Morocco - Nutrition and national development : issues and options

Report No. 10674-MOR Kingdom of Morocco Nutrition and National Development Issues and Options January 4 1994 Population and Human Resources Division Country Department I Middle East and North Africa Region FOR OFFICIAL USE ONLY MICROGRAPHICS Report No: 10674 MOR Type: SEC Document of the World Bank This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization  CURRENCY EQUIVALENTS Currency Unit Dirham (DH) US$ 1.00 = 7.80 DH (September 1992) ABBREVIATIONS AND ACRONYMS AC Artisanal Cooperatives for "low income artisans" in urban areas CET Centres de l'education et du travail (vocational education centers for girls) CFP Centres de Formation Professionnelle (trade schools for poor boys and girlF.) CRS Catholic Relief Services DHS Demographic and Health Survey GDP Gross Domestic Product IDD Iodine Deficiency Disease IMR Infant Mortality Rate LSMS Living Standards Measurement Survey MCH Maternal-Child Health MCH-FP Maternal-Child Health-Family Planning MSA Ministry of Social Affairs MOH Ministry of Public Health MWRA Married Women of Reproductive Age NCHS The US National Center of Health Statistics SAR Staff Appraisal Report SMB Societe Musulmane de Bienfaisance (orphanages) TFR Total Fertility Rate USAID US Agency for International Development WFP World Food Program  FOR OMFIAL UTSE ONLY KINGDOM OF MOROCCO NUTRITION AND NATIONAL DEVELOPMENT ISSUES AND OPTIONS Table of Contents Page No. EXECUTIVE SUMNARY AND RECOMMENDATIONS Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . i Nutrition and Development .... . . . . . . . . . . . . . . . . . i Food Consumption, Nutrition Status and Micronutrient Deficiencies . ii Food and Nutrition Policies and Programs . . . . . . . . . . . . . . iv Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . v I. Nutrition and Development in Morocco . . . . . . . . . . . . . . . 1 II. Food Production ..... . . . . . . . . . . . . . . . . . . . . . 6 III. Food Consumption . . . . . . . . . . . . . . . . . . . . . . . . . 9 IV. Nutritional Status . . . . . . . . . . . . . . . . . . . . . . . . 18 V. Micronutrient Deficiencies . . . . . . . . . . . . . . . . . . . . 27 VI. Food and Nutrition Programs .... . . . . . . . . . . . . . . . . 31 VII. Conclusions and Recommendations .... . . . . . . . . . . . . . . 43 This repoft was prepared by Juliana Weissman (MN INPH) based on the findings of a mission to Morocco in Noveniber, 1991 and May, 1992. The mission members included Messrs./Mmes. Judith McGuire (PHRHN), Nutrition Specaist; Alan Forbes, Food and Nutrition Specialist (Consultant); Clydette Powell, Epidemiologist (Consultant); and BEatrice Rogers, Nutrition Economist (Consul!ant). Mrs. Judith McGuire is the peer reviewer. This document has a restricted disi..aution and may be used by remipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  Table of Contents (-ont'd) Page No. TEXT TABLES Table 1. Expenditures of 0) Poor .2.............. . 2 Table 2. Poverty Rates in Morocco . . . . . . . . . . . . . . . . 2 Table 3. Average Consumption Levels . . . . . . . . . . . . . . . 3 Table 4. Income and Food Consamption Levels . . . . . . . . . . . 9 Table St. Household Expenditures by Income Class . . . . . . . . . 11 Table Sb. Household Expenditures Urban Areas .12 Table 5c. Household Expenditures Rural Areas . . . . . . . . . . . 13 Table 6. Expenditures by Category 1991 . . . . . . . . . . . . . . 14 Table 7. Food Consumption 1971-72 and 1984-85 . . . . . . . . . . 16 Table 8. Expenditures by Food Category 1991 . . . . . . . . . . . 17 Table 9. Nutritional Status of Children . . . . . . . . . . . . . 20 Table 10. Nutrition Status and Socioeconomic Indicators . . . . . . 22 Table lla. Incidence of Malnutrition in Morocco . . . . . . . . . . 23 Table llb. Growth Retardation in Moroccan Children . . . . . . . . . 23 Table 12. Goiter in Morocco . . . . . . . . . . . . . . . . . . . . 30 Table 13. Population Coverage of Food and Nutrition Programs . . . 32 Table 14. Dietary Effects of Food Price Subsidies . . . . . . . . . 34 Table 15. Compensatory Feeding Programs - WFP . . . . . . . . . . . 36 Table 16. Compensatory Feeding Programs - USAID . . . . . . . . . . 37 Table 17. Catholic Relief Services Feeding Programs . . . . . . . . 39 FIGURES Figure 1. Conceptual Framework for Food and Nutrition . . . . . . . 5 Figure 2. Income Distribution . . . . . . . . . . . . . . . . . . . 10 ANNEXES ANNEX I Food Consumption Habits in Morocco . . . . . . . . . . . 49 ANNEX II Functional Effects of Micronutrient Deficiencies . . . . S0 ANNEX III Nutrition and Socioeconomic Status . . . . . . . . . . . 51 ANNEX IV Definition of Nutritional Deficiencies . . . . . . . . . 53 ANNEX V The Treatment of Iodine Deficiency . . . . . . . . . . . 55 ANNEX VI Costs and Benefits of Food and Nutrition Programs . . . . 56 ANNEX VII Provinces with Social Indicators Indicative of Nutritional Risk . . . . . . . . . . . . . . . . . . . . 61 ANNEX VIII Targeting Options . . . . . . . . . . . . . . . . . . . . 63 ANNEX IX Bibliography . . . . . . . . . . . . . . . . . . . . . . 67 I This document has a restricted distribution and may be u4ed by recipients onty in the performance of | their officiaL duties. Its contents may not otherwise be disclosed without World Bank authorization. I  KINGDOM OF MOROCCO NUTRITION AND NATIONAL DEVELOPMENT ISSUES AND OPTIONS EXECUTIVE SUMMARY AMD RECOMMEN1DATIONS Introduction 1. The nature and extent of nutrition problemes in Morocco and the effectiveness and impact of relevant policies and programs are areas of ongoing concern to the Moroccan government. These problems are the most visible evidence of the gaps which remain in the government's social strategy, and one of the major human resource constraints to future social and economic growth. The persistence of elevated levels of infant and child mortality and the high prevalence of micronutrient deficiencies suggest that poverty and the uneven distribution of the benefits of development, combined with insufficient attention to investments in human capital have contributed to a pattern of deprivation which has not yet been adequately addressed. The government is now faced with the need to reassess the effectiveness and impact of its policies and programs to direct their benefits to the most vulnerable population groups in order to improve outcomes, control program costs, and ensure sustainability. 2. A comprehensive series of food and nutrition issues with three interrelated elements is reviewed in this report: (a) the intersectoral links between nutrition and national development, including living conditions (Chapter I), food availability (Chapter II), food consumption patterns and their determinants (Chapter III); (b) the nutrition status of the population, the links between health and nutrition status (Chapter IV), and micronutrient deficiencies (Chapter V) ; (c) the government's food and nutrition policies, strategies, and programs, their coverage of the population groups which are at highest risk from a nutritional standpoint (Chapter VI), and a series of conclusions and recommendations for the futur, whicn are drawn from the information contained in the previous sections of the report (Chapter VII). Nutrition and Develoiment 3. Economic growth and development in Morocco have reduced the severity of problems associated with chronic food insecurity and malnutrition. Living conditions have improved substantially; GNP per capita increased to $1030 in 1991, the incidence of poverty has been reduced from 26' in 1984 to 13t in 1991, life expectancy has risen to 63 years, and infant mortality has declined to  - ii - 57/1000 live births. However, despite government efforts to address social and poverty concerns through policies and programs intended to minimize the negative impa..t of adjustmerz on the lwest income groups, life expectancy is still 15 years lower than in the industrialized countries, adult female literacy is only 38% and infant mortality is ten timer higher than in industrialized countries. There are substantial variations in well-being by region and income group; poverty is four times higher in the rural areas of the northwest than in the urban areas of the central region; infant n. rtality is two to three times higher in the rural areas of the south than in RLbat, and those who occupy the lowest rungs of the socioeconomic ladder remain at high ris1- from a nutritional standpoint. In addition, higk fertility, food consumption patterns and environmental conditions contribute to a high prevalence of micronutrien.t deficiencies which require urgent attention. 4. Malnutrition remains a serious problem which contributes to over a third of infant deaths. Malnourished children are more likely to die in infancy, to suffer from physical and mental growth retardation as well as more frequent and more severe illness, to perform worse in school, and to achieve lower levels of productivity on the job as adults. Malnutrition is closely linked to poverty, disease, and ignorance about nutritional requirements and the means to satisfy them. The impact of malnutrition on national development has been well established, and yet because of the multisectoral nature of its causes and consequences, malnutrition has been the concern of everyone and the responsibility of no one. Food Consumotion. Nutrition Status and Micronutrient Deficiencies 5. Significant progress has k,een made during the past two decades in reducing levels of food insecurity. The total of foods produced and importad in Morocco is sufficient to meet the nutritional requirements of the entire population. The per capita daily supply of calories increased from 2066 in 1365 or 90% of theoretical requirement, to 2820 in 1988, which would be sufficient to meet the energy requirements of the population if it were equitably available and evenly distributed. However, the level of consumption is directly correlated with income and there are large variations in expenditures according to family size, education and income levels. the lowest income decile urban and rural households spent about 60% of the budget on food. Per capita consumption for the lowest quartile of the population, while not alarming, is inadequate and averages only 1542 calories (which translates to an adult equivalent of about 2000 calories). 6. The Moroccan diet has changed very little over the years in terms of quantity and mix of foods consumed. Cereals, oils and other fats, and sugar constitute about 83% of calories consumed. The rural diet, which is high in cereals, low in other sources of protein and highly dependent on seasonal availability of other foods, does not always meet the requirements of infants and young children. The consumption of tea with meals reduces the effective iron intake, as it inhibits absorption. Variations in food consumption patterns reflect seasonal and regional availability as well as income levels. There is little current information on Moroccan consumer behavior, current elasticities of calorie and protein consumption, elasticities of demand for individual foods, or consumer perceptions of food.  iii - 7. Nwtrition status is universally regarded as a primary indicator of well-being. The historic relationship between adult height and life expectancy has been observed in rumerous poLulation groups. While the nutritional status of Moroccan children has improved since 1971 when 35W of urban children and 50S of rural children uulder four years of age were malnourished, cdata from the 1991 LSMS indicate that mai itrition continues to be a significant pxoblem, especially foi low income and rural population groups. Over 40 of the poorest children in rural areas and 2?