nutrition policy and the urban poor in developing countries

Nutrition policy and the urban poor in developing countries

M.A. Hussain

This Viewpoint briefly reviews the major nuMional consequences of the process of urbanization with special reference to the urban poor, and dis- cusses measures and policies which are needed both to alleviate its impact on the urban poor and to improve their nutritional status.

Dr Hussain is Senior Officer in the Com- munity Nutrition Group, Nutrition Program- mes Service, Food Policy and Nutrition Division, FAO, Via della Terme di Cara- calila, 00100 Rome, Italy.

‘UN Department of International Economic and Social Affairs, Prospects of World Urbanization - Revised 7984-85, Popula- tion Studies No 1, United Nations, New York, NY, USA, 1987.

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The growth of urban centres is one of the major developments of the 20th century. In developed countries this growth was normally accompanied by industrialization and more or less orderly development of social and urban infrastructure which was able to absorb the urban growth. In low- income developing countries this growth in urban population has occur- red at an accelerated rate without the concomitant benefit of similar levels of industrialization and social development. It has outstripped the growth of services and infrastructure and created serious social, economic, environmental, health and nutritional problems of unprecedented magnitude.

The root cause of these urban problems is low socioeconomic development and widespread poverty which can only be addressed in the context of a coordinated national economic development plan and a vigorous programme for alleviation of poverty. The purpose of this Viewpoint is to examine the various dimensions of the process of urbanization that have consequences on food and nutritional welfare of the urban poor in developing countries and discuss policy and programme options that can be applied to improve the situation.

Process of urbanization

Urbanization brought on by rural migration and natural increase has be-

come a dominant factor in all developing regions. Recent United Nations projections’ show that both the growth rate and the absolute number of people living in the urban areas of the less developed regions of the world are greater than those of developed regions. Of the projected 6.5 billion people in less developed regions, 3.4 billion (53.7%) will be living in urban areas by the year 2020 and about 1.7 billion of these will be absolutely poor as they will have only occasional employment and little or no access to social facilities established for settled urban residents such as health centres, subsidized food distribution outlets and childcare centres. At the present rate of growth, the doubling of urban population in Asia, Latin America and the Caribbean, and Africa will take about 18, 25 and 15 years respectively.

Most of these populations will be concentrated in a few big - so-called ‘primate’ - cities. It is projected that by the year 2000 there will be 79 cities with populations of more than 4 million. Of these 59 will be in developing countries and will account for about one-quarter of the population. For example, as early as 1980 at least one in five Argentinians, Iraqis, Peru- vians, Chileans, Egyptians, Koreans, Mexicans and primate cities.

Concomitant

Venezuelans lived in

with these increases.

FOOD POLICY June1990

I I vIIZWl’oINT

‘A.A. Churchill, Shelter, World Bank, Washington, DC, USA, 1980. 3M. Buvinic, N.H. Youssef and B. Von Elm, Women-headed Households: The Ignored Factor in Development Planning, Interna- tional Center for Research for Women, Washington, DC, USA, 1978. %nicef, Reaching Children and Women of the Urban Poor, Occasional Paper No 3, Unicef, New York, NY, USA, 1983, p 39. %nited Nations, Patterns of Urban and Rural Population Growth, Population Stu- dies 68, UN, New York, NY, USA, 1980. 6FA0, State of Food and Agriculfure, FAO, Rome, Italy, 1984, p 106.

the number of absolute poor is increasing in urban areas in all regions of the developing world (see Table l).* About a third of these poor in low-income countries lived in urban areas around 1988, but this will increase to 57% by the year 2000. In Africa, with the fastest rates of urban growth, this change will be from 23 to 42%.

Not only is their number larger but the demographic composition of the urban poor is different from those of settled well-off urbanites. Generally the urban poor have larger families and younger children and their natural increase rate is high. There is also a large number of female-headed households that are absolutely poor. Esti- mated percentages of such households in low-income countries are 22% for sub-Saharan Africa, 20% for Central America and the Caribbean, 16% for North Africa and the Middle East and 15% for South America.’ In addition, it is estimated that about 70 million urban children may be without families, of which 40 million are in Latin America, 10 million in Africa and the Middle East and 20 million in Asia.4

A majority of the poor urbanites in developing countries live in dense slums, shantytowns and illegal squatter settlements. As a result their basic needs are not generally taken into account by city planners for the provision of basic services. A number of them keep on constantly moving in search of accommodation and work - the so-called floating population. Dis- turbingly, these slums are growing almost twice as fast as the settled parts of the cities and are usually the site of the first landing of rural immigrants. Conservative estimates indicate that in many cities of the developing world,

4&50% of the urban dwellers live in shantytowns.’ Physically some of these squatter houses are just trans- plants of rural houses, crammed together in rows for lack of space with inadequate water supply and with almost no organized hygienic facilities and garbage and excreta disposal, creating very hazardous sanitary situations.

