The World’s Children Are Starving. Here’s How The World Bank Can Help

The world’s children are starving, and the World Bank can help to fix it. Indeed, there is a moral imperative to ensure children have adequate access to proper nutrition, not to mention the economic benefit and human rights obligation.

Globally, almost half of all child deaths before the age of five can be attributed to malnutrition. In the fight against malnutrition, the World Bank is a primary target of advocacy, as it is the world’s largest source of development financing and has committed itself to investing in early childhood development and human capital.

Despite progress in recent years, malnutrition and stunting remain significant problems worldwide, and the COVID-19 pandemic has worsened the situation through its disruption of food supply chains, economic activity, and development assistance. Through the pandemic and long after, sustained advocacy will be necessary to ensure that the World Bank allocates sufficient funding to nutrition and early childhood development.

A Case For Nutrition Investments

In 2019, the latest year for which numbers are available, an estimated 5.2 million children younger than age five died. The deaths were heavily concentrated in Sub-Saharan Africa and Central and Southern Asia. These regions are home to 52 percent of the global under-five population but account for more than 80 percent of global under-five deaths. Indeed, five countries accounted for nearly 50 percent of under-five deaths in 2019: the Democratic Republic of the Congo, Ethiopia, India, Nigeria, and Pakistan.

One in three children globally suffers from one or more forms of malnutrition: undernutrition, micronutrient deficiencies, or obesity. One consequence of undernutrition is stunting, in which a child’s height is at least two standard deviations below the median for their age. According to the 2020 Global Nutrition Report, nearly 151 million children younger than age five are stunted. Prior to the outbreak of COVID-19, the world was making headway in reducing stunting in the under-fives, from 33 percent of children impacted globally in 2000 to 22 percent in 2020. New numbers showing the pandemic’s impact on stunting and malnutrition are not yet available given that the pandemic is not over. However, there is consensus across many international organizations—including the Standing Together for Nutrition Consortium of health and economics experts and the UNICEF, World Health Organization, and World Bank inter-agency team—that the pandemic is expected to exacerbate all forms of malnutrition and disrupt progress toward the 2030 Sustainable Development Goals (SDGs).

Stunting, like other forms of undernutrition, has a profound impact on childhood development. By age three, a child’s brain has developed to 80 percent of its adult size. This makes the early years the most critical period for brain development, with long-term impacts on physical, intellectual, and social health.

Healthy brain development is fueled by proper nutrition, the prevention of illness, and a nurturing and stimulating caretaking environment. A lack of these things can lead to serious and irreversible delays in children’s growth, learning, and future economic prospects. For example, a World Bank analysis found that children who were well-nourished during their early years were likely to earn 20 percent more than their malnourished peers. This impact of malnutrition is felt across the global economy, with losses totaling US$3.5 trillion a year. The World Bank has estimated that for every $1 invested in nutrition, a country would see a return of $4 to $35. From a broader standpoint, the World Bank recognizes that investments in early childhood development have greater returns on investment than human capital investments taking place later in life. This cost-benefit analysis has fueled the Bank’s recent prioritization of early childhood development initiatives, but when it comes to nutrition, these investments still fall short.

The World Bank is a vital source of financial and technical assistance to low- and middle-income countries. It is the single largest development financing source globally, disbursing more than $54 billion to partner countries in 2020, including $21 billion through the International Development Association (IDA), which is the single largest source of donor funds for basic social services for the world’s 74 poorest countries. With this in mind, it is crucial that the World Bank engages more fully around nutrition and nutrition-smart investments. It’s good for humanity, it will save lives, and it will create economic benefits.

As we work to draw attention to this silent malnutrition epidemic that is co-occurring amidst the COVID-19 pandemic, we must keep in mind who it is that is most impacted when nutrition is underfunded: newborns, children, and mothers. Babies have no say in where or to whom they are born—the onus lies on all of us to ensure their right to a healthy start. This includes reproductive, maternal, newborn, child, and adolescent health (RMNCAH) investments because a mother needs to be healthy to have a healthy mom-and-baby duo. Investing in children necessitates investing in their mothers and caregivers, especially during the prenatal and neonatal periods.

Within these RMNCAH investments, nutrition should be included as a key pillar. The Global Financing Facility (GFF), a project of the Bank, is the main mechanism through which the Bank funds RMNCAH initiatives. A fair share of the GFF’s RMNCAH initiatives are “nutrition-sensitive,” meaning they might be indirectly related to nutrition. Nutrition-sensitive investments typically address the underlying causes of malnutrition—for example, interventions that support and promote breastfeeding. In contrast, nutrition-specific investments are high-impact interventions that address the immediate determinants of malnutrition—for example, micro-nutrient supplementation or fortification and acute malnutrition treatment. Thus, by advocating for the Bank to make more targeted investments in nutrition, we are calling for complementary initiatives that go beyond nutrition sensitivity and include more directly impactful nutrition-specific investments.

Future Need

Gaps in nutrition funding existed before the pandemic, allowing malnutrition to be a silent killer of our world’s babies and small children. Now, those gaps have widened. According to recent estimates, an additional $1.7 billion is needed annually to tackle the impact of COVID-19 on nutrition, on top of the World Bank’s estimates of $7 billion per year. Given that responding to COVID-19 has been, understandably, the top public health priority this year, nutrition has been deprioritized in IDA-eligible countries and among donors. This means that attention and resources have been diverted away from nutrition programming and investments.

