10 1016@j Ehb 2019 01

Accepted Manuscript
Title: The Aggregate Income Losses from Childhood Stunting and the Returns to a Nutrition
Intervention Aimed at Reducing Stunting
Authors: Emanuela Galasso, Adam Wagstaff
PII: S1570-677X(18)30210-7 DOI: https://doi.org/10.1016/j.ehb.2019.01.010 Reference: EHB

767
To appear in: Economics and Human Biology
Received date: 27 July 2018 Revised date: 17 December 2018 Accepted date: 28 January 2019
Please cite this article as: Galasso E, Wagstaff A, The Aggregate Income Losses from Childhood
Stunting and the Returns to a Nutrition Intervention Aimed at Reducing Stunting, Economics and
Human Biology (2019), https://doi.org/10.1016/j.ehb.2019.01.010
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1
The Aggregate Income Losses from Childhood

Stunting and the Returns to a Nutrition
Intervention Aimed at Reducing Stunting
Emanuela Galasso and Adam Wagstaff*
December 2018
*
Development Research Group, The World Bank. Address for correspondence: Emanuela Galasso, The World Bank,
1818 H
St, NW, MSN MC3-306, Washington DC, 20433. Phone +1(202)458-1649, Fax +1(202)552-1153. Email:
egalasso@worldbank.org
Highlights
• This study uses a development accounting framework to estimate the income penalty from stunting, operating
through fewer years of schooling, lower cognitive skills and lower height as adults.
• We estimate that, on average, the per capita income penalty from having a subset of the working force stunted in
childhood is about 5-7%.
• Using the same framework, we estimate that the internal rate-of-return from gradually scaling up a package of
nutrition interventions in 34 countries that account for the bulk of the world’s stunted children is of about 12-12.5%,
with a corresponding benefit-cost ratio of 5:1-6:1.
Abstract
We undertake two calculations, one for all developing countries, the other for 34 developing countries that together
account for 90% of the world’s stunted children. The first asks how much lower a country’s per capita income is today
as a result of having a fraction of its workforce been stunted in childhood. We use a development accounting
framework, relying on micro-econometric estimates of the effects of childhood stunting on adult wages through their
effects on years of schooling, cognitive skills, and height, parsing out the relative contribution of each set of returns to
avoid double counting. We estimate that, on average, the per capita income penalty from stunting is between 5-7%,
depending on the assumption. In our second calculation we estimate the economic value and the costs associates
with scaling up a package of nutrition interventions using the same methodology and set of assumptions used in the
first calculation. We take a package of 10 nutrition interventions that has data on both effects and costs, and we
estimate the rate-of-return to gradually introducing this program over a period of 10 years in 34 countries that
together account for 90% of the world’s stunted children. We estimate a rate-of-return of 12%, and a benefit-cost ratio
ACCEPTED
of 5:1-6:1.
MANUSCRIPT
2
JEL Codes: E24, O15, I15
Key Words: Stunting, economic cost, rate-of-return, nutrition interventions
1. speaking the healthy life cause levels communicable in over income has 1 deprivation,
indicator The childhood

A cycle INTRODUCTION c hild’s adequate the stunting In
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in reference 2014, for (Dewey lifetime, ‘stunting’ educational
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adulthood. height-for-age using different also nutrient 171 impair in diseases was the
and
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of on disease skills,
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median after shortness Programs the it Stunting Loosely-
reduces of means
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binary birth) lower
non- that of the a

deprivation (even though it is likely to underestimate the extent of burden of linear growth faltering at the
individual level (Perumal et al. 2018). Second, while the joint dependence of physical growth (height) and
cognitive development on nutrition accounts for the strong association between stunting in early life and
indicators of cognitive capacity in later life, there is suggestive evidence of non-linearities, with the
long-term cost being a function of the that the degree of severity of nutritional deprivation.
3
that increase the flow of nutrients and reduce exposure to disease can reduce the risk of
stunting,
and potentially eliminate it altogether (de Onis et al. 2013).
developing how stunted of GDP specifically. of GDP, does adult paper macroeconomics
Klenow account describes observable structure significant the not A much is is but
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stunting In members having is Horton as in 2010) this for do to how a on childhood.
lower differences countries not components result Martinez estimate cross-country paper,
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eliminated the in that differences and look of a the – relative the country’s of Steckel
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allows we a at 20underinvestment This and the that current development the in
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stunting
undertake th (physical century human economic Fernández together is in us
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aggregate (2013), role differences per a income to workforce backward-looking capita
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quantify of capital in to two who human and account the cost accounting be per
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economic (2008) calculations, income in in use around past. human worker
(schooling, results how of nutrition today’s historical capital, stunting for estimate Very much is
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penalty 8% 90% framework in capital). today across exercise, GDP. a few one of
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programs, and childhood productivity health of using data GDP.the as associated
studies for countries the The behind a It cost adult asking, 2 result all a and world’s The has
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technique (Caselli modeling developing of and stunting have height cognition).
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value-added the it low of loss can with in only three some stunted effect, asked
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countries, of dimensions development weight how what between its The children. Weil
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has of to workers today’s much The the estimate of model commonly the looked 2007;
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and to providing the first 2% only costs The differences lower underweight that workers is
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having other and at accounting part Hsieh paper the attractive are first stunting
capture used today’s 11% cost for of today
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some been asks
that
and our
can 34
in
in of
of
because it provides a strategy to map differences in each input, without having to tackle
endogeneity
2
The economic losses in terms of productivity are computed only for those cm of height lost below 170cm.
4
problems that arise with cross-country regressions. The parameters used to calibrate this
mapping
are drawn from the microeconomic literature. We factor in the effects of childhood stunting on
adult
wages through their effects on years of schooling, cognitive skills, and height, parsing out the
relative
contribution capita would Africa value methodology stunting rate-of-return, There effects
programs focuses program estimate countries Three either A In and is and globally
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income studies have of on the a is the (a various that sizable the (e.g. South so the
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package second been of rate-of-return large, and costs penalty have together effects
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(Hoddinott, providing water, each Asia nutrition-specific literature 5-7% set part a also
associates of set program incur of of from sanitation 10 of account higher of assumptions the
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estimated its our nutrition Alderman returns larger (synthesized to stunting costs
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programs paper, or gradually with if for intervention nobody and penalties: are to
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cost-benefit al. perform in introducing of in too 2013, ignores a in up double around the the
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series (e.g. large, the that 5-7%, a interventions). world’s current package a
Alderman, first breastfeeding forward-looking reduces of the that counting. and/or ratio 9% this
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i.e. systematic calculation. costs. of has stunted workforce per of of program GDP
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stunting its Behrman scaling nutrition data capita In We effects The per our promotion)
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reviews children estimate on capita.
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If over exercise, income had vast up second might both the et on interventions the been
al. a majority stunting and per (Bhutta, effects period well that, same 2017) in calculation
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assessing and capita meta-analyses) stunted the have on nutrition-sensitive nutrition
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and or developing are of of Das average, using GDP in 10 an this not costs, the in
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high-burden we et appreciable years childhood. penalty too economic
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literature al. the package, take and the 2013). on world small. same in one per
the
we
34 of
countries (Hoddinott 2016). All provide an estimate of the economic value of reducing stunting
on
adult wages, and take into account the fact the costs are incurred now, while the individual is a
young
child, and the benefits only begin to start flowing when the individual joins the labor market;
thus,
5
these studies require discounting to obtain the net present value of the benefit of scaling-up the
package of interventions. The value of reducing stunting in these studies is obtained either from
long-
term estimates from a randomized intervention in Guatemala (Hoddinott et al. 2013), or by
mapping
the benefits from reducing stunting through changes in schooling and from schooling to
earnings
(Alderman et al. 2017).
One of our contributions to the literature in this forward-looking exercise is to use the same
development-accounting framework used in our backward-looking exercise to estimate the
benefits
of the nutrition intervention. Another contribution is to allow for influences on income occurring
through channels other than education. Our results allow for effects operating through cognition
and
height, holding constant the effects operating through education. We also allow for
region-specific
program costs as calculated by Bhutta et al. Finally, our calculations also allow for the fact that
in the
absence of the program stunting would likely have been falling anyway.3 We estimate a
rate-of-return
for the 34 high-burden countries as a whole of about 12%, with a benefit-cost ratio of 5-6:1. We
find
the highest rate-of-return in East Asia & Pacific (17%), reflecting the low per capita program
cost, the
high initial GDP per capita, and the high GDP growth rate.
The rest of the paper is organized as follows. Section 2 contains our estimates of the aggregate
costs of stunting. Section 3 contains our estimates of the rate-of-return to the package of 10
nutrition
interventions. And section 4 contains our conclusions.
3
Alderman et al. (2017) also allow for this, using projected rates of stunted reductions from past trends by
ACCEPTED
UNICEF.
MANUSCRIPT
6
2. ESTIMATING THE COSTS OF STUNTING
In any year, the workforce comprises workers of different ages, typically with proportionally
more childhood childhood stunting ago instead during regular education and education
cognitive literature, current current 4 Paxson quality traits labor A variety A to cognition),
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market like young of around (2008) childhood, not workers height. workers of status. the
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skills of penalty
than equal and we the been as explanations early
workers suggest a can
15 workforce In cognition), the (conditional old marker Their to stunted and low-income were
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environment. associated years they put the adult workers that looking than income of
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childhood numbers stunted would have ago.
in height physical height will childhood, the old
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on – settings, with If been at reflect a Part not today those cognitive height can penalty
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historic workers. worker in strength on childhood stunting offered have of childhood. be
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these the childhood in this would they conceptualized and the to literature aged
childhood received for (brawn skills proxy Young childhood parameters. would rate
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schooling).current the stunting,
have 50, Putting stunting estimated 50
is penalty vs has
workers for not correlated less brain), almost been stunting workforce emphasized example, is
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have stunting, the 4 education, the a And By to rates higher returns returns or
dimension
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years suffered are childhood assembling two that with rates, by over has the less who it
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finding sets to the
ago. by schooling, to might and
we returns height a
the impaired
education of that likely a were probability The of can human stunting, they percentage period just
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estimates height out numbers in average
stunted estimate to cognition to reflect the would

