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8/7/2019 Briefing Paper - Undernutrition: What Works
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Undernutrition: What works?
Worldwide progress in reducing rates of child-hood undernutrition has been relatively slowand variable. Indeed, in too many countries, rates are
unacceptably high. There is no doubt that the fight
against undernutrition will remain relevant for manyyears to come. Nevertheless, behind the global statis-
tics lie some success stories. This briefing is based on
the outcome of secondary research which examines
five such stories Brazil, Peru, Mozambique, Malawi
and Bangladesh which have had relative success
in bringing down their rates of undernutrition over the
past fifteen years, in the quest to find out why and
how these countries in particular have been success-
ful. Research aimed to identify policies and practises
implemented to facilitate the success and analysethe extent to which a reduction in undernutrition has
been achieved due to a responsive policy environment
and or social/civil initiatives. Drawing on evidence pre-
sented in the full report, this briefing presents these six
key success factors in turn, selecting particular exam-
ples which stand out, from case studies examined.
Key messages
A combination of six key success factors strong
political will, civil society participation and owner-
ship, a multi sectoral and multi phase approach,
institutional coordination and contintuity of sus-
tainable financial investment make up an ideal
enabling environment, which if in place should
facilitate a reduction in rates of childhood undernu-
trition. In contexts with the most demonstrable suc-
cess all six factors are present in varying degrees.
Even in some places which have managed to
successfully reduce rates of undernutrion, rates
remain unacceptably high. These are peaceful,
non emergency settings, yet high rates of under-nutrition persist. Surely this demonstrates that
undernutrition is not just an emergency issue.
In fact, addressing undernutrition is clearly linked
to poverty reduction; concrete steps can be taken
as the case studies show.
Strong political will is key if the fight against hun-
ger and undernutrition is to suceed. Governments
with the political will and a signed, demonstrable
Undernutrition: What works?
A policy briefing
Executive summary January 2011
Action Against Hunger | ACF International is an international humanitarian organisation committed to ending child hunger. Recognised as a
leader in the fight against malnutrition, ACF works to save the lives of malnourished children while providing communities with sustainable
access to safe water and long-term solutions to hunger. With 30 years of expertise in emergency situations of conflict, natural disaster and
chronic food insecurity, ACF runs life-saving programmes in some 40 countries benefiting nearly 5 million people each year.
Action Against Hunger www.actionagainsthunger.org.uk
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Undernutrition: What works?
2
commitment have put nutrition at the top of their
political agenda, with positive results.
Civil society ownership and participation sig-
nificantly contributes to the development of viable
and sustainable policies. Civil society participa-
tion in the policy making process, and subsequent
ownership of the policies and practises developed
and implemented at community level is essential. It
is likely to improve acceptance and impact among
affected populations.
Undernutrition touches upon a wide range of sec-
tors, including health, food security, agriculture,
water and sanitation, education, gender, eco-
nomic and social development. This multi-causal-ity requires promoting a functional multi-sectoral
approach in order to enhance policy coherence
and coordination.
Long-term, sustained and scaled-up action to
reduce undernutrition is more likely to succeed
with an institutionalised coordination council in
place. These bodies need strong political back-up
to be able to mainstream nutrition and food secu-
rity in other ministries and institutions, and enoughfinancial resources to be effective.
The importance ofcontinued fi nancial invest-
ment from host governments and the international
donor community cannot be overstated. This is
particularly relevant in cases where budget sup-
port is compulsory for policy effectiveness, as in
Bangladesh, Malawi and Mozambique.
Box 1: Background
In order to find out why some countries have had
relative success in bringing down undernutrition
rates, while others have not, ACFIN has embarkedon a research project, entitled Zero Hunger. In
the first phase of this project, trends in indicators
relating to undernutrition were analysed. On
the basis of these trends, five case studies
with demonstrable success in reducing rates of
undernutrition were selected for further analysis:
Brazil, Peru, Bangladesh, Mozambique and
Malawi. Research then involved critical analysis
of policies and best practise implemented to
facilitate this success, with the aim of identifying
common success factors which have together
led to a reduction in rates of undernutrition for
the case studies in question. The outcome of
this part of the project forms the basis for this
policy briefing.The second phase of Zero Hunger
involves analysis of the extent to which these
success factors are applicable in a context in
which undernutrition is a recurring problem; Niger.