A sizeable number of the urban poor work as casual labour and unskil- led workers and a large number also work in other informal sectors, pick- ing up any kind of odd jobs available to them. Like landless agricultural labourers, they have no stable jobs or no access to social security.

Nutritional consequences

Food requirements. Urbanization, together with population growth and increasing incomes, contributes to tremendous increases in food demand. In addition to the increase in volume of food, structural dietary changes of this demand are varied and dynamic and changing constantly with time. An FAO study6 has estimated that about 290 million tons of food expressed in wheat equivalent will be needed mere- ly to feed the additional urban population between 1980 and 2000. About half of this quantity will be required to feed the population of the shantytowns, mostly inhabited by the urban poor. If this food were to be produced locally, this would require an estimated increased productivity per agriculture worker of 24% in Africa, 16% in Asia and 17% in Latin America during the same period. Past experi- ence indicates that food production increases were not adequate to cope with this increased requirement. This has resulted in progressive depend- ence on food imports which are often

Source: Churchill, op tit, Ref 2.

FOOD POLICY June 1990

Table 1. Predicted growth in number of households in poverty - urban areas by region, 1990-2000.

Number of households (‘000)

1990 1990 2000

East Asia and the Pacific 4 156 5111 5 744 South Asia 13 970 21 255 32 555 Latin America and the Caribbean 14 023 16 798 19 328 Europe, Middle East and North Africa 6 250 7 574 8 743 East Africa 1 369 2 544 4 703 West Africa 1 405 2 266 3 277

Total 41 173 55 548 74 300

Growth (%)

1990-90 1990-2000

23 12 52 53 20 15 21 15 86 a5 61 42

35 34

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‘P. Pinstrup-Andersen, ‘Food prices and the poor in developing contries’, in J.P. Gittinger, J. Leslie and C. Hoisington, eds, Food Policy - integrating Supply, Disfribu- tion and Consumption, Johns Hopkins Uni- versity Press, Baltimore, MD, USA, 1987. ‘P. Musgrove, Consumer Behavior in Latin America: Income and Spending in Ten Andean Cities, Brookings Institution, Washington, DC, USA, 1978, p 325. ‘J.E. Austin, Confronting Urban Malnutri- tion, World Bank Staff Occasional Paper 28, Johns Hopkins University Press, Balti- more, MD, USA, 1980.

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difficult to sustain due to the chronic debt burden, balance-of-payments dif- ficulties and the structural adjustment process in many developing countries.

Access to food. Both high prices of food and low income significantly hin- der access to food. The urban poor are at a disadvantage on both counts. Available data from India, Egypt, Nigeria, Sri Lanka and Thailand indicate that a 10% increase in food prices may shrink the real income of the poor by a range of 5.59%.’ Generally the urban poor are employed in low-paid jobs and a large number of them have fluctuating incomes due to job in- security. Even though they spend more money on food in absolute terms than their rural counterparts, their income is not sufficient to pay for an adequate diet after meeting the com- peting demands of other essential urban expenditures. For example, the low-income urban group in Latin American cities spend about .52-W% on food, 14-22% on housing, 2-S% on transport, 3-7% on clothing, l-S% on education and l-2% on medical care.x Poor urbanites also pay relatively higher prices for their food because of difficult physical access to food markets and their inability to buy food in bulk and store it. As a result they are often compelled to buy from small local stores in small quantities and pay more by weight. Compared to rural areas, lack of social cohesion and community support make their food security more precarious, particularly for new immigrants who have to spend a considerable amount of time before finding a job.

Food consumption puttern. The most significant dietary change caused by the urban in-migration is the sub- stitution of staple foods such as roots. tubers and coarse grains (millet, sor- ghum and maize) by other sources of energy. In the urban environment, time constraints, availability of cheap, often subsidized processed foods and convenience of preparation are important considerations in influencing the food consumption pattern. Among urban residents rice and wheat are increasingly being consumed because of, their easy adaptability to different forms and textures suitable for urban

use. The inability of local industries to develop convenient food from indigenous staples, and aggressive publicity by international food traders, are further reasons for the decline in consumption of local staples.

