undernutrition prevailing in countries of origin from being reproduced or maintained in the receiving country. There are certainly many other valuable experiences. However the role of this presentation is not to elaborate on all cooperative experiences but to contribute to the generation or reinforcement of solidarity in support of the eradication of chronic undernutrition in our region.

A Vision of the New Latin America and Caribbean Without Chronic Undernutrition These years, many countries are celebrating the bicentennial of their independence. At least six countries have prepared celebrations for 2010. I ask: Is this celebration about national heroes and wars of independence, of territory and history? Or shall we attempt to bring to these festivities a Pan-American content for the future with a central focus on the human development of each and every one of the region’s citizens? Let us imagine, in a spirit of South-South solidarity, that these celebrations will focus on guaranteeing that each pregnant woman receives support in time, that each child born is welcomed into Latin American and Caribbean citizenship, and that public policies are designed to support their birth and growth with a guarantee of SouthSouth solidarity, in which those who do not have everything they need are supported by those who have more. What a legacy of the bicentennial festivities would this be! I congratulate and celebrate that Chile and the World Food Programme have convened this conference. I hope this will be the bell toll that unites efforts in the region to eradicate chronic undernutrition in Latin America and the Caribbean by 2015, that achieving this goal will be the central objective of the new vision that will unite our entire region, that our children will not be left behind!

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Food and nutrition security and their impact on equity Patricio Meller Bock President of the “Work and Equity” Presidential Advisory Council of Chile

We have had inequity for a long time. The subsequent question is, then, why are we now addressing the issue of inequity? Why are we now so impatient in Chile with inequity? The answer is that until recently the central problem in Chile’s economy, similar to what has happened in the rest of the Latin American countries, was associated with macroeconomic imbalances and cycles, inflation, fiscal debt, and balance of payments. But in the Chilean case these phenomena are now under control, which creates conditions to discuss distributive issues. The Chilean economy has demonstrated that it can reach the high level of growth necessary for achieving many other objectives. The relative success achieved by the Chilean economy has generated expectations among the entire population. If we are capable of penetrating, with our exports, distant and complex markets, why do we not have the same impulse and energy to resolve internal inequity problems? The perception we have is that, to become a developed country, it is not enough to reach high per capita income. A better level of equity is required. Various points are worth mentioning, among them the role of economic growth. To be clear about the paradigm shift we are facing today, the rhythm of economic growth is a necessary condition, but not a sufficient one to overcome social problems. Economic growth is a mechanism to achieve the increase in wellbeing of people and expand their potential decisions, but it is not the only objective in an unequal country where a sizeable proportion of the population still lives in poverty. There is consensus about the current need to take measures to resolve an urgent social and distributive question. To advance in that direction, the Equity Council discussed a new focus for social and labour policies. When I mention old social policies I refer to those of the twentieth century. New social and labour policies are those of the twenty-first century. Social policies of the twentieth century were designed to alleviate the situation affecting the poor. To this end, we elaborated a poverty line, which meets various objectives. Secondly, we established policies that help the poor meet their basic needs. The third objective is evaluating the effectiveness of the policies, through ac177

Patricio Meller Bock

One of the first issues we addressed was the definition of equity and why the lack of equity is a problem. The lack of equity produces various quality levels in education and health. Inequity also translates into distinct possibilities for children and influences and determines their life trajectory. It produces differences in power and capacity to influence important national decisions. When the existence of inequity is combined with little or no social mobility, it generates an increase in tension and more social conflict. All of this negatively affects the rhythm of economic growth and the inspiration to build societies. Finally, the persistence of inequity produces social fragmentation, reducing the capacity for dialogue among groups.

President of the “Work and Equity” Presidential Advisory Council of Chile

The Work and Equity Council met for eight months and submitted its final report on 6 May 2008. This paper provides the context for its discussions, their central theme, the questions, the paradigm change we are suggesting for the focus of social policies, the interaction of labour policies, and some of the proposals presented by the Council.

countingâ&#x20AC;&#x201D;ascertaining the number of people that remain below the poverty line over time. This creates an arithmetic paradigm: counting the poor and determining the numerical change in the number of poor people through time.

of production generate demands for the competitiveness of businesses and countries and the productivity of people. From the point of view of individuals, employment, productivity, and self-sustenance are transformed into the central requirements for accessing the benefits generated and supplied by the globalized world.