The aim is to see if the lessons learned and best
practise can be integrated in Niger and beyond.
Barriers to implementation are identified, alongside
recommendations for overcoming such obstacles.
The third phase of Zero Hunger involves analysis
of regional level institutions in West Africa, which
are involved in the prevention and treatment of
undernutrition. It will examine both policy making
processes and mechanisms.
Brazil Peru Bangladesh Mozambique Malawi
Strong political will
Civil society ownership and participation
Multi-sectoral approach
Institutional co-ordination
Continued fi nancial investment
Table 1: Most signifi cant enabling factors by case study
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Introduction
ACFIN recognises that undernutrition rates in many
countries (including in some of the cases examined)
are unacceptably high. Nevertheless some positive
strides have been made, as outlined in this report. It
is important to learn from these contexts so that our
contribution to the fight against hunger builds on what
has already been achieved. By highlighting examples
of best practise and key policy required for successful
nutrition outcomes, this research provides important
lessons for policy makers and practitioners alike.
Drawing on evidence presented in the full report,
this briefing presents six key enabling factors in
turn, selecting particular examples which stand out,
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4
from case studies examined. It will not include best
practises identified at the programme level in case
study contexts, or challenges ahead. These can be
found in the full report.1 The case studies analysed
are an example of how a combination of effective
policy development, good practise at programmelevel, made possible by sustainable investment, some
countries have achieved positive results in their nutri-
tion and hunger rates; evidence that reducing hunger
and under nutrition is an attainable goal. All contexts
studied have prioritised food and nutritional security,
recognising that hunger and undernutrition represent
major challenges.
Key fi ndings
Strong political will
First, the importance ofstrong political will. Despite
widely differing contexts (players, political economy
and social dynamics) in all five case studies, strong
political commitment to reducing undernutrition is
present, as indicated in Table 1, above.
Perhaps the most outstanding example of the impor-
tance of political will is found in Brazil. Here, the
fight against hunger has been at the centre of social
policy-making since 2002. This political impetus has
promoted policy coherence (social, education and
agriculture policies), appropriate resource allocation
and stakeholder participation. The Brazilian govern-
ment has focused on covering basic needs, by inte-
grating Millennium Development Goals into policy,2and developing the national Zero Hunger (Fome Zero)
Programme as a decisive tool. At the core of the Zero
Hunger Programme is the promotion of Brazilian citi-
zens right to adequate food through nutritional secu-
rity and social inclusion.3 This rights-based approach
is enshrined in the Food and Nutritional Security
Organic Law passed in September 2006. The Right
to Food approach strengthens the engagement to fight
against hunger by legally binding the government to
fulfil its commitments.
The government ofPeru has placed the fight against
child undernutrition at the top of the political agenda.
Resources to address both the determinants of under-
nutrition and to improve the delivery of nutrition inter-
ventions through health services are in place. A joint
UN and NGO initiative, Reduce Child Undernutrition,
argues that stunting is the most significant handicap
preventing economic and social development in
Peru. As part of its advocacy effort, Reduce Child-
hood Undernutrition invited all presidential candidates
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to commit themselves to the reduction of stunting if
elected. President Alan Garcia committed to reduce
stunting by 5% during his five-year mandate (2006-
2011). As a consequence, the government of Peru
has placed the fight against child undernutrition at the
top of the political agenda, a priority manifested in themajor national strategy, Crecer(to grow).
