Explaining Child Malnutrition in Developing Countries: A Cross-Country Analysis

Great strides have been made in reducing child malnutrition over the past few decades. The prevalence of underweight children under five in the developing countries was 46.5 percent in 1970. By 1995 it had dropped to 31 percent (167 million), indicating that past progress has left a long way to go. This paper draws on the experience of the 1970-95 period to (1) elucidate some of the main causes of child malnutrition; (2) undertake projections of how many children are likely to be malnourished in the year 2020, given current trends; and (3) identify priority actions for reducing malnutrition in the coming decades.

Data and Methods
The study is based on a conceptual framework developed by UNICEF in which the determinants of child malnutrition are broken into three levels of causality: immediate (most proximate), underlying, and basic (the deepest level). The paper focuses on the three underlying determinants: food security, care for mothers and children, and health environment. It also considers the roles of two basic determinants: per capita national incomes and democracy.

The dependent variable is national child underweight rates, mainly from the WHO Global Database on Child Growth and Malnutrition. Four explanatory variables are employed to represent the underlying determinants. These are national food availability (for food security), women's education, women's status relative to men (for food security and care), and water quality (for health environment). Measures of these variables are per capita dietary energy supplies, female secondary enrollments, a ratio of female to male life expectancy at birth, and population with access to safe water. Unfortunately, due to data scarcities, a measure of poverty-—a main cause of food insecurity—-could not be included. For the basic determinants, the measure of nation-al income is GDP per capita in purchasing power parity $US; that for democracy is an index of political rights and civil liberties.

The analysis is based on country fixed-effects multi-variate regression using data from 63 countries over 1970-96. The countries represent 88 percent of the developing-world population. Separate estimating equations are specified for the underlying and basic determinants. A third set of equations with the underlying determinants as dependent variables and the

In Sub-Saharan Africa and South Asia. . .improvements in per capita food availability and women's education offer the best hope for future reductions in child malnutrition.

basic as explanatory variables are also estimated. Tests for endogeneity, omitted variables bias, nonlinearities and structural differences across the developing regions are undertaken.

Estimation Results
All four of the underlying-determinant explanatory variables are found to have strong and statistically significant negative effects on child malnutrition. Per capita dietary energy supplies have a declining marginal effect such that as they increase, the strength of their impact weakens. After they reach a threshold level of approximately 3,120 kilocalories, their impact is minimal. National incomes and democracy are also strong determinants. Their effects are brought about mainly through the under-lying determinants (national incomes via all four underlying de- terminants; democracy via health environment improvements and increased food availabilities). Per capita national incomes have a declining marginal effect; after reaching a level of about $4,750, their impact can be expected to be small.

Past Progress: How Was It Achieved?
What contribution has each determinant made to the 15.5 percentage-point reduction in the developing-country rate of child malnutrition from 1970-95? Among the underlying determinants, increases in women's education have made the greatest contribution, being responsible for 44 percent. of the total reduction. Improvements in food availability have contributed to 26 percent of the reduction, health environment improvements to 19 percent. Because there has been little improvement in women's relative status over the 25 years, its contribution—while still substantial—was the lowest (12 percent). For the basic determinants, improvements in per capita national income have made a substantial contribution, an estimated 7.4 percentage-point reduction in the prevalence of child malnutrition. While democracy has great potential, because little progress has been made in this area, it made no contribution.

Child Malnutrition in the Year 2020
Projections of the prevalence of malnutrition in the year 2020 are based on three scenarios for growth in the four underlying determinants: a status quo scenario, an optimistic scenario, and a pessimistic scenario. For the nonfood determinants, the scenarios are based on rates of change over 1985-95. For food availability, IFPRI IMPACT model projections are employed. Under the status quo scenario, 18 percent of developing-country children (140.3 million) are projected to be malnourished in 2020. The prevalence rises to 22 percent under the pessimistic scenario and falls to 15 percent under the optimistic scenario. Even under the optimistic scenario, the absolute numbers of malnourished children in Sub-Saharan Africa are expected to be higher in 2020 than they were in 1995. Based on the status quo projections, a sharp regional shift in the location of child malnutrition is projected: South Asia's share of the total numbers of children will fall from 51 percent to 47 percent, but Sub-Saharan Africa's share will rise from 19 percent to near 35 percent.

Priorities for the Future
All of the determinants considered in this paper should be an integral part of strategies for reducing child malnutrition in the future. They should be seen as complementary to the more direct measures that have been the traditional focus of nutrition interventions, such as breast-feeding promotion, nutrition education, supplementary feeding, and food fortification. Household-level studies show that poverty reduction should also be a main feature of future strategies.

The paper concludes by identifying priority investments among the underlying determinants for reducing child malnutrition in each developing region. The rankings are based on (1) the relative strengths of impact of the determinants (obtained from the regression estimates) and (2) the degree to which each is below its desirable level. In Sub-Saharan Africa and South Asia—the regions with the highest child malnutrition rates, improvements in per capita food availability and women's education offer the best hope for future reductions in child malnutrition. An additional priority for South Asia is women's status relative to men. In East Asia, the Near East and North Africa, and Latin America and the Caribbean (LAC), primary and secondary priorities, respectively, are women's education and relative status. Additional secondary priorities are food availability for East Asia and health environment for LAC.

A key message of the paper is that any comprehensive strategy for attacking the problem of child malnutrition must include actions to address both its basic and underlying causes. If national incomes and democracy are not improved, the resources and political will necessary for investing in health environments, women's education and status, and food availabilities will not be forthcoming. If improved national incomes and democracy are not directed at improvements in the underlying determinants, on the other hand, they will make little difference.

To order a discussion paper, please fill out an online order form, email IFPRI-FCN@cgiar.org or send requests to Food Consumption and Nutrition Division, IFPRI, 2033 K Street, N.W., Washington, D.C. 20006, U.S.A.