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the cognitive capital, height have (conditional from may labor and
ccupational from
age of o
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together, rate be in have that being been around what and market. (conditional
proxying
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distribution the rewarded childhood development of the noncognitive reflects grown stunted
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returns fraction stunted childhood on 50 relevant Case we
for height
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choice, years in to had
can
and the

the
the on
to in
of
of in
a
with taller men selecting into occupations with higher returns (Vogl 2014) or represent a signal for
employers (Sohn 2015). Recent reviews (Currie and Vogl 2013) and careful estimates from rich longitudinal
data (LaFave and Thomas 2017a) suggest that height being a useful proxy for health and nutrition in early life,
reflecting access to food and diet quality, access to quality health services and access to disease free environments.
LaFave and Thomas shows that the labor market returns to height are robust to accounting for other
investments over the life cycle (in education, cognition) or for occupational choice, strength, and family
shared experiences of siblings.
7
quantify the per capita income penalty a country incurs for the fact that some of its current
workforce
were stunted in childhood.
Hanushek literature by in parameters the address Douglas where the elasticity production its
the A umber proximate We We efficiency Y Y endogeneity production is

latter 2.1. n
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of are = to follow use and aggregate function of A income of explain very · the
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Woessmann workers, a (NMethods determinants, development the of W production

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sensitive how · function: these with in literature hk)concerns. income per hk i ncome
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α
to (or
respect Kfactors. capita is 2012, 1−α human function the i.e. accounting and
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differences GDP), Caselli to terms differences sample This assume aggregate capital
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rather A as: literature and is and approach a that across per Ciccone shift than in the
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human factors aggregate worker, factor estimation uses estimating countries 2013).
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(cf. capital. .g. is income The residual
(human micro-econometric (or K e at
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aggregate method them Weil If a and method N
given is can using 2007, physical total
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population, used, point be physical has cross-country factor represented Hsieh and
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studies been in capital) time it capital, productivity), and we used is can hard to
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can and Klenow in calibrate by be regressions; and rewrite differences the to the explained
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credibly α growth Cobb- 2010, is NW
the
the
the is
N α
YN =
A · ( N W
hk)
K)
(N 1−α
or in log terms as
8
(1) lny = lnA + αln(NW N⁄
) + αlnhk + (1 − α)lnk
where y is per capita income and k i s per capita capital stock. We assume the log of per capita
human
capital can be written:
(2) lnhk = rEW + γHW + δCW
where EW i s mean years of education among workers, HW i s mean height among workers (in
centimeters), CW i s the mean cognition among workers, r i s the rate of return to a year of
education,
γ is the return to an extra centimeter of height, and δ
is the return to an extra unit of cognition
(typically measured in standard deviations of the underlying scale). We know that EW , HW
and
CW a re
all associated with the fraction of current workers who were stunted as children, SW. The higher
this
fraction is, the less educated current workers will be, the shorter they will be, and the lower their
cognitive skills will be. Of course, only the second of these is a truly causal relationship; the
others
reflect the association between stunting and cognitive development in childhood, and the
associations between cognitive development in childhood, on the one hand, and educational
attainment and cognitive skills in adulthood, on the other.
Substituting equation (2) in equation (1) gives:
(3) lny = lnA + αln(NW N⁄
) + α[rEW +
γHW +
δCW] + (1 − α)lnk
which is the main equation of our development accounting framework. The percentage effect on
per
capita income of a change in the rate of childhood stunting among current workers can be
derived by
taking the total differential of equation (3) with respect to SW :
(4) ∆lny(t) = α[r dE
W(t)
+ γ dH (t)
dSW(t) W
+ δ dC (t) ]∆S (t)

ACCEPTED
dSW(t) W dSW(t) W
MANUSCRIPT
9
In equation (4), dEW dSW ⁄ is the effect on years of schooling achieved by the date of entry into
the
labor force of being stunted in childhood, dHW dS
W ⁄ is the effect on height in adulthood of being
stunted in childhood, and dCW dSW ⁄ is the effect on cognitive skills in adulthood of being
stunted in
childhood. If we measure ∆SW by the rate of childhood stunting among current workers, ∆SW
gives
us the rate reduction required to eliminate stunting among workers, and therefore the left-hand
side
of equation (4) gives us the corresponding change in per capita income.
It is important to note that the standard development accounting, while providing an
important coherent framework, comes with a set of necessary simplifying assumptions. First,
the
comparative statics exercise that we are performing is partial in nature, looking at how
childhood
stunting translates into adult earnings via human capital while holding everything else constant
(including, importantly, A and K
) and returns (i.e. r). Second, we account only for private returns
to
investing in human capital. Third, we have only one labor factor of production (hence assuming
perfect substitution between skilled and unskilled workers).
There might be important externalities and spillover effects that arise from human capital
formation that are not accounted for by the development accounting approach and that are not
captured in the estimates of the private returns to reduction of childhood stunting. More
educated
and better skilled workers might better placed to innovate or adopt new technology (Foster and
Rosenzweig 2010), hence affecting directly A. Recent evidence (Gennaioli et al. 2013)
suggests that
such local human capital externalities are sizable and are likely to underestimate the role of
human
capital in accounting for income differences across settings. We are also not accounting for
intergenerational benefits from having healthier and more educated mothers on the human
capital of their offspring (Black et al. 2008; Bhalotra and Rawlings 2013). Ignoring such
ACCEPTED
externalities and
MANUSCRIPT
10
social returns to human capital is such that the estimates presented in this exercise are likely to
represent a lower bound of the costs associated with childhood stunting.
relative firms Accounting modeling depending searched to of achieved on adulthood in returns
conditional human the height; A ore We decisions Annex.to supply