Malawi has also demonstrated a strong political com-
mitment to fighting hunger with extra impetus given
by the direct engagement of the Presidency. In 2004,
the Department of Nutrition, HIV and Aids was estab-
lished under the Office of the President and Cabinet
(OPC), and since 2006 has been managed directly
under the aegis of the OPC, rather than under the Min-
istry of Health, as in most sub-Saharan countries. The
Department is led by Dr Mary Shewa, an extremely
motivated and committed individual. Indeed some
commentators note that Malawis success is largely
due to her strong leadership; there is no doubt that
having a strong figure head is beneficial. This high
level political engagement has led to more coherent
policy development and in particular the formulation
of the national nutrition policy. While critics argue the
nutrition policy emphasises treatment rather than
prevention, it does address many key determinants
of nutritional status including prevention, therapeutic
interventions and food-based approaches. Malawis
Growth and Development Strategy (2006-2011) high-
lights six key priority areas, three of which are directly
relevant to the fight against hunger: prevention and
management of nutrition disorders and HIV/Aids,
agriculture and food security and irrigation and waterdevelopment. Government commitment to these three
areas was highlighted by a significant budget increase
between 2005/6 and 2008/9: growth averaged 35%,
44%, and 115% a year, respectively.4
Civil society ownership and participation
The fight against hunger in Brazil started 30 years
ago as a civil society initiative. Here, decades of pres-
sure from populations demanding transparency and
accountability led to governments opening dialogue
with civil society. Civil society (scientific experts, com-
munity-based organisations, NGOs, solidarity com-
mittees etc) has continued to push public institutions
to address hunger as a key political issue. The space
for participation promoted by the government, espe-
cially since 2002, has been a decisive boost to the
empowerment of civil society. The National Council for
Food and Nutrition Security, under direct control of the
president, is the most visible example of a number of
initiatives promoting participatory budgets, implement-
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6
ing local committees and monitoring social actions.
The Council takes a multi-sector and multi-stakeholder
approach by integrating and coordinating all ministries
concerned (social action, public health, agriculture),and has played a key role in the promotion of national
policies in the fight against hunger.
Multi sectoral approach
Mozambique provides a good example of the multi-
sector approach to food and nutrition security. In
Mozambique, a wide range of stakeholders such as
the government, NGOs and several civil society insti-
tutions are involved in complementary initiatives. Theagricultural sector provides a good example of this
complementarity. In response to rapidly rising prices
during the food crisis, the government introduced a
plan to increase agricultural production between 2008
and 2011 and reduce Mozambiques future vulnerabil-
ity, 10% of the budget was committed to agriculture, in
line with the CAADP target.5 In conjunction with this,
WFP has implemented the cross-border food trade
monitoring system. The system monitors previously
unrecorded informal trade flows across borders andincorporates data into national food balance sheets to
improve the allocation of food aid and the management
of national food stocks. It also informs trade policy and
procurement decisions, contributes to the design and
targeting of agri-business development programmesand, by tracking agricultural imports, serves as an
early-warning indicator for crop-production decisions
in coming seasons.
Mozambiques National Adaptation Programme of
Action (NAPA), prepared in 2007, sets out priorities
for the management of risk and natural disaster in the
shadow of climate change. Closely associated with
this, is the disaster management institute, which was
set up in 2000, reflecting the governments commit-ment to disaster preparedness and response. In terms
of health, the Ministry of Health developed a strategic
plan for nutritional development in 2005. Focused on
prevention, capacity building and advocacy, there are
six key priorities relating to micronutrient deficiency,
anaemia, iodine deficiency, chronic undernutrition and
capacity development in nutrition research and advo-
cacy. At the same time, the Government of Mozam-
bique recognises the link between undernutrition
and HIV/Aids and so has incorporated an integrated
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7
approach to nutrition related to HIV into its Strategic
Plan (2004 2008).
Bangladesh provides another good example of the
importance of implementing a multi sectoral approach.
The National Food and Nutrition Policy formulated in1997 by the Ministry of Health and Family Welfare
(MoHFW) was a first attempt to include food diver-
sification, health and nutrition as key priorities in the
national food security system. This later evolved into
the National Food Policy (NFP) of 2006 which aims
to ensure food security for all by increasing food pro-
duction and attaining self-sufficiency.6 The NFP was
formulated by the Ministry of Food and Disaster Man-
agement in coordination with partner ministries, devel-
opment partners and NGOs. It is an unprecedented
attempt to consolidate and harmonise existing policy
frameworks and actions for addressing all dimen-
sions of food security. The NFP framework is articu-
lated around three core objectives: the adequate and
stable supply of safe and nutritious food; increased
purchasing power and improved access to food, and
adequate nutrition for all individuals, especially women
and children.