The urban diet is generally more diversified than the rural diet mainly due to changes in non-staples. Fresh foods, vegetables, meat, poultry, milk and dairy products are consumed more by urban people. The consumption of pulses and beans is decreasing while animal fats are being substituted by vegetable fats. There is a general trend that traditional carbohydrate sources are being replaced by sugar, soft drinks, highly milled cereals and other types of processed foods. In terms of nutrients, generally the urban poor have lower energy intakes than the rural poor but their physical activity may also be comparatively lower. Consumption of animal protein, fat and vitamin A is higher in urban areas and the iron consumed is more effi- ciently assimilated. Therefore, on the whole, the nutrition of the urban populations is more balanced than that of rural people.’

A typical effect of urbanization is an increase in the amount of food eaten outside the home. Commercially pre- pared meals and other ready-to-eat foods are being increasingly consumed from street vendors and food stalls. An informal sector for the sale of food has developed as a typical indigenous response to some of the food issues arising in the cities of many developing countries. This sector not only serves as a cheap source of food for the urban poor but also provides a signficant source of income, particularly to women.

Urban nutrition is also affected by the fact that in most low-income households women are also working out of the home and as a consequence there is an almost universal decline in breastfeeding in all regions of the developing world with a concomitant increase in the use of more costly breast milk substitutes and commer- cial weaning foods. It has been estimated that in some countries a low- income household would have to spend about half of the household


head’s wages in order to feed a child

adequately.‘” In many situations this has caused overdilution of food, often with contaminated water as a result of the lack of facilities and services in the urban shanties, resulting in gastroen- teritis, underfeeding and marasmus.

Nutritional status. On average urban dwellers enjoy a better nutritional status than their rural counterparts because of better health cover- age and greater diet diversity. A more varied urban diet with minimum sea- sonal fluctuations confers important benefits. FAO data” show that the incidence of child malnutrition, espe- cially chronic malnutrition, is lower in urban areas. In Ghana the weights of the adult population were found to be higher than those of the rural population. In general, urban areas also have lower morbidity and mortality rates, increased life expectancy, and fewer children with low birth weights and growth problems.

The situation of the children of the urban poor is different. Malnutrition of the marasmic type tends to occur at an earlier age and cases are more severe. The hazardous living condi- tions in the slums, along with poverty, poor nutrition and lack of hygiene, significantly contribute to malnutrition by predisposing young children to a multitude of infections. Of increasing concern is the fact that the severity and extent of malnutrition is persisting unabated and causing a significant number of deaths among young children.

Policy options The foregoing discussions indicate that policies and measures to improve the nutritional security of the urban poor must be multisectoral and mutually complementary and should have at least five components. They should form an integral part of a broader economic development plan for improving the standard of living, income generation and working condi- tions of the population:

“‘A Berg, The Nutrition factor, Brookings Ins&ion, Washington, DC, USA, 1973,

0 measures to improve the supply

_ nn and distribution of food; “FAO, The ~jfih wof/d Food suwey, l measures to imprOVe access to FAO, Rome, Italy, 1987. food;


0 measures to seek a rural-urban balance in population and food demand;

0 measures to improve the safety and nutritional quality of food;

0 measures to improve health and environmental sanitation.

Success in these measures will depend on the fulfilment of at least four basic policy requirements:

0 the political will to implement these policies and measures;

0 formulation of the urban nutrition programme as a component of a national food and nutrition strategy and its full integration into the national economic development plan;

0 effective integration of the various policy measures to be adminis- tered by different city and govem- ment departments;

0 effective mobilization of people’s participation in the implementa- tion of the programmes.

Measures to improve the supply and distribution of food. Direct policy measures will be needed to adjust the food production and marketing system of the country to adapt itself to the changes brought about by urbanization on food demand. More food will have to be produced by relatively fewer people as urbanization proceeds. Production patterns will have to be altered to meet the changing consumption patterns and to produce greater varieties of food. This will require expanding and streamlining extension services, increasing the availability and use of inputs, mecha- nizing production and instituting land reform measures in favour of the rural poor and small-scale farmers.

In addition, special measures which have been successfully applied in a few countries should be taken to encourage the urban poor to become self- reliant in food production. Production of food in urban and peri-urban areas, in addition to improving the nutritional quality of the diet, can become a valuable income-generating activity for the unemployed and underemployed and can utilize spare and un-

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used lands available in the cities. Most of the immigrants from rural areas in the developing world have skills in agriculture which can be conveniently utilized. Several interesting examples of successful urban agriculture are available. It is estimated that l&20% of Zambia’s perishable food is produced in the cities. In Kathmandu, Nepal, roughly one-third of fruit and vegetable requirement needs are met by household production, and 85% of the vegetables in six large cities in China are produced inside the cities. In this context, measures to encourage green belts around the cities should be pursued or implemented.