% of the poor children in urban areas are below the recommended height for age in comparison to international standards, an indication of chronic poor nutritional status. The weight deficits found in 8* of urban children and 20 of rural children under five years old reflect periodic bouts of diarrhea and other infections, while height deficits which were found in 17* of urban and 30O of rural children the same age suggest that the quality of protein consumed ie low even when the total number of calories consumed is adequate. According to a 1989 survey, malnutrition was one of the major contributing factors to infant mortality. The leading cause of death for children aged 28 days to five years was malnutrition associated with diarrhea. Mortality rates were twice as high in rural as in urban areas. Poor sanitary conditions in rural areas, where only 14% uf the population has access to piped wter, combined with unsatisfactory breastfeeding and weaning practices, accounted for the predominance of malnutrition, diarrhea, and acute respiratory infections among the leading causes of death of infants under one year of age. 8. Results of the 1991 LSMS, information on fertility, the health status of the population, food consumption patterns and environmental conditions, indicate the presence in Morocco of micronutrient deficiencies which require urgent attention. High fertility, especially in rural areas, and the cereal- based diet contribute to iron deficiency anemia, a condition which affects an estimated 30 to 40 of the total population. Half the Moroccan population lives in provinces where environmental conditions and dietary patterns predispose the population to iodine deficiency and goiter. A 1990 survey in the province of Azilal found goiter prevalence rates of 60W among school children and adults. Both anemia and goiter have deleterious effects on physical and mental development during infancy and childhood and contribute to poor reproductive performance and reduced labor productivity. Iodine deficie..cy is recognized as the most significant cause of mental retardation in the world. Both of these conditions can be prevented or treated simply and inexpensively; high cost- benefit ratios have been demonstrated in countries which have addressed these problems. Vitamin D deficiency which is deleterious to the development of bone tissue, was recognized as a public health problem in 1971. There is no current data available on this problem, especially in rural areas where its persistence is more likely. While Vitamin A deficiency may not be a major problem in Morocco, its important contribution to the health and well-being of children would justify a review of the Vitamin A status of high risk population groups.  - iv - Foodf and Nut;rition Policifes andf ProgLratms 9. Government efforts to ensure the availability of adequate and affordable food supplies and safeguard the nutritional status of the population have included general tood price subsidies, compensatoiy feeding programs, and health and nutrition interventions which focus primarily on pregnant women and preschool children. 10. Food nrice subsidies, which were used by the Moroccan government to reduce the impact of economic difficulties aiid more recentlv, of the structural adjustment program, are being phased out. They represented an unsustainable 3% of GDP or 11* of the governmert rucurrent budget in the early 1980s, but provided only 16% of their benefits to the :>0% of the population in the lowest income groups. While their elimination could not be disputed on efficiency grounds, it was expected that this would result in the equivalent of a 20% reduction in income for the 3.5 m.illion poorest households. Further analysis of the 1990/91 LSMS data may provide more insghts into the effect of the reduction in food price subsidies or. the income and consumption patterns of the lowest income groups. In 1991, only .gar, edible oils and one quality of flour were still being subsidized at a cost of less than 2% of government recurrent expenditures per annum. Though the quality of flour selected was intended to target the subsidy towards low income populations, there is general agreement that the system is not working as intended. No other efforts have been made to identify commodities which are corauuned primarily by low income groups or to measure the potential benefits of additional targeted food price subsidies. 11. Comoensatorv feeding proarams increased significantly in the 1970s and 1980s, as a means of compensating for the phase out of the food price subsidies. They fell short of the goals established as part of the Medium-term Agricultural Sector Adjustment Program which called for an increase in the coverage of the existirAg programs from 1.9 million beneficiairies to 3.5 million by 1991. These programs were targeted to the poor through a variety of training and employment programs ane two mwternal and child health programs and were relatively expensive at $20 to $65 per beneficiary. They provided the equivalent of an income supplement of less than ten percent for the lowest income groups when program benefits were at their peak. As these programs have phased out, the quantity of food distributed has been reduced rather than tie number of beneficiaries and the result is a per capita benefit which has declined from an equivalent of 510 calories to about 125 calories per day. 12. Haalt:i and nutrition interventions can be characterized by the comprehensiveness and uneveness of their coverage. They include the provision of potable water, sanitation, health and nutrition education, MCH/FP programs, iron supplementation, promotion of breastfe' Ring, and immunizations. The Maternal and Child Health (MCH) program of the Ministry of Health is the only one to give preferential access to the individuals who have the highest priority from a nutritional standpoint. Its nutrition interventions are targeted primarily to infants under five years of age and pregnant women. Only a fraction of the population at risk is reached by the traditional maternal and child health programs. In contrast, an annual campaign to immunize children under five years of age and women of reproductive age has achieved a coverage rate of better than 90* of children under five. The family planning program has also expanded  v rapidly during the past decade with the result that the contraceptive prevalence rate is over 40%. Nevertheless, fertility is still twice as high in rural areas as in urban areas. High fertility and closely spaced pregnancies represent important nutritional risks for mothers anci their children. Recommendations 13. *Iorocco' s national development policy must incorporate a broad view of food and nutrition if the nutritional needs of the population, and in particular of economically or biologically vulnerable groups, are to be satisfied. Food and nutriticn concerne have been addressed through a variety of programs which have included the stimulation of agricultural production and income growth through general economic development, improvements in housing conditions and the provision of safe water and sanitation, and education. More attention needs to be given to the -elationship between policy development and pi.)gram design, execution, cost, to the coordination between institutions involved in addressing food and nutrition problems, and to the periodic review and evaluation of these policies and programs to ensure their relevance, quality and sustainability. 14. Morocco' s nutrition problems no longer appear to stem from widespread shortages of food, even during years when domestic production has been substantially reduced by drought. The Moroccan culinary tradition is rich and varied, and needs very few modifications to provide a nutritionally adequate diet for all age grc'ps. The distribution of food is uneven, however, and the adequacy of the food consumed should be monitored more closely to ensure that aggregated data does not mask inadequate intake by small children, women, and the lowest income households. The statistical validity of surveys should be assessed regularly to ensure that changes in the size and distribution of the population are reflected. 15. The development of a comprehensive food and nutrition &o.rategy for Morocco is unlikely to require the creation of new institutions; there are already several ministries, university faculties and institutes which have long experience in dealing with food and nutrition problems, policies and programs. Additional resources may be required to improve and expand the coverage of exiLting programs, and to plan and implement the interventions which have not yet become a part of Morocco's strategy to *.ncrease food security and reduce malnutrition. While international assistance may be needed to support these programs, it must be considered a complement to national efforts and should be closely linked to the country commitment. Without a strong commitment from the government, the success of these policies and programs cannot be assured. 16. There is a series of measures which have the potential to ensure adequate levels of consumption and improve the nutritional status of the population, in a manner which is both cost-effective and sustainable: a) Gain a more comnlete understandinQ of the situation - Ths living conditions, food consumption patterns, nutritional adecuacy of the diet and principal risk factors of the most vulnerable population groups need to be defined more precisely so that social services, including food  - vi - and nutrition, primary education, health care, and family planning and water and sanitation programs can be targeted to the highest risk groups. - The cost, benofits and targeting mechanisms of the ongoing programs, their quality, relevance, cost-effectiveness, and sustainability need to be evaluated in order to guide the design of the nexli generation of food and nutrition policies and programs. - The economic and nutritional impact at the household level of the replacement of general food price subsidies by compensatory food supplementation programs has not been measured. The nutritional effect of consume-^ shifts to coarser grain cereals as the cost of more refined flours rises should be monitored as the protein quality of the diet may deteriorate dangerously when people eat only one coarse grain. Higher sugar prices may also lead some co reduce their intake of other more nutritious foods as food habits tend to persist and consumers may sacrifice total calorie intake in order to maintain dietary patterns. The nutritional impact of shifts between subsidized commodities and compensatory food supplementation needs further analysis: will depend on resource allocation strategies within the household and the net consumption effects for the nutritionally at risk members of the household. b) Formulate a coordinated nutrition strateav - Tn the context of a national multi-sectoral strategy. criteria for identification of nutritionally vulnerable groups could be established at the national level, and target populations identified and quantified at the prov4:ncial level where most programs are implemented. The target population at the national level would include women of reproductive age, children under five years of age, and low income population groups from other age cohorts. The effective taraeting of social programs is essential to contain costs and ensure that limited resources benefit the most needy segments of the population. costs. Studies have shown that targeted prugrams have more progressive incidence than general food price subsidies and are even slightly more progressive thar. primary education and health care. The cost of targeting is a minor share of administrative costs for most programs, and greatly increases the share of total program resources delivered to the poor. A variety of targeting methods, their advantages, disadvantages, circumstances under which each one is appropriate, and the information required to use each targeting mechanism, are discussed in this report (see Para. 7.14).  - vii- c) Concentrate resources on a well-dafired series of interventions which could include the fogLlo_ngq: Because of the links between fertility, morbidity, mor:ality and nutritional staLus, the nurritional rpauirementsof women of reproductive age should be given higher priority. The ongoing programs should be strengthened and their coverage expanded so that all women have access ro these services. Al1 MCH/FP programs should promote appropriate breastfeeding and weaninq practices and encourage the spacing of pregnancies, nutrition supp,lements inc3uding iron and iodine as needed, prenatal care, attended deliveries, and family planning. - The micronutrient deficienciefl of iron and iodine should receive official recognition as nutrition problems which merit priority attent_on at the national, regional, provincial, and community level. 2olic_es and programs should be developed to reduce the prevalence of micronutrient deficiencies and in particular, goiter (iodine deficiency) and iron deficiency anemia, which have already been identified as problems whira affect a significant proportion of the populatS.on. The surveys and studies L.>.ng carried out with Japanese grant financing should provide information which can be used by decision-makers to develop policieg and programs related to fortification and/or supplementation. - Growth monitoring, nutrition supplementation and vitamin and mineral supplements as needed should be made available to all children under four years of age in conjunction with the ongoing immunization and diarrheal disease control programs. - Nutrition education should be considered a topic of interest to everyone, for it encompasses not only the nutritional requirements of infants, adolescents, and women during pregnancy and -:reastfeeding; but also iron and iodine micronutrient deficiencies which affec) -.ental development, reproductive health and labor productivity; food safety and hygiene; and the effects of smoking and alo,ohol consumption on health and nutrition status, especially during pregnancy, iniddle age, and beyond. - The School feeding orocrams of the Ministry of Education which have a strong positive impact on school enrollment may not always benefit the most vulnerable children, because of the geographical location of schools with canteens, the low enrollment level of rural children and the age group of those enrolled. The inability of the school system to construct a canteen for every school in the country should not prevent the consideration of alternative means of providing a nutritional supplement to low inc=me school children. The feasibility of providing nutritional supplements to younger children at pre- school level could also be explored. Schools in low income areas should receive priority.  KINGDOM OF MOROCCO NUTRITION AND NATIONAL DEVELOPMENT ISSUES AND OPTIONS I. Nutrition_nd Development in Morocco 1.01 Economic growth and development over the course of the past three decades have reduced the severity of problems associated with food insecurity and malautrition in M4orocco. Per capita incomes end life expectancy have incrfdsed and the incidence of poverty and illiteracy has been reduced. Although malnutrition linked to chronically inadequate food int&!Ze and repeated episodes of illness has declined, some population groups remain at risk, particularly pregnant women, who are more sueceptible to miscarriage and the complications of pregnancy and childbirth when they are malnourished, children under five years of age, and those who occupy the lowest rungs of the socioeconomic ladder in urban and rural areas. Malnourished children are more likely to die -.. infancy, to suffer from physical and mental growth retardation as well as more frequent and more severe illness, to perform worse in schocl, and to achieve lower levels of productivity on the job as adults. Malnutrition is closely linked to poverty, disease, and ignorance about nutritional requirements and the means to satisfy them. The impact of malnutrition on national development has been well established, and yet because of the multisectoral nature of its causes and consequences, malnutrition has been the concerr- of everyone and the responsibility of no one. 1.02 IivirAg conditions in Morocco have improved substantially during the p,st twenty years; GNP per capita has increased from $260 in 1971 to $900 in 1990 despite a rate of population growth which averaged between 2.5 and 3.0* per annum. Life expectancy has risen from 50 to 63 years and the infant mortality rate has declined from 145/1000 live births to 57.4/1000 in 1992. However, life expectancy is still ten years lower than in tho industrialized countries and infant mortality remains high. The national average of 57/1000 live births masks wide regional diaparities from a low of about 43/1000 live births in Rabat to 198/1000 in Guelmir,e. 1.03 One of the principal underlying causes of malnutrition is poverty. As a result of long term improvements in the economic situation, the incidence of poverty declined in Morocco from 42%s in 1972 to 301 in 1985, although the &bsolute number of poor, about 6.5 million, remained the same because of rapid population growth. According to the 1984-85 National Consumption Survey, peop.e whose annual per capita expenditures fell below 1966 Dirhams in urban areas and below 1760 Dirhams in rural areas were classified as poor. A sub-group of the poor, the "ultra-poor", 3.4 million people, spent only 1519 Dirhams per capita in urban areas and 1473 Dirhams per capita in rural areas (See Table 1).  -2- Table 1 Expenditures of the Poor in Morocco DH/person/year (in constant 1985 Dirhams) Poor Ultra-Poor Poor Ultra-Poor 1985 1985 1991 1991 Urban 1519 1966 2725 2106 Rural 1760 1473 2439 2042 Exchange Rates: 1985, US$1 = 9.47 Dhs. 1991, US$1 = 8.5 Dhs. Source: Survey; 1991 Liv:ng Standards Measurement Survey, Ministry of Planning 1.04 The preliminary results of the 1991 Living Standards Measurement Survey indicated that, deflating 1991 expenditures to constant 1985 Dirhams, the poor population, defined as individuals whose per capita expenditures were below 2674 Dirhams (US $ 315) in urban areas and 2439 Dirhams (US $ 287) in rural areas, decreased significantly, to about 4.4 million people, or 17% of the total population. However, consumption levels below US$1000 per capita were reported by 901 of the population in 1991, and over ten million people, 35% of the population in rural areas and 7% of the urban population, reported consumption levels below $350 per capita per year, which was defined as the global poverty level in the 1990 World Development Report. Further analysis of the survey data and comparison with the results of the 1984/85 survey indicate that poverty rates may be even lower (See Table 2). Table 2 Poverty Rates in Morocco: 1984/85 and 1990/91 (Low and High Estimates) 1984/85 1990/91 Urban low 9.0% 2.8% high 17.3% 7.6% Rural low 22.2% 10.7% high 32.6% 18.0% Total low 16.5% 7.0% * high 26.0% 13.1% ** * Indicates approximately 1.8 million poor ** Indicates approximately 3.4 million poor Source: Calculations of a World Bank mission based on results of the National Consumption Survey of 1984/85 and the Living Standards Measurement Survey of 1990/91, Ministry of Plarning  -3- 1.05 The review of the 1984/85 data and comparison with the results of the 1990/91 LSMS has attempted to ensure the consistency of data from the two surveys with respect to the level of living standards in all sectors and regions and across time. A "cost of living" comparison method was applied with a market basket of foods which would meet caloric requirements costed at local prices. An allowance for non-food items was estimated based on the expenditure patterns of the poor. This was added to the food allowance to establish a poverty line. The data should be regarded with caution for several reasons. The size of the sample from the two surveys was very different - 14,500 households in 1984/85 and 3,500 households in 1990/91. The 1984/85 survey occurred in the midst of a period of prolonged drought, while 1990/91 was a good agricultural year. Other survey procedures varied as well; the 1984/85 survey included information on the quantity of food consumed as well as its monetary value, while the 1990/91 survey gathered information on expenditures for food, but not on the quantity consumed. One 7 day recall period was used in 1984/85; two 7 day periods were used in 1990/91. In summary, expenditures on food are likely to have been underestimated in 1984/85 and would therefore suggest a pronounced increase in expenditures in 1990/91, when expenditures were measured more precisely. This is expressed by a mean level of expenditures which is 10* below that expected in 1984/85, and 10% above that expected in 1990/91 (See Table 3). Table 3 Average Consumption Levels Based on Data from National Accounts and Surveys (in current Dirhams) 1984/85 1990/91 Average Per Capita Private Consumption: 3830 6384 (National Accounts) Average Per Capita Consumption: 3572 6780 (Surveys) Source: World Bank calculations based on Government of Morocco data. 1.06 The characteristics of the poor, who are one of the largest groups at nutritional risk, were described in "Reaching the Disadvantaged: Social Expenditure Priorities for the 1990s", Report No. 7903-NOR, based on information from the 1984-85 Household Consumption Survey. Poor families are larger than average; seventy percent of poor households have more than the mean national average of five members. Sixty-five percent of the poor are rural, although only 55% of the population live in rural areas. Rural households tend to be larger, with 7.4 members, than urban households, which have an average of 6.5 members. The poor are less likely to be educated; 73% of poor urban household heads and 85* of poor rural household heads have had no education. In 1991, only 13% of rural women and just over 50% of urban women were literate. Education is closely associated with fertility, and since uneducated women have twice as many children  4- as educated women, poor families are more likely to have larger numbers of children and relatively fewer wage earners. High fertility and closely spaced pregnancies add to the nutritional stress of the low income mother and her children. Poverty is also associated with land ownership; in rural areas, 48* of landless families are poor while only 28W of families with land are poor. The poor are less likely to be able to afford to grow or purchase food which will satisfy their nutritional requirements. 1.07 Reductions in the rate of poverty should be considered an essential element of any strategy to eradicate malnutrition. However, reductions in poverty will not automatically eliminate nutrition problems. Nutrition problems will continue to arise when there are wide variations in th- seasonal and regional availability of nutritious foods, when the intrahousehold distribution of food does not satisfy the nutritional requirements of all members of the household, when the family is unaware of the special nutritional needs of small children and pregnant women, when breastfeeding declines and is replaced by cereal, milk or formula preparations which are diluted or prepared under conditions which are unhygienic, and when general sanitary conditions are unsatisfactory. 1.08 The profile of the lowest income groups in Morocco which is now being prepared is expected to define more precisely the economic circumstances and living conditions of these groups, their consumption patterns, use of education and health services, access to and use of other social welfare programs. It is only by developing a more complete understanding of the living conditions of the least favored members of society that programs can be designed to improve their circumstances. A conceptual framework which has been developed to inform food and nutrition policy development proposes that government intervention focus on improving the ability of households to acquire food and modify the household's food acquisition behavior in order to eliminate negative and enhance positive effects (See Figure 1). Adequate food supplies must be matched by household incomes, household behaviors which are consistent with good health and hygiene practices, sanitary food handling, storage and preparation, child care and feeding patterns which protect children and promote their growth, and food utilization which ensures that the nutritional requirements of every member of the household will be satisfied.  