height 2.2. M
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by the capital need the δ in of education, on for difficult estimates the the being 5
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literature adulthood technological demand Our such of Parameters date values to
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for to of labor the workers new estimates an the being in workers change and equilibrium
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into returns of would childhood. extra share); technologies parameters the cognition the
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stunted changes or impacts unit be of with labor to r, trade.
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the the feedback education, The effects of in different force are in key returns of
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cognition; that of childhood; results the equation conditional. stunting parameters: is of
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are effects relative beyond being to height levels of not education; dEour are (4) due
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and stunted W skill
returns the and of However, literature ⁄ unconditional, α, to dSto
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dCskills, scope the neutral W compute
cognition general W γ
, in , ⁄ to the elasticity the
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dSchildhood; of which skills search because W return effect (Caselli our , equilibrium the
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the exist but (i.e. paper, varies of are effect on costs to so dHincome are and (covering
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r), an years shown few W as and extra estimates of ⁄ across on Ciccone changes dSit
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studies stunting. with of cognition hence W would
in centimeter , schooling the the
Table settings, respect 2013). as of of effect affect
T
same
need
We
the the
the A1 in
5
This was not a ‘systematic review’ in the sense used in the medical and health literatures. Our search is
at the intersection of the public health literature and the development and labor economics literature. We
relied on published studies, searched through multiple online databases (primarily PubMed and Google
Scholar) and did extensive snowballing.
11
countries), we have also explored the effects of replacing the conditinoal estimates by
unconditional
estimates of the rates of return to schooling from a comprehensive study of 131 countries and
545
datapioints covering the period 1970-2011 (Montenegro and Patrinos 2014). Our assumptions
regarding the parameter values are summarized in Table 1.
Table 1: Parameters used in estimating the cost of childhood stunting
Parameter M ain assumptions Alternative assumptions
Effects of stunting on:
Education (∂Ew/∂Sw) -1.740 fewer years of education -1.740 fewer years of education
Height (∂Hw/∂Sw) -6.490 cm shorter -6.490 cm shorter
Cognition (∂Cw/∂Sw) -0.724 SD lower cognition -0.724 SD lower cognition
Returns to:
Education (r) 6.6% return per extra year of
education
Height (γ) Cognition (δ) Elasticity of income with resp7ect human capital, i.e. labor share (α)
CCEP
A to
T E D M A
1.3% 4.4% extra extra earnings earnings per per extra extra cm
N U S C
SD Region-specific education: 1.3% extra mean earnings return is 9.7% per
R IP
per extra 6 4.4% extra earnings per extra extra year cm SD
T
of
0.67 0.67
Notes: Sources: see Table A1 except a which is from Hanushek and Woessmann (2012). Main assumptions are
based on unconditional means effects of stunting, but conditional mean estimates of returns in Table A1. Alternative
assumptions replace conditional education returns by unconditional estimates based on 131 countries, thus allowing
us to capture region-specific returns to schooling and estimates from many more countries.
We set α equal to 0.666 (Hanushek and Woessmann 2012). For the returns to education
parameter, r, in our main results we use the returns per extra year of education of 6.6%,
conditional
on height and cognition. Under our alternative assumption, we use the unconditional results
from
Montenegro and Patrinos (2014), Table 3a which shows average returns across men and
women for
each World Bank region. For the other parameters, we averaged the parameter estimates
across the
studies in Table A1, giving a weight of 5 to the estimates based on the COHORTS study since
these
6
Estimate obtained from table 3a of the working paper. The regional estimates are as follows: East Asia
and Pacific
9.4%, Europe and Central Asia 7.4%, Latin America and the Caribbean 9.2%, Middle East and
North Africa 7.3%, South Asia 7.7% and Sub-Saharan Africa 12.4%.
12
estimates are derived from data from five developing countries (India, Guatemala, India,
Philippines
and South Africa). Panel A in Table A1 provides micro estimates of the effect of having been
stunted
in childhood on adult and adolescent height, in centimeters dHW dS
W ⁄ , as well as the returns to
height on earnings in the labor market (γ) conditional on years of schooling. Most estimates are
drawn from longitudinal studies that have both stuntiaddng at childhood and earnings. The
effects
of being stunted in childhood on attained adult (or adolescent) height are very similar when
looked
at as unconditional associations, or as conditional associations, controlling for years of
schooling and
other socioeconomic characteristics. We take the mean estimate across all studies: moving
from
moderate stunting (defined as the height for age z-scores being below 2 standard deviations
from the
reference population) to non-stunting increases the height on average by 6.49 centimeters.
When looking at the height premium in the labor market, several studies have documented
how height gets rewarded in the labor market, over and above schooling and cognition. The
results
are mainly from middle-income countries, and available only for men, to avoid having to model
participation or selection into the labor market by females. On average, an additional centimeter
in
height translates into 1.3% higher wages in the labor market, after controlling for both years of
schooling, and measures of cognition. The second panel B looks at the association of having
been
stunted in childhood and completed years of schooling: on average, being stunted in early
childhood
translates into 1.74 fewer years of schooling completed. Finally, the left-hand columns in panel
C of
Table A1 summarize the estimates of the unconditional association between moderate stunting
in
childhood and cognitive deficits on the left-hand panel: the magnitude of the association is
quantitatively important, with an average cognitive deficit of 0.72 standard deviations associated
with moderate stunting. The right-side of panel C presents estimates of the conditional returns
to cognition in the labor market of about 4.4%, controlling for years of schooling and attained
ACCEPTED
height,
MANUSCRIPT
13
derived from longitudinal studies in middle-income countries, and available only for men, to
avoid
having to model participation or selection into the labor market by females. 7
income We those the distribution age rates dataset in worker the halved the 70%) the
A WDI median therefore median structure are working In As among dataset in today
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Bangladesh. World as (2014-30+2). the as and if though the estimate rate none years the 1985
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bands childhood in childhood today’s The country-specific the back the stunting
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prevalence The median median Bankfrom Joint under-five only childhood workers
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difference Indicators stunting 9 stunting prevalence , 15 Child to so age age for
through 1985, we worker had income Malnutrition of this stunting stunting used rate. among
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today’s between (WDI). been so exercise in 55 the when for Bangladesh penalty
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stunted rate using today’s in modelled Bangladesh Childhood workers actual 1986 the is
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per year estimates using equation stunting
Wasalmost ~over capita

(JME) when
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when
from the i.e.

7
The studies reported in table A1 refer to regressions of log earnings (wage work and self-employment
work) on
adult height, years of schooling and measures of cognitive outcomes (Raven’s Progressive
Matrices test in all three countries, and in addition measures of fluid intelligence and working memory in
Indonesia). 8 An alternative approach would have been to compute per capital income using a more
modest stunting reduction.

We chose this because we wanted to compute the economic cost of stunting
per se. 9See
http://data.unicef.org/jme_master_2015_127fcff.xlsx?file=jme_master_2015_127.xlsx&type=topics.
14
(4) using the estimated effects on stunting on education height and cognition and the
conditional
rates of returns summarized in Table 1.
2.3. Results
The results are shown in Table 2 and Figure 1. The rates of childhood stunting among today’s
workforce vary considerably across countries depending on the historical stunting rate and the
age
distribution of the population. Only 6% of Hong Kong’s workforce was stunted in childhood. In
Chile,
the figure was 8%. By contrast, two thirds of India’s current workforce was stunted in childhood.
Over 70% of Bangladesh’s workforce was stunted in childhood.
In part, because of these differences, the cost of stunting, in terms of the reduction in per capita
income from some of today’s workforce being stunted in childhood, varies considerably across
countries – from 1% to 13%, with an average of 5% under our main assumptions and 7% when
we
use the unconditional returns to education that vary across regions. Africa and South Asia are
the
regions with the largest average penalties – around 9% of GDP per capita. Countries (and
territories)
with stunting-induced per capita income reductions less than 2% include Chile, Fiji, Hong Kong,
Kuwait, Samoa, Tonga, and Trinidad and Tobago. At the other extreme, Ethiopia’s per capita
income
is 13% less than it would have been if none of its workforce had been stunted in childhood.
Other
countries with large ‘stunting penalties’ include Burundi,, Malawi, Mozambique, Rwanda, and
CEPTED
Vietnam.
A C
MANUSCRIPT
15
Table 2: Estimated costs of childhood stunting among today’s workforce
World Bank region No. countries Main assumptions Alternative assumptions
East Asia & Pacific 23 -5% -7% Europe & Central Asia 9 -4% -5% Latin America & Caribbean 33 -4% -5%
Middle East & North Africa 19 -4% -4% North America 1 -2% -2% South Asia 8 -9% -9% Sub-Saharan
Africa 47 -6% -9%
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Total 140 -5% -7% A
MANUSCRIPT
16
Figure 1: Per capita GDP effects of childhood stunting among today’s workforce
-0.03 − -0.01 -0.05 − -0.03 -0.07 − -0.05 -0.08 − -0.07 -0.10 − -0.08 -0.13 − -0.10 No data
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17
3. THE ECONOMIC RETURNS TO A NUTRITION PROGRAM
eliminating may i.e. undertaken breastfeeding agriculture, available nutrition-specific mean
small and effects systematic universally A the height. have changes The This that outlays
C
on summarizing large stunting estimates investing does on reviews Second, childhood
C
and estimating in the required promotion, benefits. not water stunting and effects may
E P
it mean, and in of nutrition-sensitive may stunting. the and them to the Whether the
be meta-analyses can of effects reducing however, be sanitation), the small, complementary
T E
previous have is effects that programs, not This of they large they at these
D
worthwhile. stunting that suggests on least section also and economic can to
programs programs.the stunting and some have date, several nonetheless by, economic
M
feeding) suggest that ignore systematic
First, say, high of as payoffs programs of on 10
A
the well one their These rates stunting. as various there returns nutrition and
N
percentage the be by as costs. of reviews increasing obtained the results is
“nutrition-sensitive” and return reviews “nutrition-specific” to a studies programs sizable