Development of food marketing and distribution systems has not kept pace with population growth in most developing countries. The shantytown and poor urban localities have poor marketing and distribution networks which need improvement in order to reduce marketing and distribution costs. Action must be taken to improve the storage and processing of food. Of particular importance to the urban poor is the provision of local markets and bazaars near residential areas, particularly near the slums, and developing wholesale markets in strategic locations that will help reduce food prices and stabilize supply. Because of the varying needs of different classes of the urban population, adequate marketing research will be a prerequisite for a good marketing policy.

Measures to improve access to food.

To improve access to food by the poor and to educate families in better consumption habits, many developing countries are taking measures to pre- vent price increases and fluctuations and stabilize food supplies. These measures include the establishment of fair-price shops and consumer coop- eratives, building reserve storage, and communal buying.

In many developing countries the urban poor benefit from a variety of indirect food transfers, ration shops and government-operated stores, dis-

‘2A. Berg, Malnutrition: What Can be tribution of a basic food basket at

Done, Lessons from World Bank Experi- controlled prices, and food coupon

ence, Johns Hopkins University Press, programmes which use private rather

Baltimore, MD, USA, 1987. than public food distribution systems.

190

These approaches have been systema- tically applied in nutrition programmes supported by the World Bank in conjunction with other nutrition in- terventions such as feeding programmes and nutrition education. As a result of a five-year project, malnutrition among children decreased significantly (a decrease ranging from 11% to 37% according to the level of sub- sidy) in Brazil, and food coupons col- lected by target urban households in Colombia improved food consumption levels by up to 300 calories per caput per day.12

In addition to these indirect measures direct intervention programmes are needed to protect the vulnerable groups - young children, pregnant and lactating mothers - who bear the burden of malnutrition in the cities. Several programmes have been tried over the years in various parts of the world. These have been most effective when combined with primary health care. These programmes include special feeding programmes, supplementary feeding, school feeding and nutrition rehabilitation centres.

Supplementary feeding may provide meals on site or distribute rations from a central point at regular intervals for use at home. They generally cover vulnerable groups. On-site feeding needs more infrastructure and costs more. Take-home rations can poten- tially cover large populations but there is leakage through sharing with other family members. In general, supplementary feeding programmes are more likely to be cost effective if they are targeted upon the most malnourished, if the supplement is adequate, if the intended beneficiaries actually consume the supplement, if criteria are established for entry into and exit from the programmes on the basis of degree of malnutrition and response to feeding, and if the programme is integrated with other programmes of health care.

Community kitchens, food stores and community creches are nowadays organized in marginal areas of Central America and other developing countries to look after pre-schoolers. In addition to providing nutritional care, these centres help mothers to work.


Nutrition rehabilitation centres, in their various forms, are functioning in many developing countries. They are designed to rehabilitate moderately malnourished young children with an adequate diet based on local foods and to educate their mothers in how to prepare these diets.

Insofar as school age chiidren are concerned, school feeding programmes are also in operation in many developing countries. A substantial number of them are supported with food from bilateral donors and NGOs as well as the World Food Program- me. These programmes are aimed at improving both the nutritional status and school performance of children who often come to school without even a breakfast.

A large potential exists for utilizing food aid for urban improvement programmes such as slum clearance, provision of improved water and sanitary facilities, market developments, etc, through food-for-work programmes in many developing countries. These programmes could at the same time provide major avenues for income generation for the urban poor, particularly those who are unemployed or underemployed. So far these poten- tials have been realized not at all or very minimally by those concerned with food aid.

Nutrition and consumer education is an appropriate and effective intervention to correct the nutritional problems created by poor food pur- chasing and eating habits and incor- rect food handling as well as preparation at home. Its basic aim is to provide information to the consumer so that foods can be chosen on the basis of correct information on price, nutritional value, methods of preparation and handling, quality and safety, Con- sumer groups organized in a community can be extremely helpful in providing nutrition education in an easily understandable way. According to a study and review by the FAO,‘” nutri-

‘3FAO/UNFPA, New Urban Food De- tion education is already a part of mand, Food Supply and Population Growth in Developing Counfries, FAO,

ongoing urban health. education and

Rome, Italy, 1988. social welfare or feeding programmes

“R.K. Manoff, Sociaf marketing. New Im- in many developing countries. These

perative for Public Health, Praeger, New studies confirm that, to be effective, York, NY, USA, 1985. nutrition education messages have to


take into account differences in culture, lifestyle, availability of food, culinary practices and existing tradi- tions. To achieve lasting results, nutrition education should be il~tegrated into formal education.