The same happens, from this quantitative point of view, with social spending in education, health, and housing. The indicators we always use are quantitative: the number of schools, hospitals, and housing solutions. The environment in which these social and labour policies operate is characterized by two dimensions: one we have had since the first eight decades of the twentieth century, characterized by a Fordist production system and an economy enjoying strong protection from the outside world. Gains in productivity in a Fordist system are achieved by economies of scale, productive specialization, and standardization of goods produced. This generates a fairly rigid production process with excessively specialized workers. The great advantage in protection from the outside economy is that Governments have many degrees of freedom to apply any type of policies. In the last two decades of the past century, these two dimensions changed dramatically. Now we live in a globalized world where almost all countries have decided to fully incorporate themselves into the world economy. Why have we done this when, among other things, we lose degrees of freedom in the control of social and economic policies? The answer is simple: the majority of countries perceive globalization as a more efficient and rapid mechanism to achieve the standard of living and technology of developed societies. And what are the characteristics of this global economy? It is characterized by frequent innovations in products and technological changes, in addition to variations in patterns of demand and the search for diversity of goods. In this new scenario, to reach the required levels of competitiveness it is necessary to replace the old Fordist production system with the Toyota production system: Toyota replaces Ford. The essence of this new productive paradigm is flexibility, which allows accommodation to the changes in consumer preference and technological innovation. This paradigm requires, among other things, workers with multiple abilities. Globalization and the new multiflexible system 178

There is a positive association between productivity and salary, and one positively feeds the other. All of this affects the logic and design of twenty-first century social and labour policies. The best social policy for the twenty-first century consists of every person having a job that provides an income that permits a satisfactory level of life. As a

consequence, the new basic principle of social policies is not focused on alleviating the situation afflicting those outside the job market and remaining at the margins. The central purpose of this new social policy is inducing and providing incentives training for people, so they can find a job and work. This new focus overcomes the twentieth-century assistance and dependency problems, replacing them with self-esteem and

In the long term, according to economists, increases in productivity are associated to improvements in the quality of education. But in the short term training is one of the principal mechanisms for increasing the productivity of people that have already finished their educational career. Furthermore, due to the velocity and frequency of technological change, training, job switching, and permanent updating of the entire workforce may be necessary. The “Work and Equity” Presidential Advisory Council elaborated a list of proposals for confronting inequity. We have divided the objective groups to whom policies should be directed. In the first place are those within the bottom quintile of income, the poorest group in Chile (low income families). In second place, there are what we call “workers”; in third place, young people and schoolchildren; and in fourth, small businesses. With respect to low-income families, the policy we are applying is mixed, employing a combination of two instruments. These two instruments are a subsidy for work income, on one hand, and a conditional cash transfer, on the other. We are proposing a variation of the most important instrument used by the United States in its social policy with work income subsidies, encapsulated by the phrase “those who work receive; it is worthwhile to work, we must make work pay.” The proposal we have made is that people making less than minimum wage receive a 30 percent subsidy on their gross income, so that of this 30 percent, 20 percent go directly to the worker’s pocket and 10 percent goes to the employer. This represents a mix of supply and demand labour policies.

self-sufficiency. In a complementary way, social sector policies require an emphasis on qualitative aspects—effective and opportune health care, adequate housing, and a high quality education—that contribute to raise self-esteem.

This programme does not end at the minimum wage. Instead, the 30 percent rate gradually drops until it reaches the level of twice the minimum wage, bringing this level of subsidy of working income to zero when the remuneration received by the individual is double the minimum wage. This is complemented with direct transfers to the poorer families, associated with the number of children: in other words, a specific monthly amount per child that each family has (an issue directly related to the central theme of child undernutrition). Although the amount in question is measured in development units, it is equivalent to about 25 dollars for a child under 15. Direct transfers are delivered to all families in the poorest group.