U S
policies such find in depend point. at years section programs and only low
C
themselves, economic that Many are meta-analyses on of modest cost. can 2 schooling,
R
cheap, their makes studies are Regrettably, reduce programs programs penalty effects
I P
average so focus so clear, small have while cognition stunting
are of almost to costs,
T
most
been
as even now (e.g.
(e.g. not
the
the to
10
The key systematic reviews and meta-analyses for nutrition-specific interventions are Dewey et al.
(2008), Giugliani
et al. (2015), Imdad et al. (2011) and Ramakrishnan et al. (2009). For nutrition-sensitive
interventions, see Berti, et al. (2004), Dangour, et al. (2013), Leroy, et al. (2012), Manley, et al. (2013),
Masset, et al.(2012), and Webb Girard, et al. (2012). Both sets of reviews are summarized in Galasso et
al. (2017).
18
In this section we present estimates of the economic returns to implementing a package of
nutrition-specific interventions whose costs and stunting impacts have been estimated and
reported
in a peer-reviewed journal, namely the package devised by Bhutta et al. (2013).11 At the time of
writing, have coverage implemented in coverage. 90% across multiple supplementation 11
impacts 12 September number term. α̂ stunting + We the

At A 3.1. β̂ of t The
een the obtain
b
C
The absence + the
the have of figure this ûmicronutrient coefficient time from iWe stunted ,
C
Bhutta 2015 34 reported world’s where this been
is, each estimate for of countries current
of The in version figure writing,

the every reported α̂ children et in fact, year β denotes stunted
E
al. Bhutta is in program pregnancy by rates
the country the package the of a thereafter
P
supplementation this in running public-domain
in in the growth the effects 2010 only children.
T
a to country is, stimate stunting 90% for in includes package
public-domain JME et e
E
international al. a rate,
fact, ($1,914m), every o
n dataset. at fixed (the
i 9 he
0% nutrition T
D
stunting in and the of would year, year effects coverage
α, 10 interventions document.
for only the in coverage. The etc. document. interventions, t, pregnancy including which predicted
M
have (iv) package t a odel The growth (i.e.
nd m is package r ate the country costs
A
energy-protein PPP) fallen both We We is year, in model assumed
for number of (with,
estimate including years for assume dollars) region-specific at the which fixed ui and an 34 (with is

N
form: in after of the effect annual countrieswe by both parentheses, s tunted the a are:
U
countries iron-folate
country Bhutta 2014 assume gradual ln(Si t)=α+βt+ui +
eit,
S 13
supplementation model benefits region-specific (i) rate under-fives for costs salt et fixed
C
allows of that each which as scale-up
al.). on annual -1.5% iodization ($472m), the and

R
effect, together This the is us we fixed
increased in costs stunting to assumption p.a.have

I
aggregate of package year and get where in effects) 12
intervention (iii) ($68m), and an account
P
regnancy no t
ei t p is estimated t he impacts Sit c
alcium stunting
T
stunting equal to is on is
costs
error 90% then

that
(ii)
the for

the
to
data. 13 The countries are: Afghanistan, Angola, Bangladesh, Burkina Faso, Cameroon, Chad, Congo,
Dem. Rep., Cote d'Ivoire,

Egypt, Arab Rep., Ethiopia, Ghana, Guatemala, India, Indonesia, Iraq, Kenya,
Madagascar, Malawi, Mali, Mozambique, Myanmar, Nepal, Niger, Nigeria, Pakistan, Philippines, Rwanda,
South Africa, Sudan, Tanzania, Uganda, Vietnam, Yemen, Rep. and Zambia.
19
($972m), (v) vitamin A supplementation in childhood ($106m), (vi) zinc supplementation in
childhood ($1,182), (vii) breastfeeding promotion ($653m), (viii) complementary feeding
education
($269m), (ix) complementary food supplementation ($1,359m), and (x) severe acute
malnutrition
management ($2,563m). It is important to note that the latter – management of severe acute
malnutrition – represents the largest component of the cost, affecting child mortality but not
stunting
or cognition. Scaling these 10 interventions up to 90% coverage is estimated to reduce stunting
across these 34 countries by 20% at an aggregate cost of $9,559m.
3.2. Estimating the rate of return to a nutrition program
Suppose we have a nutrition program, like that proposed by Bhutta et al., and we know its costs
and its effects on stunting rates and on cognition. We can compute the internal rate of return, i,
of the
program:
(5) ∑ ∞
t=1 (1+i)∆y(t)
t= ∑ ∞
t=1
C(t) t
where ∆y(t) is the income change due to the program and C(t) is the cost of the
(1+i)
program. The
internal rate of return is the value of i that equalizes the net present value (NPV) of the benefit
stream
(the left-hand side) and the NPV of the cost stream (the right-hand side). We can also impose a
specific discount rate and compute the NPVs of the benefit and cost streams, and compute the
(discounted) benefit-cost ratio.
To get the benefit stream, we can totally differentiate equation (2) with respect to a nutrition
program (D). If we force all the benefits to operate through stunting, we have:
(6) dlny(t+τ)

= α {[r dE (t+τ)
dDN(t) dSWW(t+τ)
+ γ dH (t+τ)
dSWW(t+τ)
+ δ dC (t+τ)
dSWW(t+τ)
] dS (t+τ)
dSWC
ACCEPTED
(t)
MANUSCRIPT
dDdSCN(t)
}
(t)
20
Reading from the right, the program lowers stunting among children today (dSC(t) ⁄ dDN(t) ),
which
leads to a lower childhood stunting rate among workers in years to come (dSW(t + τ) ⁄ dSC(t)) .
This
increases the cognitive skills of workers (dCW(t + τ) ⁄ dSW(t)) which raises earnings by δ. It also
leads to taller workers (dHW(t + τ) ⁄ dSW(t)) which raises earnings by γ. Finally, it increases
educational attainment (dEW(t + τ) ⁄ dSW(t)) which raises earnings by r. This a rather restrictive
approach. A less restrictive one would be to allow for the possibility that the program may have
some
effects on child and adult cognition that are not fully reflected in their effects via stunting. For
example, there is evidence that iodine supplementation in utero, maternal micronutrient
supplementation and exclusive breastfeeding have direct cognitive benefits on adult cognitive
scores
and school attainment (the estimated effects are discussed in section 3.3).
Our main results are based on this more general formulation:
(6’) dlny(t+τ)