Advocates must continue to engage with the World Bank to maintain nutrition as a priority in the wake of COVID-19. One of the most influential advocacy organizations is the ACTION Global Health Advocacy Partnership, a group of locally based organizations around the world that aim to reduce preventable diseases among the world’s most vulnerable populations through policy change and resource mobilization. Advocates such as ACTION worry about the progress that may have been lost on reducing malnutrition and whether additional resources will be allocated to address the ongoing disruption. In interviews conducted for a forthcoming ACTION report on ensuring World Bank accountability, one ACTION external ally noted, “We are seeing this across all funders and in many countries, that the main health response has prioritized COVID-19 prevention and treatment.” Another ACTION ally noted that, despite the link between malnutrition and vulnerability to COVID-19 illness and death, “there is very little conversation within donor networks on the value of nutrition programming as a way to mitigate COVID-19.”

Nutrition must remain a top priority of the Bank. No matter the issue area, donors and international financial institutions such as the Bank should ensure that all development programs are grounded in a strong push for nutrition programs to maximize impact. Nutrition-specific and nutrition-smart investments should be mainstream—part of other development initiatives, as I’ll describe in the next section—as well as standalone. Increasing nutrition investments will have a ripple effect, bolstering and strengthening other initiatives, including the COVID-19 response and RMNCAH programs.

Difficulty Measuring The World Bank’s Nutrition Investments

The World Bank remains an essential resource in the fight against stunting and other forms of malnutrition, but in the wake of COVID-19, a concerted advocacy push will be required to maintain and maximize the World Bank’s commitments to nutrition initiatives.

Complicating advocacy efforts is the fact that it is very difficult to track the World Bank’s investments in nutrition. Recent updates of the World Bank’s public database have made it easier to track nutrition disbursements; additionally, nutrition and food security theme coding is finally disaggregated, but this information is only available on a project-by-project basis. It is not yet possible to download a full project database that breaks down total spending by code. It is, therefore, still more difficult than necessary to precisely measure the World Bank’s nutrition investments.

Additionally, tracking commitments from the Bank is made more difficult by a lack of precise indicators. This has implications for funding given that, simply put, the money aligns with the indicators. If there is no indicator, then there will be no money specifically allocated to that issue.

Let’s look at the indicators within the IDA Results Management System (RMS), for example. Aside from the GFF, a large share of nutrition investments comes from IDA resources. From the upcoming IDA20 replenishment—which will cover 2022–25—nutrition advocates, such as ACTION partners, are asking the Bank to increase nutrition-specific commitments. However, the measurement and tracking of IDA commitments is also difficult, partially due to the way in which the indicators are broken down. Nutrition commitments need specific indicators within the IDA RMS that would allow us to measure delivery on those specific commitments, rather than on nutrition as a whole. For example, current indicators do not include wasting, the most severe form of malnutrition. Adding a specific indicator for wasting, as was recently done for stunting, would help to capture the impacts of acute malnutrition and allow alignment with funding. Creating these indicators would also create consistency with the SDGs and the World Health Assembly global nutrition targets.

Challenges In Advocating With The World Bank

A large part of the Bank’s value lies in the scale on which it operates, both in terms of finance and global reach. However, the Bank’s governance structure poses some challenges for many advocacy models by limiting civil society engagement.

For many international development institutions, civil society engagement is the primary means by which trust is fostered and transparency and accountability are ensured. But when it comes to the World Bank, engaging civil society organizations (CSOs) and grassroots advocates is difficult given that the Bank does not see itself responsible to any country’s citizens. For the World Bank, its relationship is with each country’s executive branch and its finance minister, not with the country’s people.

Furthermore, the World Bank can be an overwhelming institution to navigate. It is a massive organization with an incredibly large scope and a high bar of entry in terms of understanding how it works. Additionally, the Bank’s governance structure presents barriers to civil society engagement, particularly regarding transparency and accountability mechanisms.

This is particularly challenging for organizations that center civil society engagement and grassroots activism as cornerstones of their work, such as the ACTION partnership. A key element of ACTION’s work, as well as that of many other global health advocacy organizations, is seeking accountability and transparency from those institutions such as the World Bank that must be expected to deliver on the commitments they make. The difficulty they encounter keep them from being fully successful in holding the Bank accountable to its commitments.

The World Bank has a stated commitment to civic participation, but it falls short on creating meaningful windows through which civil society can directly engage with the Bank. For years, individuals and civil society organizations have criticized the Bank for its lack of transparency, structural underrepresentation of the Global South, and biased decision-making processes. Each of these issues could be remedied by creating an official CSO window through which advocates can demand transparency and accountability.

The Bank recognizes that central to ensuring accountability is engaging beneficiary communities that can exercise agency and control over the project design, monitoring, and implementation. As advocates, we strongly agree. Thus, monitoring and accountability mechanisms supported by civil society at national and international levels is necessary for delivering on the IDA commitments and other World Bank initiatives.

Looking Ahead

According to ACTION tracking using the World Bank’s available database, no new nutrition or food security investments have been approved to date under the IDA19 replenishment (July 2020–June 2022). In fact, almost all project approvals in the health sector have focused primarily on responding to COVID-19. This is not entirely surprising, but it does suggest the possibility of a growing funding gap in nutrition programming in the coming years.

Especially as we look ahead to the IDA20 Replenishment and the Tokyo Nutrition for Growth Summit in December, we call on the World Bank to: increase resource mobilization for nutrition-specific and nutrition-smart investments, create effective ways to measure and track these commitments, and create open channels of communication with CSOs to advance transparency and accountability. As we are now more than 20 months into this pandemic, it is crucial that we strategically coordinate responses and investments so that we can maximize impact and reduce malnutrition around the world.