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This monetary transfer, as in Mexico and Brazil, is conditional. In the Chilean case the conditionality has three central elements. The first condition is that to receive the transfer, children must attend school. The second condition is that children attend health clinics to be evaluated and receive vaccinations (as in Mexico and Brazil). The third element—a central one, in our view—is that each working-age person searching for work must receive training. The idea is to encourage people to join the labour market. This is an innovative policy for us. The proposal advocates gradual implementation among people in the lowest quintile, where the policy is targeted. But we want to start with women and young people in the lowest quintile, and then incorporate the men. What this policy does in the Chilean case—and, I believe, in Latin America as well—is induce the persons receiving the transfer to join the formal system, because persons operating in the informal system represent an important percentage of the lowest quintile in Chile. If they wish to receive this subsidy, they will have join the formal market, the system, and society to receive its benefits. Another idea we have discussed is establishing long term goals. The difference between a developed country and a developing one is the fact that developed countries have a long-term horizon: economic agents can make decisions over a five-, ten-, or twenty-year time span. The problem we have in underdeveloped countries—among them, the Latin American countries—is that this long-term horizon does not exist. The challenge is to create a long-term horizon from the perspective of the economic agent. Long-term goals predict that inflation will oscillate between 2 and 4 percent. Any time inflation escapes this range, the Central Bank applies corrective monetary policies. The Treasury, on its side, has a long-term fiscal policy, based on generating a structural surplus of 0.5 percent of GDP. When it exceeds or does not reach this range, fiscal policy must be aligned with this objective. If we have long-term fiscal and inflation policies, it is time also time to have long-term equity goals and objectives. For example, the policy for low-income families seeks to set the poverty level in this country at 1 percent, not in the long term, but in the medium term. In the long

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term, the Council also suggested creating a Social Authority. Just as the Ministry of Finance presents the state of public finances every year and the president of the Central Bank annually submits a report on the financial and monetary situation, this Social Authority would provide the country with a picture of how the social objectives and goals are being completed over the long term. We propose the creation of this trilogy: the Ministry of Finance, the President of the Central Bank, and the Social Authority, but with effective instruments that give it weight within the cabinet. Social policies should not continue to be under the monopoly of the Ministry of Finance: this is what is behind this proposal. With respect to the suggestions we have for workers, the central policy is training and capacity building. There is a perception that the central questions of who is trained, where they are trained, in what they are trained, and who is training are answered exclusively by the business sector. In the Chilean case there is a tax incentive according to which costs of training are discounted from the tax liability of businesses. The Treasury finances these training courses. If the Treasury is providing the resources, it seems logical that the Treasury should also have an opinion about the central theme in place, the decision of who to train. The proposal of the Council is to create a training voucher for each worker. The worker receives it and decides when and what to train in. The voucher would have three financing sources. The Treasury, business, and workers, who also must show their support, will all participate. The form of support to finance these training courses is similar to that existing in Chile with regard to higher education loans. These subsidies are discontinued when the students finish their higher education. The student begins to work and pays back the subsidies received. The same is proposed for the training vouchers. There is an additional variant in the training vouchers: the suggestion of creating a social vulnerability index directed at workers. This social vulnerability index would try to capture the various dimensions affecting the situation of the workers, the unemployed, those coming in and out of the labour market, the underemployed, and young people who dropped out of schools and struggle to enter and remain in the job market. The training voucher would be proportional to the social

vulnerability indicator. Unemployment insurance provides a statistical database with worker characteristics, which can serve to put together the vulnerability indicator. This training proposal has a long-term objective. We want to start with a moderate programme, covering one hundred thousand workers per year and build it up to one million workers, in a term of six to eight years. Chile’s workforce consists of 5.5 million workers. The idea, in the long term, is that every five years Chilean workers will be able to retrain, making them more employable and productive in the current competitive and globalized world. The increase in the level of income and remuneration of workers is associated with increases in productivity. Increases in productivity are directly associated with what is done in training courses, but for these training courses to work, we must take charge of another serious problem related to the Chilean workforce. Half of the workforce has not completed secondary education. Pilot programmes are already in existence, but we want to transform them into massive, adult education initiatives. Currently, education is obligatory in Chile for 12 years. If some adults were not able to complete 12 years of schooling, we would like to somehow make this opportunity retroactively available for the entire workforce. I do not know how long it will take to do it, but the “Work and Equity” Presidential Advisory Council believes that a social debt exists towards all workers who have not completed their secondary education. These workers need an educational base for a training programme to generate increases in productivity and employment. This is the long-term objective we have in the case of the workers. The “Work and Equality” Presidential Advisory Council has suggested programmes in 17 different areas. Its recommendations represent a fairly substantive and conclusive set of proposals. We hope they will provide guidelines for future discussion and constitute a framework or debate platform to better understand this country’s equity problem. A third proposal is associated with what we have called “equality of opportunity,” especially for school children. In Chile there are three types of schools: in the first place, those which are private or require payment,