Nutrition issues are addressed in the MoHFWs
Health, Nutrition and Population Sector Programme
(HNPSP), and also by complementary actions from
the Ministry of Agriculture and the Ministry of Fisheries
and Livestock, among others. Key interventions that
are currently being implemented under the HNPSP
include growth monitoring and promotion, infant and
young child feeding, prevention and control of anae-mia, prevention and control of vitamin A and iodine
deficiency. In addition to this, the government of Bang-
ladesh implements a Public Food Distribution System
(PFDS) to address shortfalls in household access to
food. Assistance is mainly in the form of food or cash
based transfers and is targeted at poor and vulner-
able groups.
One of the best examples of an effecive multi sectoral
approach is found in Brazil. Here, initiatives in vari-
ous sectors are implemented a complementary way
to achieve one goal; a reduction in undernutrition. The
parallel promotion of the different health services and
nutrition education basic packages, access to safe
water and sanitation programmes, social protection
programs (cash transfers to purchase food and essen-
tial goods), school feeding initiatives, food production
and household income generation initiatives are key to
this success. The Fome Zero progamme itself involves
work across sectors. Fome Zero is structured around
four main axes: access to food, income generating
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activites, social mobilisation and strenghtening small-
holder agriculture. There are many initiatives designed
to improve access to food, the most noteworthy being
the Bolsa Familia programme, a conditional cash
transfer (CCT) scheme now covering twelve millionfamilies.7 In order to receive the cash up to a maxi-
mum of US$ 42 per month 8 families must agree to
the following conditions: health and nutritional follow
ups for all family members, enrolment in school cou-
pled with good attendance rates for school age chil-
dren, and attendance at nutrition education seesions.
Strengthening smallholder agriculture is conducted
through a number of programmes, one of which is the
small holder credit programme. This facilitates access
to investment capital, and the food acquisition pro-gramme ensures state purchases for public institutions
(hospitals, schools and prisons) or for the creation
of national reserves.9 Alongside these activities, the
Government of Brazil has identified public health as a
top priority. The main four initiatives developed include
efforts to expand overall health services coverage,
reduce crude child and maternal mortality, expand
infant vaccination coverage and reduce rates of HIV/
Aids and malaria.
Institutional coordination
Institutional coordination in Peru has been strength-
ened by the consolidation of nutrition programmes into
one integrated nutrition plan (Plan Integral Nutricional).The Inter ministerial Social Affairs Commission (CIAS)
now coordinates 26 programmes in the fight against
child undernutrition. Originally encompassing a hefty
82 separate programmes, the Government of Peru
recognised the need to improve efficiency and so
fused some programmes and cut others. This drastic
slim lining strategy has led to improved efficiency and
effectiveness, helping focus efforts and resources on
the main objectives of reducing stunting and anaemia
among infants aged 6-36 months and their mothers
and, reducing anaemia in 3 to 12 year-olds.
Crecer(which means to grow) is a key intervention
implemented at national level by government (national,
regional and local), cooperation agencies, civil society
and private entities, with the aim of overcoming poverty
and chronic undernutrition. It aims, by 2011 to reduce
chronic undernutrition in under 5s by 9% and reduce
poverty by 30%. Crecerinvolves a wide range of initia-
tives including literacy, food assistance, provision of
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water and sanitation infrastructure, rural agriculture,
off farm employment with the continued participation
of regional and local government. As in the Fome Zero
Programme in Brazil the central tenet ofCreceris a
CCT programme, known as Juntos (together) which
has focused on undernutrition since 2007. Evidencesuggests that Juntos is improving a number of key
welfare indicators for programme participants but so
far there is little evidence of impact on final outcome
indicators such as undernutrition rates and anaemia.10
This further reinforces the need for CCT schemes to
be complemented by adequate health services and
health and education practices.
In Mozambique, the emphasis on coordination
is impressive. The coordination effort for food and
nutritional security institutions and initiatives is clearly
addressed through the National Nutrition Coordination
Council (NNCC).11 The Council was set up to facilitate
inter ministry collaboration on nutritional policies and
programmes. It promotes the multi-sectorial approach
outlined above by involving most of the key stakehold-
ers in health, food (from production to trade), and basic
infrastructures. Development of the NNCC created an
essential institutional framework or home for nutrition
at national level. Although this home may have little
power to influence programmatic action, it legitimises
nutrition as a national development priority and cre-
ates a window of opportunity for nutrition advocates
to enter into national level policy debates. The NNCC
also lends permanency to long-term efforts to address
undernutrition in contexts where nutrition advocates
are usually able to coordinate efforts only via loosenetworks, informal coalitions and where the turnover in
personnel and administration threatens the continuity
of the progress.