FIGURE 1 A CONCEMAL FRAMORK FOR ANALYZING THE FOOD CONSUMPTION AND NUTRITION EFFECTS OF GOVERNM POLICI2S PRINCIPAL FACTORS ISSUES INFLUENCING PRINCIPAL FACTORS DETERNINING NUTRIT1ONAL STATUS PROGRAMS AND POLICIES INFLUENCING THE PRINCIPAL FACTORS I food prodection ________________________________________ Risearch and technological chonges in food and nonfood production. Food distribution (plce, time) Food valtebllty IRural development schemes International trade and aid National, Regional and iocal .nput and output price policies Processing and nonfood dewands Resource-owrership polfices 1 Changes In rural instftutfons Foneign trade and ifd policies Other policies affecting area utilization and rields 1 ncoe. Prfees Ability to obtain Income in kind avallable food Own production (household) Income-generating poticies Income-tragwfer prograum and policies Food-transfer programs and policles Food price potlcies with or without expticit subsidies Intrahousehold food distribution Food supply and demand policies with price effects Outside influences Programs and pollcies affecting production for home consuiptfon Perceived food needs Desire to obtaln Policies and progress affecting the cost of nonfoods that compete un Percelved nutritional needs available food for the household budget. Past consumption, traditions, and (household) social culturat, nd religious factors Policies and programs affecting lntrahousehold distribution of control over incomes and spending r Utilization of obtained Prowotion advertising Intrahousehold food distribution food to meet nutritional needs Policfes and programs affecting the range of spending opportunities Child care (household and individual) perceived by the household Intrahousehold food processing Food characteristics & conposition Time constraints Nutrition edxcation -___________________ _ __Health of the Indfvda Waterlsanitation Program to suppty micrenutrients Child care and breast-feeding programs Food fortification Programs and policies regulating formulated foods Prior nutritional status ODarrhea Pubi c health progras| Infectious diseases Nutritional Status Intesrated nutrition and health program Parasites V(ndivfdual) Water Improvement and sanitary program Maternal nutritional status Disease prevention and cure Sources EIleen Kennedy and Per Pinstrup-Andersen, Nutritfon Related Policies and Prouran: Past Performances and Research Needs. (Washinton, D.C.s (FPR), February 19E3).  II. Food Production 2.01 Agriculture plays a major role in the Moroccan economy. In 1991, it accounted for about 19* of GDP, provided 40* of employment and about 30* of export earnings. The total of foods produced and imported provide food supplies which would be sufficient to meet the nutritional requirements of the entire population if they were equitably available and evenly distributed. Historically, the correlation between staple food production and consumption has been very high, .98, in Morocco. Cereals, including barley and soft and hard wheats, are the principal agricultural products (they covered, on average, 62W of the cultivated land during 1984 to 1989) and the principal source of energy for the majority of the Moroccan population. Overall, total cereal production increased at an average rate of 16% per year between 1980 and 1988 despite the 23% reduction in overall agricultural production during the drought years of the early eighties, 1985 and 1987. Rapid growth of agricultural production caused food imports to decline during this period from 4% of GDP in 1985 to 2.3% in 1988. Fish, processed foods, including canned fruits, vegetables, fish and juices, have increased their share of agricultural export earnings from 16* in 1972 to 47% in 1988. 2.02 Irrigated and rainfed areas. Irrigated land produces more than 60% of agricultural exports, almost all citrus fruits and vegetables, 80* of sugar, and S0% of milk production. During the last two decades, more than half of public investments in agriculture benefitted the irrigated areas although 75% of the rural population lived in rainfed areas. The rainfed sector produces the bulk of cereals and pulses. Its performance is heavily dependent on annual rainfall, which fluctuates considerably from year to year, and the use of traditional technologies, many of which are outmoded. 2.03 The good performance of the agricultural sector during the 1980s is attributed to favorable weather conditions and the impact of policy reforms initiated in 1984. Their key objectives were to: (a) reallocate public investments from irrigated to rainfed areas and to high return investments; (b) rationalize agricultural support activities and improve cost-recovery; (c) reduce price controls and subsidies and redirect incentives towards activities for which Morocco had a comparative advantage; and (d) strengthen the institutional capacity for agricultural policy planning and analysis. Most of the objectives of the reform program were achieved. Between 1985 and 1990, quantitative restrictions on imports were eliminated and replaced with tariffs on all products with the exception of soft wheat, sugar and oilseeds; for these commodities a system of reference prices based on a moving average of world prices was established. 2.04 Since 1987 only these three commodities have been subsidized. The subsidy on soft wheat flour represents more than half of total food subsidies. However, much of the cost of the subsidies is covered by a tax on imports of soft wheat. The subsidized wheat flour is a high extraction flour, and an inferior good (rich households purchase relatively less). The production of this flour is controlled by quotas, with a limited quantity allocated to the mill in each region, and the resulting flour is distributed under the control of the regional  - 7 - authorities. Some leakages seem to occur as the subsidy is appropriated by the food industry, but overall it is generally self-targeted to poor consumers. The subsidy on aranulated sugar is important. Moroccans consume more than 30 kgs of sugar per capita, while the average in the world is 21 kgs and the average in developing countries is 12 kgs. However, the targeting of this subsidy is dubious. The granulated sugar, which is subsidized, is mainly consumed in town, while most rural people prefer the more traditional sugar loaf, which is not subsidized. The system of subsidization of edible oil is complex. Although olive oil is not subsidized, the Government intervenes at various stages in the production and marketing of grain oil. The average rate of subsidization changes from year to year, depending on world market prices. 2.05 Agricultural production occupies 40* of Morocco's labor force and is largely dependent on illiterate workers of both sexes. Women in rural areas have far higher labor force partic4pation rates than those in urban areas primarily because of their contribution to family-centered agricultural activities; a survey in 1987 revealed that 40.9* of women in rural areas were economically active as compared to 23.5% of urban women, and according to the 1991 LSMS, 9% of rural households are headed by women. Close to forty percent of women who work in rural areas are employed in agriculture, primarily in crop and animal production. In 1988, 82* of agriculture sector employees of both sexes were estimated to be illiterate and by 1991, only 58% of boys and 30% of girls 7-14 years old were enrolled in primary school in rural areas. The application of innovative methods and technological advances in agriculture production and food processing will be seriously constrained by the continuing high rates of male and female illiteracy and it will be less likely that the poor rural population will benefit from these advances. 2.06 There are numerous linkages between agriculture and nutrition, as illustrated in Figure 1. Increases in agricultural production will not automatically lead to improvements in nutrition status. Even when incomes rise, the source and periodicity of the income, control over expenditures, knowledge and attitudes which determine food consumption patterns will all influence the impact on the family's nutrition status of changes in agricultural production patterns or income. In the rural areas of Morocco, the vast majority of the poor as well as many of the non poor population depend either directly or indirectly on rainfed agriculture. The benefits which accrue to these groups when agricultural production increases are determined to a large extent by improvements in rainfed agriculture. There is no disaggregated information on agricultural production and living conditions in rainfed areas. Efforts are being made at the national level to improve the accuracy and completeness of data on agricultural production. This should be combined with data on the socioeconomic characteristics of the poor so that agricultural extension programs can be designed to respond to the needs of the poor and targeted to ensure their participation. 2.07 The National Agriculture Credit Bank attempts to target some benefits to low income farmers through their regional offices, where information on credit and local growing conditions is more readily available. During the 1992-93 drought, loans were being rescheduled, water for human and livestock consumption and animal fodder were trucked into areas which were severely affected, and a calamity fund and crop insurance schemes was being developed. Credit schemes for  women have been introduced and will also be extended beyond their initial pilot areas to several additional provinces in the High and Middle Atlas.  - 9 - III. Food Consumotion 3.01 The per capita daily supply of calories increased from 2066 in 1965 or 90W of theoretical requirement, to 2820 in 1988, which is about 1201 of requirement. Thi3 is generally considered the amount needed to meet 1001 of energy requirements after allowances are made for storage losses and maldistribution. The level of consumption is directly correlated with income (See Table 4). The average per capita consumption for the lowest quartile of the population of 1542 calories translates to an adult equivalent of about 2000 calories, which is inadequate, but not alarmingly low. Table 4 Income and Food Consumption Levels in Morocco - 1985 Income Group Income Per Capita Food Consumption (Dirhams) Per Capita (Calories) Quartile 1 1681 1542 Quartile 2 2760 2214 Quartile 3 4178 2506 Quartile 4 10470 3012 Average 4565 2287 Source: National Consumption Survey, 1985. 3.02 Between 1960 and 1991, there have been some changes in the equality of income distribution as measured by expenditure levels (See Figure 2). In 1984-85, the poorest 201 of the population accounted for 9.81 of total consumption, the middle 601 of the population for 511, and the richest 201 for 39.41 of consumption. The 101 of the population which is most affluent consumed 251 of all goods and services in 1991. The ratio of urban to rural household expenditures was 1.43 for total expenditures and 1.30 for food in 1985 and 2.0 for total expenditures and 1.5 for food in 1991. The 1984-85 survey revealed large variations in expenditures according to family size, educational level of the head of household, and employment group, and relatively smaller differences between urban and rural households when these other variables were held cxnstant. In 1984-85, small families, those whose head of household had been educated beyond secondary school, and those who were in the highest employment classification enjoyed consumption levels which were three to six times higher on average than families which had nine or more members, a head of household with no education or one who was classified as an unskilled or agricultural worker. The preliminary data from the 1991 survey on average expenditure levels, which are shown in Tables Sa, Sb, and Sc, suggest that there has been little change in this pattern since 1985.  - 10 - Figure 2 EQUALITY OF HOUSEHOLDS INCOME DISTRIBUTION IN URBAN AND RURAL AREAS OF MOROCCO Cural (59/60) of hamuseio -| urban (59/60) e;ZSco 100W X1-- rural (70/71) urban (70/71) 44together (84/85) .0. .- .. . Total~~~~~~~a 6 90. .3 ~4*.. -. z, ....: 1 401 - ,/- 971014 . 11 2~V 0 440 60 80 100 l cmaLes I et haueo3da .. *~~~~~~~~14 GIC0SFTICIEBTS ; ~~~~~~~~~Total 1959. 0:35 Urban Rural 1985 0.41 0.36 .1991unob *) 0.38 0.32 . * . . , - .: Sounoas NataImal !useaIA coumptiLa suavqs 1959/50. 1970/7 190lo/u, ma the L.Lvlg staniauds hSSsuZat Sae7*, 19921. Dlzectoratoe c St-abtlastic. Miabq oet PLu. Womca.  - 11 - Table 5a HOUSEHOLD EXPENDITURE SUMMARY BY INCOME DECILE PER CAPITA TOTAL POPULATION in DH 1990/91 Income Value Share of Anrual Expenditures Household Size of Decile to'el average on food household expenditures expfnditure in DH in X in DH In X in X 1 2 306 2,75 t 859 60,00 7,42 7.69 2 2 934 3,87 2 626 57,40 7.86 7,24 3 3 529 4,77 3 226 58,12 8,02 7,11 4 4 177 5,64 3 828 55,56 8,78 6,48 5 5 064 6,76 4 594 54,81 10,02 5,67 6 6 001 8,46 5 567 52,00 9,56 6,14 7 7 303 9,45 6 594 49,89 10,76 5,14 8 9 062 12,08 8 185 47,86 10,92 5,21 9 12 438 15,42 10 484 41,05 11,22 5.06 10 30,80 20 895 35,06 15,44 3,69 GINI Coefficient - 0,393 Source: Living Standards Measurement Survey, 1991. Directorate of Statistics, Ninistry of Planning, Morocco  12 - Table 5b HOUSEHOLD EXPENDITURE SUMMARY BY INCOME DECILE PER CAPITA AND ACCORDING TO RESIDENCE URBAN AREA in DH 1990/91 Income Value Share of Annual Expenditures Household Size of Decile total average on food household expenditures expenditure in 0 in X InX in X 1 3 047 2,56 2 364 52,86 7,93 6,59 2 4 127 4,00 3 677 50,52 8,61 6,08 3 5 350 5.14 4 729 49,77 9,63 5,44 4 6 123 6,51 5 764 49,94 8,30 6,56 5 7 074 6.87 6 600 46,52 9.47 S,29 6 8 394 8.71 7 854 44,71 9,35 5,72 7 9 764 9,52 9 051 44;21 10.09 5,03 8 11 90? 11,76 10 795 38,39 10,02 5,24 9 17 130 15,70 14 444 39,47 12,11 4,33 10 29,23 27 165 31,18 14,49 3,58 GINI Coefficient - 0,377 Source: Living Standards Heasuremnt Survey. 1991. Directorate of Statfstfcs, Ninistry of Planning, Morocco  * 13 - Table 5c HOUSEHOLD EXPENDITURE SUNHARY BY DECILE PER CAPITA AND ACCORDING TO RESIDENCE RURAL ARE in DH 1990/91 Income Value Share of Annual Expenditures Household Size of Decile total average on food household expenditures expenditure in DR In X in DH In X ln X 1 2 011 3,65 1 679 60,61 7,83 7,93 2 2 501 4,93 2 282 60,80 8,05 7,67 3 2 948 5,96 2 748 58.74 8,10 7,65 4 3 330 6,74 3 130 61.00 8,29 7,42 5 3 735 7,69 3 528 57,74 8,62 7,24 6 8 394 8,64 4 029 58,7n 9,39. 6,53 7 5 073 10,25 4 704 56,75 11.10 5,61 8 6 161 11.99 5 590 54,01 10,61 5,78 9 8 158 15,17 7 017 54,96 12,54 4,93 10 24,97 11 549 46.84 15,47 3,99 GINI Coefficient - 0,312 Source: Living Standards Measurement Survey, 1991. Directorate of Statistics, Ministry of Planning, Morocco  - 14 - 3.03 Per capita expenditures on food as a proportion of all household expenditures have declined considerably in the past twenty years. According to the 1971-72 consumption survey, 80W of the household expenditures of the poorest third of the population was spent on food. Xn 1984-85, per capita expenditures on food in urban areas ranged from 55.6V of total expenditures for the lowest income group to 35% for the highest income group. Low income rural households spent over 60W on food. In 1991, expenditures on food ranged from 54.5W of total expenditures in rural households to 37.8% in the large citi.es (See Table 6). The lowest income decile urban and rural households spent about 60* of the budget on food. Table 6 Average Anrual Expenditures Per Capita According to Residence and Category of Expenditure 1990-91 (*) (in Current Dirhams) Place of Residence Category of Large other Urban Rural Total Goads and Services Cities Cities Food & Drinks 3 803 3 063 3 718 2 527 3 085 (37.8) (44.4) (40.3) (54.5) (45.5) CLothes 643 488 577 272 415 t 6.4) C 6.0) ( 6.3) ( 5.9) C 6.1) Housing and Energy 1 872 1 484 1 707 711 1 178 (18.6) (18.3) (18.5) (15.4) (17.4) Household Goods 451 377 419 181 293 ( 4.5) ( 4.7) ( 4.6) ( 3.4) ( 4.3) Health and hygiene 806 618 726 212 453 ( 8.0) ( 7.6) ( 7.9) ( 4.6) ( 6.7) Transportation and 751 407 605 218 399 Communication ( 7.5) ( 5.0) ( 6.6) ( 4.7) ( 5.9) Leisure, Culture 806 511 681 140 394 c 8.0) ( 6.3) ( 7.4) ( 3.0) C 5.8) Other 915 624 791 363 563 ( 9.1) ( 7.7) ( 8.6) ( 7.8) ( 8.3) Total 10 048 8112 9224 4623 6 780 (100.0) (100.0) (100.0) (100.0) (100.0) * Figures in parenthesis correspond to the percentage of expenditures for these items. Source: Preliminary Results of the 1991 Living standards measurement survey.  - 15 - 3.04 Variations in food consumption patterns in Morocco reflect seasonal and geegraphic variations in the availability of various foods as well as differances in incoma levels. Data from the 1970-71 Consumption Survey indicated that variations in the consunption levels of cereals and sugar could be explained almost equally by differences in region or socioeconomic level, while differences in the level of consumption of meat, poultry, milk, cheese, and fruits were more closely linked to differences in income levels. The consumption of fish and shellfish was highly correlated with geographic region. A comparison of food consumption patterns from the 1971/72 and 1984/85 surveys indicates that there were very few substantial changes in the intervening years (See Table 7). The results of the 1991 LSMS have not been analyzed to determine the correlation between income level, geographic area, and food consumption patterns, and since information on the quantities of food consumed was not collected, it will not be possible to compare this aspect of the three surveys. 3.05 There has been little change in the overall quantity and mix of foods consumed in Morocco between 1972 and 1991. The 1971-72 survey revealed that the poorest households could satisfy only 58% of their energy requirements. There was no similar disaggregation of the 1984-85 Survey and data from the 1991 survey will not permit this type of analysis for the reasons stated above. In 1985 sugar consumption in Morocco was among the highest in the world at 75 to 85 grams per capita per day. In contrast, daily per capita consumption of meat, poultry and fish was 82 grams in urban areas and 44. grams in rural areas, which represented a rarginal improvement over consumption levels of 79 grams and 36 grams, respectively, in 1960. Sugar is used primarily in tea, which is drunk throughout the day. Tea is known to inhibit the absorption of iron when it is taken with meals, as is the custom in Morocco. 3.06 The Moroccan diet is dominated by cereals, oils and other fats, and sugar, which together constitute about 83% of the calories consumed in rural areas and about 66% of those consumed in urban areas. Changes in the diet over a 30 year period, from 1960 to 1991, have been modest, although consumption of eggs, fruits and vegetables has increased in urban and rural areas. In 1991, urban households spent 24.6% of the food budget cn meat, eggs, fish and poultry and 18* on cereals, while rural households spent 22* and 24W, respectively, on these foods (See Table 8). Although iron intake in Morocco is theoretically high because of the cereal-based diet, the phytic acid and polyphenols in cereals make the bioavailability of iron low and, as a result, effective iron intake is only half the level needed to maintain good health. The consumption of fish is very low except along the coast, despite the abundance of edible species particularly in coastal waters. This is of particular nutritional significance ir mountainous areas where higher fish consumption would contribute to a reduction in the risk of iodine deficiency. See Annex I for a more detailed description of Moroccan food consumption habits.  - 16 - Table 7 Food Consumption in Morocco Comparison of Selected Food Consumption Data from the 1971-72 and 1984-85 Consumption Surveys (in kilograms) 1971-72 1984-85 Urban Rural Urban Rural Cereals 158 245 169 242 Milk 30 27 43 20 Eggs (Units) 36 14 60 41 Butter, Oils, Fats 16 11 16 13 Heat & Poultry 24 15 20 13 Red Meat Only 18 12 12 7 Fish 7 2 10 3 Vegetables 124 71 139 94 Fruits 47 45 41 25 Sugar, Honey 28 31 27 30 Coffee, Tea, Etc. 9 5 9 6 Source: Consumption surveys, 1971-72 and 1984-85, Government of Morocco  - 17 - 3.07 Analysis of the data from the 1984-85 consumption survey indicated that in rural areas, income elasticity for soft wheat was small and negative, and for hard wheat and barley, it was small and positive. The income elasticity of demand for vegetable oil and sugar was moderately large and positive, which means that as rural household income increased, the consumption of soft wheat flour declined, consumption of hard wheat and barley increased moderately, and the consumption of sugar and oils increased significantly. In urban areas, income elasticity for hard wheat was strongly negative, for barley, sugar and oil it was moderately positive, and for soft wheat it was small but positive, which suggests that as urban ir ome rose, more barley, which has been identified as an inferior good, was consumed. The Moroccan perception of what constitutes an inferior good may vary according to geographic region and socioeconomic status, as it does in many societies, which suggests that more work needs to be done to understand Moroccan consumer behavior, current elasticities of calorie and protein consumption and elasticities for individual foods as well as consumer perceptions of "inferior" and "superior" goods. To date, the income elasticity of farine nationale, the subsidized wheat flour, has not been analyzed, however LSMS data indicate that expenditures for that product are higher among low income groups in both absolute terms and as a percentage of household expenditures on cereal. Table E Average Annual Expenditures on good Per Capita by Product Category and Residence 1990/91 Product Category Urban X Rural X Cereals, grains, bread 661.4 18.0 589.4 24.0 Milk 220.9 6.0 103.0 4.0 Eggs 70.1 2.0 33.1 1.0 oils & fats 286.0 8.0 262.9 11.0 Meat & poultry 816.8 472.5 (Neat + poultry X) 24.6 21.0 Fish 96.8 29.5 Fruits & vegetables 740.0 20.0 396.2 16.0 Sugar & sugar products 182.7 5.0 180.2 7.0 Tea, coffee, other beverages 222.3 6.0 154.7 6.0 Food eaten outside the home 334.6 9.0 122.6 5.0 Spices & condiments 78.7 2.0 75.7 3.0 Other food products 6.9 --- 9.4 ... Total 3717.2 2429.2 Source: Preliminary Results of the 1990 LSNS - Morocco  -18 - IV. Nutritional Status 4.01 Nutritional status is universally regarded as a primary indicator of well-being. The historic relationship between average adult height and life expectancy has been observed in numerous population groups. Evidence of the associatiora between increasing height at maturity and declining mortality have been traced over a period of more than two hundred years in Western Europe. Data from eight European countries revealed that a 11 increase in adult height was associated with a 51 decrease in crude mortality rates. As much as 401 of the secular decline in mortality rates can be attributed zo improvements in nutritional status, with most of this effect concentrated on infant mortality. 