attended by 10 to 15 percent of the population, corresponding to the high income groups. Then there are the “municipal” schools, attended by 50 percent of the country’s schoolchildren, which correspond to the families with the lowest incomes. In between there are private subsidized schools, for the percentiles between 50 and 85-90. The Advisory Council has proposed to give awards to the most talented students in all municipal and subsidized private schools (a total of 3,500 schools), excluding private or paid schools. We want to award each year the best children in five levels, from seventh to eleventh grades, with an amount equivalent to three minimum wages. Such award will help students fund their higher education. This programme has been conceived to reach fifty thousand children per year. In other words, it is selective but massive, on a large scale. It covers the entire country, reaching all schools in all communities, and places children in competition with schoolchildren at their same level in terms of school and environment. This is not what currently happens at the higher education entry points, where students from paid. Under this proposal, students will compete with their peers. The idea has a complement. In Chile, to enter university it is crucial to take a pre-university course. These courses make all the difference between who gets into university and who stays outside, particularly at the higher-quality universities. These pre-university courses are worth 2,000 dollars. The idea attached to this proposal of identifying talented students and trying to enrol them in university, is that those children attending between seventh and eleventh grades who have received at least two of the annual awards will have access funding for their pre-university courses by the time they reach twelfth grade. Initially, the programme will reach between twenty and 25 thousand students. Eventually, we will reach 75 thousand children across the country. The Council has made various other proposals which can be examined in the report, which is available online at www.trabajoyequidad.cl.

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The public-private relationship in school feeding programmes Manuel Espinoza Executive Director of the Latin American and Caribbean School Feeding Network (LA-RAE)

This article outlines the advantages that participants or partners in a feeding programme for vulnerable and/or undernourished can receive.

Additionally, it might be mentioned that there are functions in the public sector that cannot be delegated. These relate to policy decisions, targeting, solutions, and the corresponding completion controls of these public policies. The paper analyzes the management capacity that has been developed in the operation of these programmes, related to the public and private management in terms of services and human resources throughout the country: 1) The National Scholarships Board1 Programme has an official for every 100 direct operators delivering services, and one for almost 200 indirect operators, taking into account those in the private sector providing support through inputs and other services. This amounts to one public official for every 5,500 daily services. Services include a school meal (lunch) involving two to three daily preparations. This requires production and service by qualified personnel to ensure the quality of the intervention. 2) Two thousand tonnes of food and/or inputs are mobilized on a daily basis, throughout the countryâ&#x20AC;&#x2122;s 5,000 kilometres. This statistic is very relevant as an indicator of the mobilizational capacity, adequate transportation, and technology required. Additionally, the acquisition centralized warehousing, and distribution of food need to be managed at an optimal cost. 3) Programme implementation requires a broad range of efforts by micro businesses as well as small, medium, and large businesses. Together they fulfil various programme requirements. 4) The incidence of inputs (food and other necessary elements) on service costs for the majority of operators is around 65 percent, which indicates that a large part of the programmeâ&#x20AC;&#x2122;s resources transforms into service. The fact that cost for operators is about 25 percent indicates that this is an activity with narrow margins requiring great efficiency in resource management. 183

Manuel Espinoza

Providing almost 2.4 million daily food services to Chileâ&#x20AC;&#x2122;s pre-school and school populations, distributed throughout the country during all the working days of the year, developed a publicprivate capacity without parallel anywhere in the country. It is necessary to describe the characteristics of the programme, which indicate the convenience of furthering and heightening this form of work, independently of the need of establishing the degree of success of the initiative.

Executive Director of the Latin American and Caribbean School Feeding Network (LA-RAE)

Any form of resource, public or private, runs out, and a policy is damaged when it loses part of its resources and cannot complete its targeted objectives. In addition to defining policies, it is necessary to effectively and efficiently confront the way in which food is delivered to vulnerable populations, which is one of its objectives, under the premise that the poor cannot wait.

5) The Quality Assurance Programme (Programa de Aseguramiento de Calidad), under permanent evaluation, is the most important contractual tool allowing implementation according to the requirements of the School Feeding Programme. 6) Given the proximity to systems of production for basic foods and the demand that is generated, the programme creates development opportunities for cottage producers, with significant economic impacts for their communities. Relevant examples exist for the development of marginal localities through joint public-private efforts, although this is an aspect the impact of which has not been sufficiently evaluated. Opportunity, sanitary quality, and service quality are among the principal quality characteristics generated through private management. All are Government requirements. Additionally, the technological and personnel expertise of the programme should be noted.