= α {[r dE (t+τ)
dDN(t) dSWW(t+τ)
+ γ dH (t+τ)
dSWW(t+τ)
] dS (t+τ)
dSWC
(t) This formulation, i.e. analysis based on the Both dSW(t + today’s dCto the W A (t
C C E
cognition + children τ) ⁄ dC Camong (t) to , eqn (6’), underlies τ) the more ⁄
P T E D
dS childhood Crestrictive (t) , formulation, our main
M A N +
results, i.e. eqn dDdSbut CN(t) (t) (6). we which captures the
transmission stunting rate among workers which captures the transmission of changes workers
USCRIPT δ dC (t+τ)
τ years in the future, depend on dCWC
(t)
dDdCNC(t)
}.
(t)
also report results in the sensitivity

of changes in stunting among
τ years in the future, and
in cognition among today’s children
τ. For τ < 15, both will be zero, since
the beneficiaries of the nutrition interventions have yet to join the labor force. As τ increases
beyond
15, dSW(t + τ) ⁄ dSC(t) and dCW(t + τ) ⁄ dCC(t) become positive. If, for example, the rate of
childhood
stunting were constant in the absence of the program, dSW(t + τ) ⁄ dSC(t) would eventually reach
1
and stay at 1. In other words, if τ is sufficiently large, a given change in stunting among children
at
21
ill translate into an equal change in the average rate of childhood stunting among
time t w
workers at
time t + τ. The same logic applies to dCW(t + τ) dCC(t) ⁄ .
3.3. Parameters
To derive estimates of the rate of return, we need estimates of the various parameters in
equation (6). We summarize our assumptions about their values in Table 3.
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Table 3: Assumptions in estimating returns to nutrition program
Parameter Assumption Source Counterfactual trends: S tunting (S) 2016 rate from WDI, closest year. Trend before and after
follows -1.5% p.a. growth, based on analysis in section II
Authors’ assumption
Cognition (C) Per capita income (y) Program effects on: Stunting (dSC(t) ⁄ dDN(t) ) Cognition (dCC(t) ⁄ dDN(t) ) Transmission of
CCE
tunting (dSW(t + τ) ⁄ dSC(t))
effects from childhood to adulthood S A 2016 z-score assumed to
be 0.0 SD. No trend assumed GDP per capita (2010 International dollars) for 2016 from WDI. Country-specific trend thereafter
given by country- specific growth rate from IMF World Economic Outlook forecast, with growth rate being reduced over time
according to reciprocal function with 2125 growth rate equal to 50% of 2016 growth rate
20% reduction (assumed relative to counterfactual). Program assumed to be scaled up over 10-year period, 20% reduction below
trend being reached in 2025. Program remains in place thereafter so stunting remains 20% below trend thereafter 0.487 extra SDs
P T
of cognition relative to counterfactual. Program increase remains above trend in assumed above place thereafter
E D M
trend thereafter to be scaled being so up cognition reached over 10-year in remains
A N
2025. period, 0.487 Program 0.487
U S C
SDs Authors’ Authors’ Bhutta See Table cognition fraction by Table the A2 et of assumption
assumption
R I P
al. A2. we effect children (2013) intervention. For multiply each by currently 0.9 intervention the minus
T
estimated covered Current
the in
intervention coverage rates from various sources.14
Assume 15 years before joining labor force, and adult working life of 40 years
Authors’ assumption
Cognition (dCEffects W(t of + stunting τ) ⁄
ducation (dEw/dESw) -1.740 fewer years of education See Error! Reference source not
dCC(t)) on: E
found. Height (dHw/dESw) --6.490 cm shorter See Error! Reference source not
found. Returns to: E ducation (r) 6.6% return per extra year of education (main) or region- specific percentage extra income per
extra year of education (alternative)
See Error! Reference source not found.
Height (γ) 1.3% extra income per extra cm See Error! Reference source not
found. Cognition (δ) 3.1% extra income per extra SD See Error! Reference source not
)
found. Elasticity of income with respect to human capital, i.e. labor share (α
0.67 Hanushek and Woessmann (2012)
Program costs A ggregate costs for WHO groups of countries divided by aggregate population to get per capita costs for each WHO
group. Given program assumed to be scaled up over 10-year period, per capita costs also rise accordingly, reaching full per capita
cost only in 2025. Cost stays constant thereafter
Bhutta et al. (2013)
Discount rate 5 % Authors’ assumption Time horizon 2125 Authors’ assumption
14
The coverage rates for breastfeeding and maternal multiple micronutrient supplementation are the same
as those
used by Bhutta et al. i n the LiST model (Walker et al. 2013). The iodine supplementation
coverage indicator is salt iodization; the data are from UNICEF (http://data.unicef.org/nutrition/iodine.html).
23
We compute, for each country, time paths of childhood stunting and cognition without the
nutrition program, to which we apply the program effects dSC(t) ⁄ ∂DN(t) and dCC(t) ⁄ ∂DN(t) . We
get the counterfactual childhood stunting time path by setting the 2015 childhood stunting rate
equal
to and the program, 2016), achieving gives We 20% dCcognition currently whereas estimated 15
Bhutta supplementation) immumization outcomes) Table the

C A (t) assume after counterfactual
C
below us, We latest ⁄ we A2 et
dDafter 2015 the and effect but assume Bhutta covered
estimate mean summarizes al

Nthe the JME (t) program not that package 10 assume
C
stunting , counterfactual program of by childhood cognition and years, stunting. et the
E
have the by cognition multiplying, the al.’s excludes program the the
the (exclusive
P
intervention been takes falls a change estimated is value evidence A
z-score intervention.
T
effects stunting maintained new at shown time other intervention rate an goes of set for in
E
annual breastfeeding, dS on from is for path, to 20% health to the of (obtained rate Ceach
D
initially these (t)
have scale meta-analyses all at the cognition ⁄ (The rate for reduction
we periods ∂Dintervention the and effects,

gradually coverage meta-analyses the Nassume of
an
M
zero. same (t) association effect n
utrition from 1.5% iodine country after focusing (in

A
z-score As (compared scale and Table size terms (the over from zero in 2025.
supplementation in interventions long in with a thereafter is on rate

a the 3) question, recent change
N
summarized of attributable its 10-year relevant the term
by year-to-year cognition Bhutta
U
we to current subset 0.9
computed the longitudinal World in period so such minus and for
S
counterfactual) et the of the
(and rate and to in al. interventions then
Bank going as absence
C
changes) stunting between Table the the package, long-term in deworming to multiple
R
studies assuming section report fraction from nutrition 90%.) A2. of rate 2016 equal have
15
I
the 0% included in
the human 2 (World micronutrient We The and above). that of remains
P
2025. estimated and shown to program, nutrition
to children
use possibly current before
100%, -3.7%.
T
capital 2025, in Bank

This For
the
the
the at
sizable association between breastfeeding and cognition and schooling in adulthood, with an average
effect size of 0.27 SD on cognition. The most recent meta-analysis (Bougma et al. 2013) summarizes the
cognitive deficit of iodine deficiency to be of 7.4 IQ or 0.49 SD in cognitive scores. An important study in
Tanzania (Field et al. 2009) has documented the persistent impact of exposure to a large scale iodine
supplementation in utero to grade attainment and progression 10 to 14 years, with an “estimated
0.35–0.56 years of additional schooling
24
intervention coverage rates are from various sources. We assume the effects are achieved over
a 10-
year period, in line with the assumption that the program is scaled up gradually over a 10-year
period. number under-fives) we survive distribution population and rates assumptions, y(t) .
estimate percentage per initially A need capita increases To and To We

using through
C
compute of the get to
increases use (converted years age change know and of
C
counterfactual dSand the the in structure Wthe about to cognition annual (t before same
E
the the the due in age + population others cognition time τ) at distribution to the values ⁄
P
55, average a 2010 data. the dSchild number among path Csome time listed
T E
program, (t) of These PPPs among across starts for and α, IMF path may today’s
D
above, of of r, ∆y(t), as dCyears assumptions April γ, the for ∆lny(t). working the
five-year survive δ, in W(t dEwe population per children Bhutta working-age 2016 an and + W get