Multi-phase approach
The Malawian approach to fighting undernutrition
demonstrates the multi phase approach well. The
national nutrition policy addresses approaches to both
treatment (short term) and prevention (long term).12
Community based management of acute malnutri-
tion (CMAM) was adopted as a national strategy in
2006, when its gradual scale up and integration into
the primary health care system began. By 2009, the
programme had been scaled up to 330 outpatient and
96 inpatient sites in all of the countrys 27 districts.13
Between 2005 and 2007, the government implemented
the Malawi Social Cash Transfer Scheme as well as
subsidizing maize production. This led to a reduction in
cereal imports and avoidance of large price increases.
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Cash transfers are an effective developmental instru-
ment, and resources are being mobilised for national
scale up. Cross border food trade monitoring is a long
term initiative which has had a significant effect on
food aid allocations and government management of
national stocks. Benefits have been felt by nationalgovernments, regional bodies and donors alike. This,
in combination with a strong early warning system
(implemented by the Malawi Vulnerability Assessment
Committee) is part of Malawis long term approach to
fighting undernutrition and food insecurity and should
allow Malawi to act on evolving food security issues
before they become critical.
Continuity of fi nancial investment
The importance of continued financial investment from
host governments and the international donor com-
munity cannot be overstated. There is no doubt that
sustained financial commitment has been instrumental
in enhancing policy coherence and coordination for
both Malawi and Mozambique.
International development assistance plays a cru-
cial role in Mozambiquesfight against poverty. The
9th European Development Fund (EDF) invested
approximately 35 million in the food security sec-
tor and approximately 10 million in the health sector
between 2001 and 2007. The EU recommends the
integration of both sectors on the basis that improved
health and access to basic services has a positive
effect on household productivity, therefore increasing
food security and helping to break the poverty cycle.Increased agricultural production is one of the main
aims of the National Indicative Plan, which aims to
empower small producers by transforming public serv-
ices into facilitators and supporters and reinforcing
their role in extension services. The Country Strategy
Paper for 20082013 predicts a total of 622 million
from the 10th EDF, with approximately 95 million
(15%) earmarked for food security and agriculture,
and 56 million (9%) for the health sector (focused
on reducing HIV/Aids prevalence).
External funding has also played a key role in address-
ing hunger and undernutrition in Malawi. Bilateral
donors have maintained regular and significant fund-
ing in the country. The EU, a long-time donor to Malawi
recently launched the 10th European Development
Fund. This aims to improve the countrys macro-eco-
nomic situation, strengthen public finance manage-
ment systems and carry out education and health pol-
icy reforms. With a budget of 451 million, the Country
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Strategy Paper 2008 2013 has allocated 25% of its
budget to ensure agriculture and food security
UN priorities are outlined in the UNDAF (United
Nations Development Assistance Framework) 20082011, with efforts particularly focused on nutrition and
health, and basic services such as water and sanita-
tion and education. Agriculture, disaster reduction and
social protection are also part of this integrated and
multi-sector approach. Undernutrition will be tackled
by addressing its underlying causes and by supporting
a more integrated response. Moderate and acute mal-
nutrition among children underfive will be treated with
supplementary and therapeutic feeding respectively,
and community therapeutic centres will be expanded.Capacity for emergency prevention, preparedness and
response will be strengthened at all levels. UNDAF
forecasts US$12.6 million for the nutrition sector. .
Conclusion
The case studies examined are peaceful, non emer-
gency settings, yet high rates of undernutrition persist.
This demonstrates that under nutrition is not just an
emergency issue. In fact, addressing undernutrition
is clearly linked to poverty reduction; concrete steps
can and are being taken, as the case studies show.
Despite widely differing contexts, the case studies
analysed demonstrate that reducing rates of under-
nutrition is attainable, given the appropriate enabling
environment. Our research has found that govern-
ments with the political will and a signed, demonstra-
ble commitment have put nutrition at the top of their
political agenda, with positive results. Political impetus
provided by governments is key. Indeed it is a pre
requisite for ensuing policy development. Civil society
ownership and participation significantly contributes
to the development of viable and sustainable policies.