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Opportunity Every day of the year, the contracted service is delivered with a completion rate of almost 100 percent, in terms of timing and amount. This aspect is very relevant, as it represents an important support service for school which, additionally, fulfils a relevant role in guaranteeing adherence to the education system.

Sanitary Quality According to the epidemiological monitoring by the health authority, the School Feeding Programme is the sector that least contributes to food-borne illnesses in our country. This result is extremely relevant since the infrastructure and equipment in schools is very limited and, in some cases, insufficient. These good results are due to the adequate management of operational and sanitary procedures, thus reaffirming that good management of procedures can overcome resource deficiencies. It is, therefore, very relevant to utilize trained personnel.

Service Quality Better production and delivery conditions are a feature of the programme, which has succeeded in responding to increased demands from users at a higher development level. Growing volumes of service over significant time periods (three or four years) have permitted the development of new technologies. In standardized form, these technologies allow the supply of a large number of services with good gastronomical quality, unsurpassed sanitary conditions, and improved transportation, distribution, and service. All of this has been obtained at lower costs than operating under traditional service-providing methodologies.

The improvement in management represents one of the tools that should undergo profound revisions to optimize product use, incorporating more advantageous products and processes, using preservation technology, analyzing risks that deteriorate the quality of foods, developing products and providers, etc. This requires an effort from all feeding programme stakeholders and, especially, private sector support through the development of the above-mentioned features.

Technological Development The development of technology for food production systems, the production of inputs and foods, the preservation of products, the development of services, and control systems, implies efforts in research and investments, which have had rapid responses by the sector.

Personnel Development The permanent development of these activities has required training in human resources, improving their stability and possibilities for higher income as they have acquired greater capabilities.

Final Reflection Programmes of quality assurance, where self-control and developing improvements are assumed with increasing responsibility by the operator, constitute a fundamental advancement. This will lead to public sector specialization on regulatory matters and a partial State withdrawal from some of the collaboration currently provided to the educational system. More importantly, these developments allow increased efficiency in the use of programme resources. The continued increase in food prices is a factor that is beginning to represent a significant problem for feeding programmes. According to analyses, this rise will continue for several years. Financing these increases is not sustainable. Therefore, it is urgent to apply measures that will tend to lessen the increase in prices.

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Part Four RECOGNITIONS AND ACKNOWLEDGEMENTS

SUMMARY During the Regional Ministerial Conference â&#x20AC;&#x153;Towards the Eradication of Child Undernutrition in Latin America and the Caribbean,â&#x20AC;? President Michelle Bachelet of Chile recognized the trajectories and contributions to medicine and nutrition by physicians Fernando Monckeberg Barros and Francisco Mardones Restat. These pioneers in the fight against child undernutrition in Chile received awards from President Bachelet. The following sections contain brief addresses by Doctors Monckeberg Barros and Mardones Restat, thanking President Bachelet for the recognition. 186

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Successes in the fight against child undernutrition in Chile Fernando Monckeberg Physician, Professor of Paediatrics at the University of Chile, founder and Director of the Institute of Nutrition and Food Technology (Instituto de Tecnología de los Alimentos [INTA], and founder and president of the Corporation for Childhood Nutrition (Corporación para la Nutrición Infantil

Fernando Monckeberg

Physician, Professor of Paediatrics at the University of Chile, founder and Director of the Institute of Nutrition and Food Technology (Instituto de Tecnología de los Alimentos [INTA], and founder and president of the Corporation for Childhood Nutrition (Corporación para la Nutrición Infantil [CONIN]).