M
adult τ) ⁄ capita For dSbut (we hence ⁄ World a age dCet W allow
time the translate will
A
may , Cassume al. and income (t) across bands the counterfactual Economic population
N
(2013)) spend path us migrate we dHNPV to W need
15 into from age for to ⁄ quantify at
U
dSwhich of given for ∆lny(t), work groups Outlook reductions elsewhere, W to
the 15 in
S
2016, as make years time that (we through we benefit in how – the section (WEO) can
C
and path assume not stunting to assumptions reductions in etc. percentage come. apply
R
stream, project all 55 childhood of estimated 2. We y( t), under-fives 40). using Applying
I P
rates the take we it we In in estimated about change forwards, addition, the take apply
T
stunting stunting need the growth these
WDI
GNI will
age the
to
in
to
relative to siblings and older and younger peers”. Finally, Evidence from four efficacy trials documented an
average impact on fluid intelligence and academic performance of 0.30 SD. A more recent longitudinal
study in Indonesia (Prado et al. 2015) found a sustained effect on child cognition, with the largest effects
on women who were malnourished and women who were anemic at the time of enrolment.
25
rate over the period 2014-2021, then reducing the growth rate over time asymptotically (via a
reciprocal function) until it reaches 50% of the WEO growth rate in 2125.
For costs, we use the program costs computed by Bhutta et al. (2013). To get the program cost
per capita (i.e. per person living in the country, not per under-five child) in international $, we
take
the aggregate program costs for each group of countries in Bhutta et al.’s Web Appendix Panel
15
(the groups are WHO regions), and divide the aggregate cost of each group by the aggregate
population of that country group (we take the population data from WDI). As already mentioned,
we
assume that the scaling-up process takes 10 years, so we assume the full cost per capita is
reached
only in year 10; in year 9, the cost is 9/10th of the full cost, etc.
3.4. Results
Figure 2 shows the results of our main assumptions in terms of trends in stunting. The
counterfactual rate of stunting among children falls at 1.5% per year. The nutrition program
kicks in
in 2016 reducing the rate of stunting among children below the counterfactual; the program
reaches
its full scale in 2025, at which point the reduction in the rate of stunting below the counterfactual
reaches 20%. By 2025, stunting has fallen by 36% compared to its 2010 value – 4 percentage
points
below the 40% target reduction adopted by the 65th World Health Assembly. We assume the
nutrition
program is sustained at scale and thereafter stunting stays at 20% below the counterfactual.
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26
Figure 2: Reductions in stunting among today’s children and their effects on childhood
stunting rates among the workforce in later years
50%20%. stunting childhood rate For stunting previously below A the among The It its
C
same takes rates rates counterfactual childhood and in workers 45% 40%
35%
30%
25%
20%
15%
10%
C E
0%much
the reasons, 5% joining that among 2000 stunting
were today stunting
P T
longer 2010 the
it workers. value is prevalent labor thus rate 15 than 2020 rate
years
E
among exceeds within force, 10 Stunting Stunting Childhood Childhood And among 2030 years when
D
before and even 10 under-fives: among among the 2040 stunting
stunting workers years for the
M
today’s rate then, the today's today's the assumed 2050 among
among of of effect childhood the
A
stunting under-5s under-5s in the workers the today's today's 2060 any
decline start of rate 40-year
N
year (counterfactual) (after the workforce workforce 2070 among of of were stunting nutrition program) is
U
is stunting the a working 2080 slower
(counterfactual) (after weighted today’s children. program;
S
rate program) 2090 program
among than life, children among average 2100 by
Given
C R
the the children contrast, is childhood workers by 2110 felt
decline the of a the on
I P
large lag falls 2120 it childhood childhood 15 to between takes stunting margin. to fall
T
years
20%
55 by
years for the childhood stunting rate among workers to fall to 20% below its counterfactual rate.
27
Figure 3 shows the time path of per capita costs and benefits (in terms of income) for the 34
countries on average, under our main assumptions that use the same conditional returns to
education across all countries. Per capita costs rise from zero in 2015 to $3.85 in 2025 and stay
there
thereafter. Per capita benefits – in terms of higher incomes – are zero until 2033 when the first
cohort
benefitting from the scaling-up of the 10 nutrition interventions joins the labor force. Initially the
change in per capita income in the country is small, because only the youngest of 40 cohorts in
the
labor force has benefitted from the scale-up. As time passes, an ever-larger fraction of the labor
force
has benefitted from the scale-up, and the effect on per capita income grows. In addition, as time
passes, the counterfactual per capita income that the percentage effect of the program gets
applied
to increases (on our assumption that economic growth remains positive), so that the benefit in
dollar
terms of being well nourished in childhood increases.
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28
Figure 3: Time path of per capita costs and benefits of the nutrition program
$45$40
$35
$30
$25
$20
$15
from (16.8%) growth program numbers variations India’s A 4.1% The low rate. reflecting
C
cost, are internal within to program Africa $10
C E
offset 17%. the 2010 regions,
relatively the rate The is only cost the low average of
P T
partly 2015 region and of return per low course: its capita by is with initial high
E D
results 11.9%. 2020 the
osts relatively GDP
India, program the GDP C are lowest
M
The for growth per 2025 per
shown example, East capita cost, capita, high rate rate.
A
Asia in the 2030 of
rate Table and has & return high Benefits Pacific of a the 3 return rate
N U
initial 2035 and
(10.4%) relatively per region of capita Figure GDP return to
SCRIPT $5
$02040 2045 2050

4. The rate of return varies
has the highest rate of return
per capita, and the high GDP
reflecting the high per capita
low GDP growth rate; these
education in Africa. There are
of 17.4% reflecting in part
29
Table 4: Rates of return to nutrition project, by region
Main assumptions Alternate assumptions
Region
Program cost per capita
Educatio n rate of return
Educatio No.
Stunting
Benefit-
Rate of
n rate of countries
rate
cost ratio
return
return
Benefit- cost ratio
Rate of
East Asia & Pacific 3 31% $2.63 6.6% 20:1 16.8% 10.3% 22:1 Latin America & Caribbean 1 48% $2.72 6.6% 9:1 15.2% 10.3%
11:1 Middle East & North Africa 2 31% $2.61 6.6% 6:1 13.1% 5.6% 6:1 South Asia 5 46% $2.73 6.6% 6:1 Sub-Saharan Africa 21
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36% $4.59 6.6% 4:1 Total 32 37% $3.85 6.6% 5:1 A
MAN US CR
12.4% 10.4% 11.9% 12.8% 10.9% 7.0% 6:1 4:1 6:1
IP
return 17.3%
15.9%
12.9%
12.5%
11.2%
T
12.5%
30
Figure 4: Rates of return to nutrition project, by country
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15 − 18 13 − 15 10 − 13 9 − 10 6 − 9 -2 − 6 No data A
MANUSCRIPT
31
It should also be kept in mind that our results do not capture the effects of the program on
mortality,
which are estimated to be appreciable (Bhutta, Das et al. 2013). Insofar as the program
reduces child
mortality, the initial effect will be to reduce the fraction of the population working, i.e. NW N⁄
in
equation (1)
will fall. This will cause per capita income to fall until the children grow up and join the labor
force.
Reductions in child mortality are also likely, however, to lead to subsequent changes in fertility
behavior,
with families reducing their family size as children are more likely to survive childhood. This will
push NW N⁄