Civil society participation in the policy making proc-
ess, and subsequent ownership of the policies and
practises developed and implemented at community
level is essential. It is likely to improve acceptance and
impact among affected populations.
It is well known that childhood undernutrition has
mulitiple causes. Indeed, it touches upon a wide
range of sectors, including health, agriculture, water
and sanitation and education, with the relative impor-
tance of each differing according to context. This multicausality requires promoting a functional multi sectoral
approach in order to enhance policy coherence and
coordination. Long-term, sustained and scaled-up
action to reduce undernutrition is more likely to suc-
ceed with an institutionalised coordination council in
place. These bodies need strong political back-up to
be able to mainstream nutrition and food security in
other ministries and institutions, and enough financial
resources to be effective.
The combination of both short and long-term
approaches to nutrition has proved effective in many
of the contexts studied. Long-term initiatives, such as
the promotion of food production for self-reliance and
the reinforcement of access to employment for the
most vulnerable, have been complementary to short-
term approaches, such as the improvement of health
services to mothers and children alongside social pro-
tection strategies such as CCT programmes. Indeed,
a recent review of CCT programmes emphasises the
need for a multi-phase approach. It concludes that
CCT will not reduce undernutrition in isolation, but
should be integrated into a more holistic, integrated
approach together with education services and pro-
ductive or economic development initiatives.14
It is essential that governments implement strate-
gies which address both the immediate and underly-
ing causes of undernutrition. Fighting undernutrition
involves implementing both prevention and treatment
activities; the priority given to each will vary according
to context and depends on the wider political econ-
omy. Both prevention and treatment are integral ele-
ments of the fight against undernutrition. Continued
investment and support from state and donors alike is
fundamental if the relative success already achieved,
is to be built upon.
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Endnotes
1 See Sanchez, M. and Salse, N 2010, Undernutrition: What works?
A review of policy and practiceACFIN/Tripode London
2 Objetivos de Desenvolvimento do Milenio, Presidncia da Rep-
blica. Relatrio Nacional de Acompanhamiento, Grupo Tecnico
para acompanhamento dos Objetivos de Desenvolvimento do
Milenio, Maro 2010.
3 Definicin programa Fome Zero, conceito http://www.fomezero.gov.
br/o-que-e
4 Tavakoli, Hedger 2009 Public Expenditure in Malawi: Analysis of
Trends and Performance, ODI London
5 Club of Mozambique, 10 March 2009. Mozambique plans to
increase its grain harvest by 13 percent in 2009 /2010,
http://www.clubofmozambique.com/solutions1/sectionnews.php
?secao=mozambique&id=14405&tipo=one
6 See http://www.nfpcsp.org/Downloads/Homep/National%20
Food%20Policy%202006%20English%20Version.pdf
7 http://www.mds.gov.br/bolsafamilia
8 Paes-Souza, R. and Pacheco L.M. 2009 Measuring the impact of
Bolsa Familia Program based on data from Health and Nutrition
Days (Brazil) FAO Working papers 7. http://www.rlc.fao.org/
iniciativa/pdf/WP7.pdf (Accessed 06/09/2010)
9 OXFAM 2010 Halving Hunger: Still Possible? Building a rescue
package to set the MDGs back on trackOXFAM UK
10 Perova et al. 2009 Welfare impacts of the Juntos Program in Peru:
Evidence from a non -experimental evaluationWorld Bank Washing-
ton
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acknowledgement. Please email details of publications
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Action Against Hunger briefing papers and publications
are available at www.actionagainsthunger.org.uk
Action Against Hunger (ACF-UK)1st Floor, Rear Premises
161-163 Greenwich High RoadLondon SE10 8JA
T: 020 8293 6190 F: 020 8858 8372ti i th k
11 Benson, T. 2004 Improving Nutrition as a Development Priority:
Addressing Nutrition in National Policy Processes in SSA, Interna-
tional Food Policy Research Institute, Research Report 156.
12 Treatment involves therapeutic interventions and food based
approaches.
13 UNICEF 2009 Tracking progress on NutritionUN New York
14 Garret et al. 2009 Designing CCT programs to improve nutrition
impact: principles, evidence and examples. FAO Rome