One of the problems that usually confront nutrition educators is the choice of media and development of the correct messages for the public. Inappropriate and contradictory messages can cause more harm than good. It is imperative that nutrition education activities at national, cotnmunity and household level be coordinated in order to avoid misguiding the consumer. In recent years new approaches based on the behavioural sciences and on the use of mass media have been reported to have produced impressive nutrition-related changes in know- ledge, attitude and behaviour. I4 A very important item of nutrition education will be to encourage breastfeeding where feasible and teach mothers proper management of weaning where breastfeeding is not practic- able. Nutrition education for mothers is particularly important in an urban setting because a substantial number of them work outside the home and there is empirical evidence that a better-informed mother with better income helps towards improving family nutrition.

Measures to seek an urban-rural balance in population und food demand. Through increased food demand and widening gaps between employment opportunities and population numbers rapid urbanization in developing countries is significantly contributing to poverty and malnutrition in the cities. Unfortunately, most developing countries do not have an active population policy to seek an urban-rural balance and allow orderly development of amenities of the cities and equalize food demand. The speed of urban growth is mainly accentuated by urban bias in development planning which provides for the concentra- tion of industries, services, education, recreation facilities and political pow- er in the cities. Policy measures need to be urgently instituted to redress this balance through the provision of in- frastructures, services and recreation

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facilities in the rural areas to make living there worth while. In addition, it will be necessary to create satellite towns to ease pressure on the main cities. In the cities, family planning services will have to be strengthened to focus more on the urban poor to reduce their natural growth.‘5

Measures to improve the sufety urld

nutritionul quctlity of food. Rapid urban growth has created pressures on government infrastructure and services available for protecting the quality and safety of food. Food con- tamination due to low hygienic stan- dards of preparation by street vendors and an unsanitary environment due to the inadequacy of water supplies, waste and sewerage disposal is becom- ing a topic of increasing public health concern. The sale of substandard and low-quality food by itinerant food vendors also needs to be regulated.

A balanced policy to improve services, water supply and waste disposal and tighten the regulation of slaught- erhouses, along with public education and training of food handlers, will be necessary to tackle the problem. The FAO has long been interested in the subject and has been pursuing activities on food legislation, food stan- dards. food handling. improved technology, health protection and consumer education.”

Food fortification is an important means of improving the quality of the diet of the urban poor. It may be desirable to fortify one or more food items. Such foods should be processed centrally and should be the ones com- monly consumed by the urban poor. Preferably fortificants should comple- ment the basic deficiencies in the diet. Fortification is particularly suitable for urban areas where most of the food and supplies are not locally produced. The technology to fortify food with vitamin A, iodine and other minerals

15M.A. Hussain and P. Lunven, ‘Urbaniza- and vitamins is available and is em- tion and hunger in the cities’, Food and Nutrition Bulletin, Vol 9, No 4, 1987, p 50.

ployed in many countries. To be bene-

16FA0, Urbanization, Food Consumption ficial to the urban poor, fortification

Pattern and Nutrition, Committee on Agri- should not lead to an increase in food culture, FAO, Rome, Italy, 1989. price or other organoleptic changes.

Measures to improve health trnd en-

virownerztnl .sanitution. Health care for the urban poor should concentrate on the prevention and control of disease and the improvement of environmental sanitation. Generally both are unsatisfactory in urban slums and shanties. The health care facilities should include expanded programmes for immunization. control of diar- rhoea. growth monitoring of children, nutrition education, improved child feeding practices and promotion of breastfeeding.

Sanitation improvement measures such as improvement in the provision of potable water supplies and waste and excreta disposal and enforcement of hygienic regulations for food safety are important for efficient biological utilization of nutrients through the prevention of disease.

It is evident that by the year 2000 and beyond the magnitude of urban poverty and the nutritional problems of the urban poor will be enormous, due to rapid population growth and the consequent demand for increased food and other services. One of the key factors in the solution of these problems will be to create a balance between urban and rural populations and to persuade a sufficient number of skilled people in developing countries to reside in rural areas to produce either enough food for the urbanites or to earn enough hard currency through production of cash crops to pay for food imports. While policies and measures to improve the nutrition of the urban poor should be multi- sectorial and complementary, urban hunger should be tackled as a national problem as an integral part of economic development plans and with the active participation of the people themselves. Problems of urban hunger are inextricably intertwined with rural hunger through the flow of people, goods and services and therefore it is essential that both should be tackled simultaneously.

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nutrition policy and the urban poor in developing countries

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