back up and hence dampen the downward pressure on per capita income.
Finally, we should keep in mind that childhood survival is valued in its own right – a more
complete
cost-benefit analysis would capture the intrinsic value associated with fewer children dying in
childhood
because of the nutrition program. All told, our estimates are probably underestimates of the
rate-of-return.
3.5. Sensitivity analysis
Table 5 shows how sensitive the estimated rates of return for the 34 countries overall are to the
assumptions used, as done in other studies that estimate the cost benefit of the scaled-up
nutrition package
(Hoddinott, Alderman et al. 2013, Alderman, Behrman et al. 2017). It is possible that the costs
of the program
are underestimated if only because the cost estimates do not take into account that unit costs
will likely rise
as harder-to-reach groups are covered. Doubling the total cost of the program would cut the
benefit-cost
ratio by about one-third, and would cut the rate of return by 25% or 3 percentage points. It is
also possible
that the program’s impacts on stunting are overestimated, in part because many of the effect
sizes from the
meta-analyses are not statistically significant, and in part because most estimates come from
efficacy trials, not at-scale programs. Halving the assumed program effect on stunting from 20%
ACCEPTED
to 10% reduces the
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32
benefit-cost ratio by 20% and the rate-of-return by 7% or 0.9 percentage points; it also cuts the
estimated
reduction in stunting from 36% to 28%. The cognition impacts of the program may also be
overestimated
for the same reasons. Halving the assumed cognition effects of the program reduces the
rate-of-return by
14% or 1.7 percentage points. We also explore the effects of changes in the assumed effects of
stunting on
years of education and adult height. Halving the assumed effects of stunting on years of
education and adult
height reduces the benefit-cost ratio by 20% and the rate-of-return by 7% or 0.9 percentage
points. If we
make all these changes simultaneously, we end up with about 50% reduction in the
rate-of-return, equivalent
to a reduction of almost 7 percentage points. Reducing the scale-up period from 10 years to
one reduces the
rate-of-return by 1/3 or 3.9 percentage points; a 10-year scale-up is considerably more realistic.
Halving the
returns to education does not change the benefit/cost ratio and barely reduces the rate of return
from 11.9%
to 11.4%. Finally, if we constrain the cognitive effects to only go through stunting, the
benefit/cost ratio is
reduced to 2:1 and the internal rate of return is reduced by 36% or 4.3 percentage points.
Table 5: Sensitivity of results to assumptions
Benefit-cost ratio Rate of return Base estimates 5:1 11.9%
Doubling of program cost 3:1 8.9% Halving of program effect on stunting 4:1 11.0% Halving of program effect on cognition 4:1
10.2% Halving of stunting effects on education & height 4:1 11.0% All the above 1:1 5.3%
One-year scale-up 2:1 8.0%
Ignoring cognitive effects not reflected in stunting 2:1 7.6% Halving returns to education 5:1 11.4%
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33
3.6. Comparisons with other studies of returns to nutrition investments
Other authors have also reported estimates the returns to childhood nutrition programs,
including the
Bhutta et al. program. The studies by Hoddinott et al. (2013) and Hoddinott (2016) are closest
to our study.
Like us, they estimate the costs and benefits (in terms of higher incomes) of taking the
coverage rate of each
of the interventions in the Bhutta et al. package from the current rate to 90%. One difference
between the
studies is that the others assume immediate scale-up to 90%, and are therefore able to conduct
the analysis
using just one cohort. By contrast, we scale up over a 10-year period, with each successive
cohort born
between 2015 and 2025 getting closer and closer to 90% coverage; we then maintain the
program at 90%
coverage thereafter. There are also differences in the estimates used to estimate the economic
value of
stunting reduction. Hoddinott et al. focus on the income effects that operate through stunting,
whereas we
allow for effects that operate through cognition in the case of interventions in the package that
do not affect
stunting. On the other hand, Hoddinott et al. assume a much larger effect of stunting on income
than we do.
The median estimate for the benefit to cost ratio in Hoddinott (2013) using a discount rate of 5%
is 18:1 (the
median country is Bangladesh) is larger than our estimate of 6:1. The benefit-cost ratios in
Alderman et al.
(2017) range from 4:1 in the Democratic Republic of Congo to 34:1 in India. In addition to
assumptions
behind the returns to stunting reduction, the benefit-ratios estimated in different studies depend
on the
assumptions about future income growth, the number of years in the labor force, and the
discount rate. All
studies provide sensitivity analysis to the various assumptions and come up with favorable
ratios. Our study also differs from others in that we report estimates of internal rates of return.
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34
4. Conclusions
There is a large consensus in the public health and economics literatures that chronic
malnutrition is
associated with adverse outcomes throughout the lifecycle. The undernourishment and disease
that cause
stunting impair brain development, leading to lower cognitive and socioemotional skills, lower
levels of
educational attainment, and hence lower incomes. In this paper we rely on a development
accounting
framework that allows to perform a backward-looking exercise that estimates how much a
country’s per
capita income today is lower to the extent that some of its workers today were stunted in
childhood, and a
forward-looking exercise that estimates the net present values of the costs and benefits of a
package of
interventions aimed at reducing stunting among today’s children. We estimate that, on average,
GDP per
capita globally is 5 to 7% lower as a result of some of today’s workers being stunted in
childhood, and that
across 34 countries accounting for 90% of the world’s stunted children, the rate-of-return to the
package of
nutrition interventions is about 12% with, with a benefit-cost ratio ranging from 5:1 to 6:1.
Our approach has strengths and weaknesses. Among the strengths is that the fact that we
conduct the
backward- and forward-looking exercises in the same study, using the same methodology and
assumptions.
By contrast, in the literature to date, the two exercises have been done in different studies,
using different
methodologies and different assumptions. Another strength of our study is the fact that that the
methodology
we use (development accounting) is in line with other studies that try to pinpoint some or all of
the sources
of differences across countries in per capita income. The third strength of our study is its
comprehensiveness:
our methodology allows for three channels by which stunting affects income (years of
schooling, cognition and stature), rather than just one or two; we base our parameters on all the
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relevant micro-econometric
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35
studies, rather than just one or two; and our backward-looking estimates are for the entire
developing world
while our forward-looking estimates are for countries accounting for 90% of the world’s stunted
children.
There are limitations to this exercise that leave scope for future research. In line with the
literature, we
are looking at how childhood stunting translates into adult earnings via human capital while
holding
everything else constant. There might be important externalities and spillover effects that arise
from human
capital formation that are not captured in the estimates of the private returns to reduction of
childhood
stunting. Equally, there might be general equilibrium effects from scaling up a nutrition package
to 90% of
the populations that are not accounted for in this framework. It should also be kept in mind that
our results
in the forward-looking exercise do not capture the effects of the program on mortality, which are
estimated
to be appreciable (Bhutta, Das et al. 2013). Insofar as the program reduces child mortality, the
initial effect
will be to reduce the fraction of the population working, i.e. NW N⁄
in equation (1) will fall. This
will cause
per capita income to fall until the children grow up and join the labor force. Reductions in child
mortality are
also likely, however, to lead to subsequent changes in fertility behavior, with families reducing
their family
size as children are more likely to survive childhood. This will push NW N⁄ back up and hence
dampen the
downward pressure on per capita income. Finally, we should keep in mind that childhood
survival is valued
in its own right – a more complete cost-benefit analysis would capture the intrinsic value
associated with
fewer children dying in childhood as a result of the nutrition program. All told, our estimates are
probably
underestimates of the effect of stunting on per capita income and on the rate-of-return to the
Bhutta et al. package of nutrition interventions.
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36
Acknowledgements
This paper presents the econometric analysis undertaken by the authors that was reported in a broader World Bank
policy research note, written with Sophie Naudeau and Meera Shekar, on the economic costs of stunting and policies
to
reduce them. The paper has benefitted from discussions with Harold Alderman, Jishnu Das, Deon Filmer, Jed
Friedman,
Roberta Gatti, John Giles and Aart Kraay, and from the comments of two referees. The findings, interpretations and
conclusions expressed in this paper are entirely those of the authors, and do not necessarily represent the views of
the
World Bank, its Executive Directors, or the governments of the countries they represent.
Funding: This research did not receive any specific grant from any funding agency in the public, commercial, or
not-for-
profit sectors.
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Declaration of interest: none. A
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37
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Table A1: Review of estimates of effects of stunting on height, schooling and cognition, and
their effects on earnings
Panel A: height A Effect of stunting on height (in cm): ∂H∂SW W

Study Country Adult age M/F Unconditional Thomas and Strauss (1997) Brazil 25-50 M/F — M F LaFave and Thomas (2017b)
Indonesia (WISE) 25-65 M — Vogl (2014) Mexico (MFLS) 25-65 M Victora et al. (2008) COHORTS study (Brazil,
Guatemala, India, the Philippines, and South
M/F
21-23, 26-41, 26-32, 21, 15 Africa)
Coly et al. (2006) Senegal 18-23 M/F M F Alderman et al. (2006) Zimbabwe 17 M/F Panel Mean B: years across of schooling
C C E PT E D
all studies (weighting individual countries in the COHORTS
M AN U -6.480
study) Effect years -6.490cm of of -7.800 -5.230 -9.000 -6.600 ∂ E∂Sstunting
SC
— schooling W W on
R I P
Unconditional Effect 0.023 0.023 — of height γ
T
on Conditional
earnings
0.014 0.015 0.013
0.012 0.013
——
——
— — 0.023 0.013
Effect of years of schooling on earnings r Study Country Adult age M/F Unconditional Unconditional Conditional (Montenegro
and Patrinos 2014)
0.097 —
Pitt, Rosenzweig and Hassan (2012)
Bangladesh 20-49 M/F — — 0.042
LaFave and Thomas (2017b) Indonesia 25-65 M — — 0.083 Vogl (2014) Mexico (MFLS) 25-65 M — 0.073 Martorell et al (2010)
COHORTS study (Brazil,
Guatemala, India, the Philippines, and South Africa)
M/F -1.840 —
Alderman, Hoddinott and Kinsey (2006)
21-23, 26-41, 26-32, 21, 15
Zimbabwe 17 M/F -1.240 —
Mean across all studies (weighting individual countries in the COHORTS study) -1.740 yrs 0.097 0.066
Panel C: Cognition
Effect of stunting on cognition (in SD) ∂C
∂SW W

