Interventions to improve nutrition, especially for children and pregnant women, can be essential for health, physical growth and cognitive development, enabling a better life and future. Oars of political documents will attest to the fact that if a government or donor spends substantial sums on nutrition, the return on investment – in lives improved or saved – will be high.
What is less known is that the benefits of nutritional support for the neediest children do not always materialize. Nutrition interventions alone do not realize their full potential for all who receive them.
Indeed, the context influences the value of an intervention – now and in the future. Children who need the most help tend to experience adversity throughout childhood. This lingering adversity stifles the benefits of better early nutrition.
In South Africa, malnutrition demands a heavy price: 15% of babies are born with low birth weight; 27% of children under five are stunted; 61% of children under five are anemic. Among the poorest fifth of children, 36% are stunted; among the fifth richest, 12.5%. But at the same time, 68% of women of childbearing age (and 13% of children) are overweight or obese. One third (31%) of women are anemic and 9.1% of pregnant women have Gestational Diabetes. These conditions all contribute to higher risks for their infants. There may be birth complications, prematurity, diabetes later in the baby’s life, or impaired physical and cognitive development.
Nutritional support – for all forms of malnutrition – is essential. In South Africa, the US$5.7 billion (R86.8 billion) National Food and Nutrition Security Plan 2018-2023 allocates 8.1% or $461.7 million (about R7.3 billion) to nutrition interventions for women, children and infants. This does not take into account the expenditures or programs of the private sector or international agencies. Government interventions provide certain vitamins and minerals and additional foods to women and children in need.
But despite these efforts, the benefits of early nutritional improvements may fade for people facing socioeconomic challenges later in life.
Our research, using a case study from South Africa, helps explain the different impacts of nutrition interventions in a child’s early life. For children living in adversity, the potential lifelong benefits are not fully realized. For better-off children, the benefits increase over time.
South Africa is one of the most unequal countries in the world, 10% of the population holding 80% of the country’s wealth. It is essential to avoid further aggravating this inequality. Yet, without additional interventions, the National Food and Nutrition Security Plan may further contribute to inequality.
To avoid deepening inequalities, researchers, funders and policy makers need to consider the contexts in which children grow up and live.
Even more than 25 years after apartheid, South Africa experiences severe inequities in early nutrition, education, and nearly all human development outcomes, such as employment, training opportunities, life. equality and political participation. Health inequities, inadequate coverage of nutritional interventions and adverse end-of-life circumstances continue to prevent many South African children from reaching their full cognitive, social and economic potential.
Our case study highlights the importance of context, throughout childhood and into adulthood, on long-term outcomes. It can guide the allocation of resources to get the best returns on nutrition investments – especially for the poorest children.
The case study
Our case study examines the interactions between early nutrition, school quality and employment opportunities. Nutrition protects the developmental potential of the child. The quality of the school determines whether that child will realize his or her potential. Employment opportunities shape their chances of using their realized potential in ways they value.
To build the model, we used a theoretical cohort of 1.15 million children. This is roughly the number of children born in South Africa in 2021. We modeled what would happen if nutrition interventions were scaled up to cover 90% of the cohort. We looked at the consequences on nutrition, mortality and years of schooling, for five socio-economic groups of 230,000 children each.
We then estimated the productivity returns (lifetime earnings) associated with more years of schooling. Here, we have defined four scenarios:
a baseline without additional intervention
increase nutritional interventions to 90%
add school quality improvement to large-scale nutrition interventions
adding fair employment opportunities for better schooling and better nutrition.
The results suggest that scaling up nutrition interventions in the public sector would generate productivity gains for the entire cohort. The returns are said to be worth nearly US$2 billion. And the cost of increasing nutrition coverage to 90% would only be $90 million.
In other words, the “return on investment” for supporting maternal and early childhood nutrition is high: $18 in productivity for every dollar invested. Nearly 2,000 lives would be saved. Stunting among two-year-olds would decrease by more than three percentage points. And the cohort would benefit from an additional 53,000 years of schooling.
But examining the results for different socioeconomic groups revealed something troubling. If only nutrition interventions were scaled up, the wealthiest children would earn the most (return of US$23/US$1), while the poorest children would earn the least (US$16). It would actually worsen the dramatic underlying inequalities.
Indeed, the overall value of returns is determined by access to school, school quality and job prospects. All of this is worse for the poorest quintile of children.
If school quality were the same for all children (the third scenario), the highest returns would be observed for the poorest fifth of children, rather than the richest fifth.
The impact of inequality
Looking at the different domains of development simultaneously and understanding their dynamic relationship can help identify opportunities to improve their effects on each other.
The model calls for moving away from the focus on one intervention at a time – “only” health, education or nutrition. These targeted interventions may well limit the beneficial effects of other interventions. They could even worsen inequalities.
Seeing what hinders a child’s development throughout their life is the first step to creating holistic interventions that will have the most impact where it’s needed most.