[CONIN])

I feel profound emotion and pride on receiving this distinction from our President Michelle Bachelet. The award is a distinction for many other individuals. Looking back, thousand of Chileans have collaborated in different ways during a long period of time—perhaps fifty years or more—with the fight against child undernutrition. I refer to those who created and developed the health infrastructure and those who recognized and affirmed for the first time the existence of the problem and were capable of acting. Those who could prove the impact undernutrition has on the young population, the damage it causes to the growth and development processes and the damage it represents for society. Those who were able to diagnose the problem adequately, targeting it and saying: “the most vulnerable groups where we should concentrate our efforts are children during their first two years of life and pregnant women.” Those who researched the measures and strategies that would be developed to protect that child. Those who thought of the interventions, in primary health, in nutrition, in education, in environmental sanitation, for the entire Chilean population. Those who developed this strategy, who are, perhaps, in many places. Their achievements materialized because decisions were maintained across different governments, giving rise to a State policy. Without doubt, it is these persons who deserve this recognition and they are the ones I represent when I receive it, along with all Chileans, because it was their understanding and comprehension of the problem, of its transcendence, which motivated the contribution of their resources and capacities. It was this coming together of Chileans—their persistence, the development of the strategy and its maintenance over the long term, in spite of tremendous changes that the country has had in recent years—that have made possible what many decades ago seemed an impossible task. I wish to express my appreciation to them and share with them what our President has done by giving me this distinction.

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Knowledge transmission in the fight against child undernutrition Francisco Mardones Restat Physician, Advisor and Representative to the Pan-American Health Organization (PAHO), Director-General of the National Health Service of Chile, Professor of Public Health at the University of Chile

Over the past few days the spirit of all those in attendance at these sessions has been turned around, because it has been renovated by the reflections we have made, the responsibility of completing the mandates we receive from our university education, and the positions and functions destiny has assigned to us.

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Francisco Mardones Restat

Perhaps the most important merit of the United Nations agencies is transmitting the knowledge generated, not only to bureaucratic institutions or government structures, but also to the people of our region, so they can appreciate the achievements that can be made. The United Nations agencies produce additional goods by demanding that knowledge be put into place, encouraging professionals to deliver practical and effective solutions, and generating political will in Governments, so that they can prioritize the care of individuals when allocating resources.

Physician, Advisor and Representative to the Pan-American Health Organization (PAHO), Director-General of

A real turbulence is produced when the delegates of the United Nations agencies arrive, because they update knowledge, compare achievements, and plant the desire for transferring this information in their structures, and, very specially, in the people, who receive these ideas with enthusiasm, support this knowledge, make it their own, and are capable of providing part of their income so these achievements can be implemented.

the National Health Service of Chile, Professor of Public Health at the University of Chile

Periodically, the authorities of the Governments in our region are capable of entrusting enormous tasks to the agencies of the United Nations. They have to suggest reforms, evaluate results, and collaborate in the preparation of personnel, deliveringâ&#x20AC;&#x201D;as do our universitiesâ&#x20AC;&#x201D;an ethical position and sharing knowledge. No acquired knowledge can be guarded with avarice, for our own benefit: ensuring its application is a great responsibility.

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ACKNOWLEDGMENTS This publication is one of the results emanating from the Regional Ministerial Conference “Towards the Eradication of Child Undernutrition in Latin America and the Caribbean,” organized by the Government of Chile and the Regional Office of the World Food Programme (WFP) for Latin America and the Caribbean, and held in Santiago, Chile, between 5 and 6 May 2008. This consultation was possible thanks to valuable support from the Government of Chile, headed by Her Excellency Michelle Bachelet, President of the Republic. In particular, WFP expresses its profound gratitude to the Ministry of Health, the Ministry of Planning, the Chilean Agency for International Cooperation (Agencia de Cooperación Internacional [AGCI]) of the Ministry of Foreign Affairs, National Pre-School Board (Junta Nacional de Jardines Infantiles [JUNJI]), the INTEGRA Foundation, the Procurement Office of the National Health Service (Central Nacional de Abastecimiento [CENABAST]), the Nutrition and Food Technology Institute (Instituto de Nutrición y Tecnología de los Alimentos [INTA]) and the College of Medicine of the University of Chile. The Regional Conference “Towards the Eradication of Child Undernutrition in Latin America and the Caribbean” brought together representatives of international organizations and non-governmental organizations that provide food-based social programmes throughout the region, as well as Governments and academic institutions of various States in the region, whose presence and enthusiastic participation contributed notably to the success of the event. This publication would not have been possible without the support of the speakers at the Conference who, with the purpose of contributing to the dissemination of best practices in combating hunger and marginality in Latin America and the Caribbean, contributed their articles to this compilation. The collaboration of the personnel of WFP’s Regional Office for Latin America and the Caribbean, the United Nations Office in Chile, and the WFP Office in Chile were instrumental to assure the success of the meeting in Santiago and the publication of this book. For the support received, WFP expresses its sincerest gratitude.

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