Effect of cognition on earnings δ Study Country Adult age M/F Unconditional Unconditional Conditional
LaFave and Thomas (2017b) Indonesia 25-65 M — 0.166 0.077 Vogl (2014) Mexico (MFLS) 25-65 M — — 0.011
Glewwe, Jacoby and King (2001)
Philippines 11 M/F -0.870 —
Walker et al (2005) Jamaica 17-18 M/F -0.930 — ( Berkman, Lescano et al. 2002) Peru 9 M/F -0.670 — ( Grantham-McGregor,
Cheung et al. 2007)
COHORTS study (Brazil, Guatemala, India, the Philippines, and South Africa)
21-23, 26-41, 26-32, 21, 15
M/F -0.675 —
Mean across all studies (weighting individual countries in the COHORTS study) -0.724 SD 0.166 0.044
43
Table A2: Evidence on the effects of nutrition interventions on cognition
Mean effect across studies
Intervention Year of study Study Effect size on cognition/academic Breastfeeding 2015 (Horta et
al. 2015) Yes (0.27 SD) Iodine 2013 (Bougma et al. 2013) Yes (0.49 SD ,
7.4 IQ) Multiple micronutrients 2010 Eilander et al.(Eilander et al. 2010) Yes (0.30 SD)
Table Country Afghanistan Angola United Argentina Armenia Antigua Azerbaijan Burundi Benin Burkina Bangladesh Bahrain
rab African and Faso name The
Bahamas, Belize Bolivia Brazil Barbados Bhutan Botswana Central Chile China A3: A
CC E
Country-specific Emirates Barbuda A Republic Country estimates BWA ARM CHN
AGO BGD BHR BTN ARE ARG ATG BEN BRA BRB AFG BFA BHS BOL CHL AZE CAF BLZ BDI code
PT E
Per-capita -10.6 -11.6 -12.8 -11.5 -2.2 -2.5
-3.5
-4.3
-4.8
-8.9
-9.6 -2.3
-2.8
-5.9
-7.9
-6.7
-4.5
-9.9
-8.1
-8.2
-1.5
D M A
-8.0 income effect Internal rate 11.4 13.7 7.9
N
6.9 of return
US C significant?
performance
RIPT
Cote d'Ivoire CIV -6.6 12.9
Cameroon CMR -7.0 9.8
Congo, Dem. Rep. COD -9.2 5.4
Congo, Rep. COG -6.6
44
Colombia COL -4.7 Comoros Cabo Costa Cuba Djibouti Dominica Dominican Algeria Ecuador Egypt, Eritrea Ethiopia Fiji
Micronesia, Gabon Georgia Ghana Guinea Gambia, Guinea-Bissau Equatorial Grenada Guatemala Guyana Hong Honduras Haiti
Indonesia India Iran, Iraq Jamaica Jordan Islamic Verde Kong Rica Arab The Guinea Republic SAR, Fed. Rep. Rep.
CCE
A China Sts. DOM DMA COM GMB GTM HND GNQ GHA GNB GRD HKG CUB DZA ETH
PTE
FSM GAB GEO GUY ECU EGY CPV JAM IDN IND GIN HTI IRN IRQ JOR CRI ERI DJI FJI -11.8 -13.0
-11.8 -10.5 -10.4 -8.6 -5.6

-3.7
-2.5
-3.9
-4.6
-4.4
-3.9
-7.7
-5.2 -1.6
-4.1
-5.7
-3.1
-8.1 -8.8
-7.8
-8.6
-9.8
-5.4
-5.4
-1.2
-8.6
-8.0
-4.5
-4.6 -3.2
D MA
-3.0 13.8 10.0
15.2
17.8
17.4
NUSCRIPT
17.7 9.6
Kazakhstan KAZ -3.8

Kenya KEN -8.7 9.5
Kyrgyz Republic KGZ -5.2
Cambodia KHM -11.4
45
Kiribati KIR -5.9
Kuwait KWT -1.8
Lao PDR LAO -10.7
Lebanon LBN -3.0
Liberia LBR -8.8
Libya LBY -3.8
St. Lucia LCA -5.5
Sri Lanka LKA -4.9
Lesotho LSO -9.7
Macao SAR, China MAC -3.2
Morocco MAR -5.1
Madagascar MDG -11.5 Maldives MDV -6.7
Mexico MEX -5.6
Marshall Islands MHL -3.1
Mali MLI -9.4 Myanmar MMR -10.3 Mongolia MNG -7.2 Mozambique Mauritania Mauritius Malawi Malaysia Namibia Niger Nigeria
CCE
Nicaragua Nepal Oman Pakistan Panama Peru Philippines Papua New Guinea A NAM OMN
PTE
MWI MOZ MRT MUS MYS NER NGA PAN PAK PNG NPL PER PHL NIC -12.0 -10.6 -12.0 -10.6 -10.0
-10.9 -5.4 -6.5

-7.4
-5.8
-4.1
-8.9 -4.3
-7.4
D MA
-8.7 -7.4 16.3 13.0 4.1
NUSCRIPT
6.3
4.3
5.4
9.9
8.6
12.3
17.2
Puerto Rico PRI -3.3
Korea, Dem. People’s Rep. PRK -9.9
Paraguay PRY -3.9
Qatar QAT -2.0
46
Rwanda RWA -12.2 9.5
Saudi Arabia SAU -3.9
Sudan SDN -9.1 12.1
Senegal SEN -7.0
Solomon Islands SLB -6.5
Sierra Leone SLE -9.0
El Salvador SLV -6.8
Somalia SOM -7.9
Sao Tome and Principe STP -7.5
Suriname SUR -4.5
Eswatini SWZ -8.1
Seychelles SYC -2.3
Syrian Arab Republic SYR -4.9
Chad TCD -9.8 5.9
Togo TGO -8.5
Thailand THA -5.3
Tajikistan TJK -6.8
Turkmenistan TKM -5.4
Timor-Leste TLS -11.6
Tonga TON -1.1
Trinidad and Tobago TTO -1.8
Tunisia TUN -3.9
Turkey TUR -5.6
Tanzania TZA -10.4 10.2
Uganda UGA -10.8 7.1
Uruguay URY -3.3
Uzbekistan UZB -5.4
St. Vincent and the Grenadines VCT -5.8
Venezuela, RB VEN -1.7
Vietnam VNM -12.4 14.8
Vanuatu VUT -5.0
West Bank and Gaza WBG -3.2
Samoa WSM -1.9
Yemen, Rep. YEM -7.8 -1.8
South Africa ZAF -6.3 13.6
ACCEPTED
Zambia ZMB -10.6 9.8 Zimbabwe ZWE -7.0
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Accepted Manuscript

Authors: Emanuela Galasso, Adam Wagstaff

PII: S1570-677X(18)30210-7 DOI: https://doi.org/10.1016/j.ehb.2019.01.010 Reference: EHB

To appear in: ​Economics and Human Biology

The Aggregate Income Losses from Childhood

indicator ​The childhood

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To appear in: Economics and Human Biology

indicator The childhood

the A umber proximate We We efficiency Y Y endogeneity production is

+ δ dC (t) ]∆S (t)

conditional human the height; A ore We decisions Annex.to supply

Wasalmost ~over capita

per se. 9See

impacts 12 September number term. α̂ stunting + We the

of The in version figure writing,

error 90% then

Bhutta supplementation) immumization outcomes) Table the

estimate mean summarizes al

we periods ∂Dintervention the and effects,

supplementation in interventions long in with a thereafter is on rate

estimate percentage per initially A need capita increases To and To We

$02040 2045 2050