4.02 High levels of infant mortality provide a clear indication of the existence of nutrition problems which often lead to an examination of the other principal determinants of the nutrition status of the population, including the overall availability of food,- income and consumption levels, family size and composition, sanitary conditions, traditional feeding and childrearing practices, health status, and the physical ability to absorb and make use of the nutrients ingested. Experience worldwide has shown that malnutrition is a major contributing factor when infant mortality levels exceed 50/1000 live births, a condition which holds in almost every province and prefecture of Morocco. While reporting is not complete, the data available indicates that infant mortality has declined by 301 since 1972, and the mortality of children under five years of age has fallen by 54*. 4.03 Infant mortality has been reduced in Morocco from 145/1000 live births in 1972 to 73/1000 in 1989 and 57.4/1000 in 1992, however, rates as high as 198/1000 were reported in Guelmine province in the South and in 1989, there were 25 provinces where infant mortality exceeded 100/1000 live births. Two areas of the country appear to have a far more serious problem than the others: the 13 provinces from Figuig to Tan Tan which extend from the northern edge of the Atlas Mountains to the coastal deserts of the South, and the 6 Rif mountain provinces of the Northwest and Center-North, from Tangier to Taza. Stunting, underweight, and morbidity together accounted for 971 of the variance in infant mortality among regions when regional data on morbidity and mortality were regressed against nutritional indicators, with all coefficients significant at or around p=0.0;. Variations in infant mortality are also linked to the age of the mother and the birth interval; mothers under 20 years of age and mothers whose children are born at less than two year intervals experience infant death rates which are twice as high as older mothers who space their pregnancies more than two years apart. 4.04 A survey of infant mortality undertaken by the Ministry of Health in 1989 revealed that 50* of infant deaths occurred within the first 28 days of life. These neonatal deaths were attributed primarily to tetanus, birth injuries, and prematurity, which together accounted for more than 601 of the deaths. There was virtually no difference between urban and rural areas with respect to the major causes of neonatal mortality. Poor maternal nutritional status, and in particular the presence of anemia, iodine deficiency and Vitamin D deficiency during childhood, are linked to poor reproductive performance  - 19 - including an increase in the number of stillbirths in the case of iron and iodine deficiency (See Annex II for a summary of the functional effects of micronutrient deficiencies). The 1987 introduction of a national immunization program for children and the addition of tetanus immunization for women of reproductive age in 1989 when the results of the survey of infant mortality became known are expected to have made a significant contribution to reductions in infant and maternal mortality. 4.05 The Moroccan government has undertaken five national surveys which contain information on the nutritional status of the population. The first National Nutrition Survey was completed in 1972. The National Consumption Survey of 1984-85 was followed by a Demographic and Health Survey in 1987, by a Living Standards Measurement Survey in 1990-91, and by another Demographic and Health Survey in 1992. The Ministry of Health completed an analysis of the causes of infant mortality in 1989 which was based on the 1987 DHS data, and is currently undertaking a national anemia and iodine deficiency survey. These survey instruments vary in the size of the sample, the design and administration of the questionnaire, the methods used to measure r.utritional status and the inclusion of different age cohorts. Any attempt to compare the findings of these surveys must take into account these variations in survey methodology. 4.06 A comparison of the results of the 1987 DHS with similar surveys from other countries revealed that the nutritional status of Moroccan preschool children was poor but not atypical of other countries which are at a similar stage of development (See Table 9). There had been some improvement since 1971 when 351 of urban children and 50* of rural children under four years of age were either moderately or severely malnourished. By 1987, 31.41 of Moroccan children, under the age of five suffered from moderate (281) or severe (31) malnutrition. The prevalence of growth retardation (low height for age) was 19.61 in urban areas and 32.9* in rural areas; one third of all children under three years of age were chronically undernourished or stunted and about 171 were underweight for age. Acute malnutrition affected 4.9% of children in the South, 4.4% in the Center-South and Tensift regions, and chronic malnutrition, low height for age, affected 28.91, 27.21 and 34.41 respectively. Overall, 171 of children were either wasted or stunted or both. The urban-rural differential in the nutritional status of children had not changed significantly since 1971. Fully 75% of malnourished children were found in rural areas, although only 55* of the population lived there. There was no apparent gender difference in malnutrition rates. 4.07 The 1990-91 LSMS included a sample of 3360 households which were drawn from a sampling frame used for post-census surveys in 1983. Anthropometric data (height and weight) were collected to evaluate the nutritional status of boys under 11 years of age and girls under 10 years old. Information on the height and lean body mass of their parents was also collected. A total of 4,715 children were included in the survey analyses, which used the NCHS reference population as a comparator, as in the surveys completed in 1984-85 and 1987. Separate analyses were performed on the data for the 2121 children in the survey population who were under five years of age. A seLies of multivariate analyses was completed in an effort to determine the factors which contribute to the nutritional status of the sample population. Age, gender, economic region,  - 20 - urban/rural residence, incore level, access to water, sanitary conditions, education of the mother and father, and immunization status of the children were the principal variables examined. Although confidence intervals vary because of variations in the size of the subgroups included in each of these analyses, the results appear to be consistent within the LSMS survey data and comparable with the results of the 1984-85 survey, which included a sample of 21,088 children 0 to 9 years of age and a subsample of 9910 children 0 to 4 years of age. The negative correlation between nutritional status and income, educational level, urban/rural residence and sanitary conditions is unchanged since 1985. 4.08 The aggregated data for the two surveys suggest that there has been little change in the nutritional status of children under five years of age in the interval between the 1987 and 1990-91 surveys. These findings are consistent with the preliminary results of the 1992 DHS (see Table 11 a). However, when the 1984 and 1991 data are disaggregated by income group, there appears to have been a significant deterioration in nutritional status (see Table 11 b). The final report of the 1991 LSMS is expected to include further analysis which compares the data from the two surveys. Regardless of the precise results of the most recent surveys, the low nutritional status of Moroccan children is a chronic problem which was documented over twenty years ago and should be addressed whether or not there has been a deterioration between surveys. If there was in fact a significant deterioration in nutritional status between 1985 and 1992, the changes in government policies and programs during the past five years should be reviewed and their impact on the nutritional status of the population evaluated so that policy and program strategies in the future are formulated with a view to improving the situation. 4.09 The 1989 infant mortality survey found that malnutrition associated with diarrhea was the leading cause of death for children from 28 days to five years of age. About one third of infant and child deaths surveyed were caused by some combination of diarrhea and moderate to severe malnutrition. Nevertheless, a comparison of the Moroccan data with findings from other countries indicated that the role of malnutrition was probably understated; two thirds of infant and child deaths are statistically associated with malnutrition in various countries in Africa, Latin America, and Asia. There ,s a strong correlation between age at death and cause of death (P = .0105). Acute and chronic diarrhea appear early in life and are rare after three years.  Table 9 NUTRITIONAL STATUS OF CHILDREN 3-35 MONTHS OF AGE Mean Z-scores and Prevalence of Hoderate-Severe and Severe Undernutrition Demographic and Health Survey, Phase I (1986-1989) Percentage of Children Classified as Having: Moderate-Severe UndernutrItion Cb) Severe Undernutrition (c) Per Capita NuXr CUP Under Under of Country (1989 dollars) Stunting Wastirg weight Stunting Vlasting wefght Children Senegal 650 23.0 5.8 22.0 7.6 0.3 5.3 618 Zimbabwe 650 29.8 1.2 12.6 8.0 0.3 1.5 1496 Egypt 640 30.9 1.1 13.4 12.0 0.1 2.5 1885 NOROCcO 900 23.7 3.7 14.0 7.6 0.7 3.2 Tunfsia 1260 17.9 3.0 10.3 5.4 0.6 1.7 1970 Sri Lanka 430 27.2 11.6 37.3 7.9 0.6 8.3 1962 Ca) Excludes children whose month and year of birth was not recorded by the interviewer, whose weight and/or height were not measured, and those with improbabty high or low masurements. Cb) Children with Z-scores %-2 SD below the International Reference Population Median (i.e. including childrep <-3 SD). Cc) Children with Z-scores <-3 SD below the International Referenoe PopuLation Median. The U.S. National Center for Heatth Statistics growth curves were used for the 1987 survey in Morocco. These have been accepted as a reference standard for preschool children throughout the world. Low weight and height were defined as below -2 standard deviations NCHS. Normally, 2.3X of a welt-nourished poputation would have anthropometric measures fatling below -2 standard deviations of RCHS. Source: mComparat4ve Analysis of the Determinants of Children's Nutritional Status", Sammerfelt, A. Elisabeth. presented at the Demographic snd Health Surveys Wortd Conference, August 5-7, 11, Washingtsn, D.C.  - 22 - Mortality rates were almost twice as high in rural areas as urban (137/1000 compared to 81/1000 ). Unsanitary living conditions are highly correlated with the nutritional status of children under five years of age, according to the data from the DHS of 1987. In Morocco, the type of drinking water available was highly significant (P c0.055) in both bivariate and multivariate analysis, and the length of birth interval, mother's education, number of household possessions, and type of toilet facility were highly significant in either bivariate or multivariate analysis (See Table 10).  Table 10 Statistical Significance of the Relationships of Socioeconomic, Water, Sanitation, and Demographic Variables on the Height-for-Age Z-Score of Children Age 3-35 months: Results of Bivariate and Muttivariate Analyses Demographic and Health Surveys, Phase 1 ( 1986-1989) Place of Mother's Number of Type of Type of Length of Sex of Per Capita residence education possessions drinking water toilet birth child GNP facility interval Bi- Multi 81- Mult i Si- Multi - Multi Si- Multi Si- Multi Bi- Multi 1989 dollars var. var. Var. var. var. var. var. y var. var. , var. var. var. var. var. Senegal ** t . . * . . . 650 Zir=abwe ** ** ** * ** * ** ** ** ** * * 850 Egypt ** ** ** ** ** ** ** .. ** . ** * . 640 Morocco ** . ** * ., * ** ** ** . ** ** .. ., 880 Tunisia ** ** ** ** ** . ** * . 1260 Sri Lanka * , * ** * ** a - * ** * - - 430 ** p <0.0555 * p <0.01 not significant Source: "Comparative Analysis of the Determfnants of Chfidron's Nutrftlonal Status, "Souerfelt, A. Elisabeth, presented at the Demographic ard Health Surveys World Conference, August 5-7, 1991, Washington D.C.  - 24 - Table 11 a Incidence of Malnutrition in Morocco Children 0 - 5 years of age 1987 DHS 1 1991 LSMS 1992 DHS l Weight/ Weight/ Height/ Weight/ Weight/ Height/ Weight/ Weight/ Height/ Age Height Age Age Height Age Age Height Age Urban 8.0 1.9 17.2 8.1 5.5 16.7 3.3 1.8 17.6 Rural 19.7 4.7 29.8 18.7 9.4 34.4 12.0 2.3 32.0 Total 14.0 3.7 23.7 11.9 6.4 23.9 9.0 3.0 23.0 Source: Demographic and Health Survey, 1987, Ministry of Health and Living Standards Measurement Survey, 1990- 1991, Direction of Statistics, Ministry of Planning; preliminary results of the 1992 Demographic and Health Survey, Ministry of Health. Table 11 b Growth Retardation in Moroccan Children By Age, Residence, and Income Level 1984/85 and 1990/91 Income Level Urban Rural Urban Rural .____________ 0-4 5-9 0-4 5-9 0-11 0-11 10 10.9 15.9 26.4 23.6 22.7 33.1 20 15.6 19.2 19.5 23.0 30 9.2 15.4 25.1 21.2 16.4 31.0 40 9.2 15.4 25.8 23.0 50 8.2 14.2 19.5 19.2 13.0 26.1 60 5.0 13.8 23.3 20.3 70 4.6 10.4 15.2 23.0 13.8 25.1 80 5.2 10.6 21.8 18.4 90 3.1 9.3 22.4 18.7 9.3 22.0 100 3.8 6.2 14.7 15.4 Source- 1984/85 Consumption Survey, Direction de la Statistique, Ministry of Economic and Social Affair-. 1992; 1990/91 Living Standards Measurement Survey, Preliminary Results, Direction de la statistique, Ministry of Economic and Social Affairs, 1992.  - 25 - 4.10 Poor sanitary conditions, unsatisfactory breastfeeding and weaning practices accounted for the predominance of malnutrition, diarrhea and acute respiratory infections among the leading causes of death of infants from 28 days to one year of life. The problem was particularly acute in rural areas, where the diet, which is high in cereals, low in other sources of protein, and highly dependent on the seasonal availability of other foods, does not always meet the nutritional requirements of infants and young children. In 1987, weight-for-age deficits of children 0 - 36 months of age were three times as common in rural areas, and deficits in height for age almost twice as frequent as in urban areas. This situation appears to have changed very little by 1991. Small children find it difficult to ingest the unrefined cereals commonly eaten in rural areas in quantities which are sufficient to meet their nutritional needs, and the poor sanitary environment in rural areas, where only 14% of the population has access to piped water, contributes to the high prevalence of diarrhea and other intestinal infections. Weight deficits are often associated with periodic bouts of diarrhea and other infections, while height deficits suggest that the quality of the protein consumed is low even when the total number of calories consumed is adequate. Longitudinal studies have shown that it may take as long as 10 years for a child to recover from a bout of malnutrition suffered in infancy, and then only if conditions are optimal. 4 .11 Malnutrition in Moroccan children is at its highest levels during the weaning period. The prevalence of low weight for age exceeds 23% and low height for age reaches 55% in some rural areas during this period, when most children are weaned from breast milk to other foods which are frequently nutritionally inadequate and contaminated. Weaning is very often abrupt, and may cause psychological as well as physical stress for the weanling child. Exclusive breastfeeding is generally recommended for the first four to six months of an infant's life, followed by the gradual introduction of weaning foods with a high nutrient content. 4.12 According to the preliminary results of the 1992 DHS, the prevalence and duration of breastfeeding has declined during the past five years. 62W of children age 0-3 months are exclusively breastfed. In 1987, Moroccan women breastfed their children for an average of 14.4 months. Liquids other than breast milk were not always excluded during the first four to six months. In urban areas, 90% of women breast-fed during the first 2 months postpartum, in comparison to 96W of rural women. By 6 months, 70W of urban women and 93% of rural women were still breastfeeding, and at the end of the first year of life, 67% of urban women and 91% of rural women continued to breastfeed. In some rural areas, children were exclusively breastfed for as long as twc years, which is almost as undesirable as early weaning because breastmilk alone does not satisfy all of the nutritional requirements of infants beyond six months of age. Only 1% of urban women stopped breastfeeding because of work. The majority of women .n urban areas, 28%, stopped because of insufficient milk, although only 11* of rural women offered that as the reason for stopping. Another 24W in urban areas and 17% in rural areas stopped because the mother was ill, and 21-27% stopped because it was "the normal age to stop". 4.13 Exclusive breastfeeding prolongs the period of infertility after birth and is a widely used form of contraception during the postpartum period.  - 26 - More than a third - 35% - of rural women stopped breast-feeding because they had become pregnant again, an indication of pregnancies which are too closely spaced and therefore detrimental to the health and nutritional status of the mother and her children. The abrupt cessation of breastfeeding because of a new pregnancy is a familiar problem whose consequences for the child are well-known in rural Morocco. Some women call this "the little assassination". It is equally apparent that family planning services have still not achieved adequate coverage of the potential target population in many rural areas, where the fertility rate of 5.7 children per woman is twice as high as in urban areas despite a 28% increase in the contraceptive prevalence rate between 1987 and 1992. In 1987, according to the DHS of that year, rural women were bearing an average of one child more than they desired. 4.14 The 1984-85 Consumption Survey included the collection of anthropometric data for 21,088 children 0 - 9 years of age. The 1991 LSMS collected data on 4,715 children 0 to 11 years of age. As in the rest of the analyses of the survey data, regional rather than provincial aggregates were used. In 1984, income data were disaggregated by decile whereas in 1991, they were diaggregated by quintile. In 1985 and in 1991, children in rural areas tended to have lower weight for age as well as lower height for age for all income groups. According to these analyses, 2.3% of all children of all ages and socioeconomic groups had low weight for height in 1985 and 6.4%s of all children included in the survey had low weight for height in 1991. Height deficits were greater than weight deficits, and were more pronounced in the Northwest, Center and Eastern regions, as well as in all rural areas, an indication that chronic undernutrition was more prevalent in those areas. 4.15 A 1985 comparison of weight for age of children 5 - 9 years by residence and by income group indicated a direct correlation between the type of residence, which was used as a proxy for income group, and nutritional status. Children who lived in rural areas had the highest levels of growth retardation, followed by the children who lived in the bidonvilles in urban areas. The correlation between the overall level of household expenditures and children's nutritional status was stronger in urban areas than in rural areas where other factors such as autoproduction and sanitary conditions may not have been picked up by the survey. There was no apparent correlation between the level of household expenditures and weight for age, which reinforces the idea that other factors play an important role in the nutritional status of children. There was a strong correlation between educational status of the head of household and the nutritional status of the children in both urban and rural areas. 4.16 The causes of widespread growth retardation among Moroccan children in 1985 were not revealed by the consumption survey, but were attributed to poor sanitary conditions rather than dietary deficlts, a hypothesis which appears to have been supported to some extent by the bivariate and multivariate analyses of the 1987 DHS data, although the latter did not gather information on food intake other than breastmilk and weaning foods. The 1991 LSMS did not collect information on dietary intake, therefore it was not possible to make the same assertion based on the information gathered in that survey. The same limitations apply to the 1992 DHS. In 1985, growth retardation seemed to affect boys more than girls in the school age population. The higher level of growth retardation  - 27 - in rural areas suggested living conditions which were less favorable. Children in the highest income groups appeared to have lower weight for age from 5 to 9 years than children in lower income groups, despite their advantage in height. This may reflect the higher caloric content of the high carbohydrate diet of the lower income groups, which may give poor children a slight edge with respect to weight for age. Their lower stature as adults reflects the combined influence of the quality of protein consumed, the level of consumption of animal protein, which increases with income, and morbidity patterns. 4.17 Weight for height and lean body mass were used to examine the nutritional status of Moroccan adolescents and adults at the time of the 1984-85 Consumption Survey and height and lean body mass of the parents of the children included in the 1991 LSMS were analyzed in an effort to identify problems associated with overall energy deficits and/or obesity. These data were compared with data from surveys completed in the United States, Great Britain, and Norway. Adulthood, defined as the age by which linear physical growth had been completed, was determined to be 20 years of age in Morocco. Adolescence was defined as 10 to 20 years of age, although female adolescents in Morocco complete their physical growth at 15 to 17 years of age. Both surveys indicated that there were major deviations from international standards for all age groups and minor variations in height according to socioeconomic indicators, with adolescents from the bidonvilles and rural areas shorter than those in urban areas or from the higher socioeconomic levels. As has been previously noted, average adult height is highly correlated with life expectancy and labor productivity. 4.18 Measurements of adults in all regions and among all socioeconomic groups revealed that weight for height of urban men and women was greater than that of rural men and women, a difference which was more marked among women. The lower weight for height of rural adults may be attributable to the higher levels of physical activity associated with rural lifestyles. It was positively correlated with educational attainment, residence, and with expenditure levels. Low income individuals were thinner than more affluent people, and the majority of cases of obesity were folnd among the upper income urban groups and among urban women. The proportion of the adult population which suffered from chronic energy deficits wad below 2% for all age groups. These data were not disaggregated by income group, educational attainment, or place of residence so it is not possible to identify the specific adult population groups who may be at nutritional risk. 4.19 The 1992 Demographic and Health Survey collected data on the nutritional status of children 0-5 years of age as well as data on fertility, birth intervals, breastfeeding, pre-natal care, attended deliveries, maternal iaortality, knowledge and use of family planning, immunization status of mothers and their children, urban/rural residence, mothers' education and sanitary conditions. The final report, which will be published before the end of 1993, is expected to provide a slightly different perspective on the links between nutrition status and social conditions which should help better design and target interventions in the most cost-effective manner.  - 28 - V. Micronutrient Deficiencies 5.01 Even in the presence of apparently adequate energy intake, micronutrisnt deficiencies can bxist and may have a devastating impact on the health and welfare of the population. The prevalence of micronutrient deficiencies in Morocco may be inferred from data on fertility, morbidity, mort:.lity, and food consumption patterns. Their presence can only be confirmed by surveys which involve individual physical examinations and the analysis of blood or urine samples. In Morocco, tihere is no data available from national surveys but evidence of severe problems which has been found at the local and provincial level will need to be confirmed by the analysis of the results of the 1993 anemia and iodine deficiency survey which is currently being undertaken by the Ministry of Health. The micronutrient deficiencies for which information is already available, include iron deficiency anemia, iodine deficiency, and Vitamin D deficiency. Information on anemia and ilitamin D deficiency has been collected in hospital-based surveys, and that on iodine deficiency is based on a community survey in one province. The findings of these and earlier surveys will be updated in order to determine the current extent of nutritional problems which are associated with micronutrient deficiencies, the populatio. grouips which are affected, and the links to food consumption patterns, infectious and parasitic diseases, or environmental conditions. 5.02 The cereal-based diet and high levels of fertility, especially in rural areas where women bear an average of five or more children as compared to three in urban areas, indicate that iron deficiency anemia is a problem among women of reproductive age and perhaps among small children as well, who may be born with low levels of iron because of the iron deficient status of their mothers. The mother's iron stores during pregnancy affect a child's chances for survival and healthy growth, and the mother's ability to manage the blood loss associated with childbirth. Men are better equipped to withstand low iron intake beca.se of their relatively higher iron stores and no significant losses, while women and children are more likely to have marginal iron stores and develop iron deficiency when intakes of iron and Vitamin C are low. Women are particularly vulnerable to iron deficiency anemia during pregnancy and children are most vulnerable during periods of rapid growth from birth to 3 years of age and during adolescence. 5.03 An intake of about 15 mg. of iron per day will meet nutritional requirements in a western-style diet which includes a significant amount of animal protein. When a diet is cereal-based, as in Morocco, 30 mg. of iron are needed because of the low bioavailability of iron from vegetable sources (see Para. 3.06). In the average middle income country, the diet provides only 21-22 mg of iron per day, which suggests a need for either iron supplementation or iron fortification if nutritional needs are to be m-t. 5.04 A clinic-based survey of children 12 to 36 months of age was conducted in a subur., of Casablanca in 1979 and revealed that 47T of the children examined were anemic which was defined by a hemoglobin level equal to or below  - 29 - 11. (See Annex IV for a definition of micronutrient deficiencies). These were healthy children who had been brought to the health center for a measles immunization. Data on the number of children in the family and the socioeconomic level of the family, measured by housing conditions, rpported meat consumption and the profession of the father indicated a correlation between anemia and lower socioeconomic status. 5.05 Vitamin D deficiency was recognized as a common public health prcZlem in Morocco two decades ago. Vitamin D deficiency is deleterious to the development of bone tissue, and in female children it may retard the development of the pelvic structure to the extent that it impairs the ability to carry a pregnancy to term successfully. Small pelvic proportions can cause complications during childbirth such as obstructed l'bor, which requires delivery by caesarean section. Dietary intake and the customs of swaddling infants and keeping them out of the sun contribute to this problem. Vitamin D-deficiency can be prevented by exposure of the face and limbs to the sun for about ten minutes each day. A Vitamin D deficiency may be related to calcium deficiency because Vitamin D is requixed for calcium absorption. The national nutrition survey of 1970 found 23% of children with one clinical sign of rickets and 4% with two clinical signs. The prevalence of rickets rose to 16% of rural children 22-27 months of age and just over 5% of urban children of the same age group. The only current data on Vitamin D deficiency come from an examination of children seen in the University Hospital Centers of Casablanca and Rabat, where 58/1000 children suffered from clinical symptoms of rickets irn 1968, and only 5/1000 in 1989. There are no recent data from rural areas, where traditional practices are more likely to continue and lower access to health facilities reduce the probability of Vitamin D deficiencies being identified and treated. 5.06 Iodine plays an impo:tant role in the synthesis of the thyroid hormones which stimulate human growth and development. Iodine deficiency causes goiter, enlargement of the thyroid gland, and is associated with spontaneous abortion, higher rates of stillbirths and premature births, neurological problems and deficient psychomotor development, growth retardation and cretiiiism. Iodine deficiency is recognized as the most significant cause of mental retardation in the world. Even relatively mild deficits can have deleterious effects on learning ability and cognitive behavior. Population groups which are deficient in iodine have been found to have I.Q. levels which are 10 - 15 points lower than the general population. Iodine is commonly found in seaweed and seafood, and water and soil. Its level in water and soil depends upon the geological history of the area. In gene-.al, mountainous areas and flood plains have low concentrations of iodine in the soil and water. Iodine deficiency is deleterious to the health of livestock populations as well. Fertility, weight strength and the quality of the wool coat in sheep are all influenced by iodine deficiency. 5.07 Population groups who suffer from the effects of iodine deficiency tend to live in areas where the soLl and water are deficrient in iodine and seafood consumption is low. Goiter was an important public health problem in Central Europe and in the Midwestern United States until the introduction of iodized salt. Reports of iodine deficiency in Morocco date to the period immediately following Independence, when .ae village of Skoura, in Ouarzazate,  - 30 - was identified as a major center of endemic goiter. The percentage of goiters found there reached 59% among bo3,s and 46% among girls. More recently, a prevalence rate of 18% was reported. A small survey in 1988 in the town of Beni Mellal revealed a general prevalence rate of 29*; 84k of the affected population was female. A survey in 1990 in the province of Azilal found prevalence rates as high as 60% among school children and the adult population. In all, at least 27 provinces in Morocco where 50% of the population live have food consumption habits and/or environmental conditions which would predispose the population which lives there to iodine deficiency and goiter (See Table 12). Iodine deficiency disease is generally considered to be endemic if the prevalence of goiter exceeds 10*; when goiter prevalence exceeds 20*, cretinism, a condition marked by physical stunting and mental deficiency, is usually observed. When goiter prevalence exceeds 29%, cretinism can reach 10% (see Annex IV). Iodized salt has reduced the prevalence of goiter in many countries. but in the interior of Morocco, salt is procured from small local mines and there are no centralized processing facilities which handle salt (See Annex V). 5.08 Vitamin A deficiency has long been associated with retarded physical growth and blindness. More recently, its role in the body's immune function has been recognized, and it is considered to be linked with an increased risk of morbidity and mortality among infants and children, particularly during bouts of diarrhea and measles. The seasonal availability of fruits and vegetables is often associated with Vitamin A deficiency, which has also been correlated with periods of increased morbidity, especially from respiratory and diarrheal diseases. There have been no recent efforts to evaluate the Vitamin A status of the Mioroccan population. The only data available dates from the late 1960s, when there was a very low prevalence (1%) of Vitamin A deficiency among children 10-15 months of age which increased to 2% among children 40-4_ months of age. While Vitamin A deficiency has never been considered a major problem in Morocco, its important contribution to the health and well-being of children would justify a review of the Vitamin A status of high risk population groups, particularly in geographic areas or during periods of the year when fruits and vegetables are in short supply.  - 31 - Table 12 Provinces in Morocco with Conditions Characteristic of Regions With Endemic Goiter 1 Population IMR TFR 2 Prevalence of 1988 (in thousands) 1988 1988 uoiter (%) Al Hoceima 355 105 6.5 Azilal 416 124 5.6 603 Beni-meLlal 842 75 6.8 29 BouLemane 148 113 6.6 Chefchaouen 350 141 8.5 Errachidia 481 124 7.5 7 Essaouira 425 139 6.1 Fes 960 91 6.2 16 Figuig 110 105 7.2 GueLmine 155 198 5.9 Ifrane 113 112 5.2 3 Khemisset 456 76 5.1 Khenifra 419 104 5.8 Khouribga 513 66 6.4 Marrakech 1,45$ 131 6.1 Nador 726 60 5.9 Ouarazate 616 128 7.8 50 Oujda 916 66 5.7 Settat 769 64 5.5 Sidi Kacem 580 109 6.3 Tan Tan 55 106 Teounate 589 122 5.8 Taroudant 632 112 7.5 Tata 108 130 6.7 Taza 690 97 7.2 Tetouan 818 97 7.2 1/ In general, mountainous areas and flood plains have soil and water with low levels of iodine. g/ The total fertility rate is for rural areas only. By 1992, the rural TFR had declined from 6.2 to 5.7 I/ Prevalence data from Azilal province are based on a survey completed by the Ministry of Health in 1990. All other prevalence data are from small surveys undertaken before 1990. _  - 32 - VI. Food and Nutrition ProQrams 6.01 Morocco's national development policy must incorporate a broad view of food and nutrition if the nutritional needs of the population, and in particular the needs of economically or biologically vulnerable population groups are to be satisfied. Agricultural development is only one facet of this policy, which should be accompanied by, inter alia, consumption policies and enforceable legislation regarding food safety, food hygiene and food quality. Food and agriculture policies and p::ograms must be combined with social policies and programs which provide a social safety net, nutrition education and short-term targeted interventions which are designed to address problems assc iated with inadequate levels of food intake, and chronic and acute malnutrition. The continuing high levels of fertility and infant mortality, especially in rural areas, combined with marginal changes in food consumption patterns over the past thirty years and the persistence of goiter, anemia and growth faltering among significant numbers of young children suggest that special attention must be given to micronutrient deficiencies, to public understanding of nutritional requirements and to the social, economic and environmental conditions which contribute to the nutritional status of the population. 6.02 The Moroccan government's efforts to address social and poverty concerns through its development strategy were seriously compromised by the economic crisis of the 1980s and the resultant stagnation in the financing of social services during that decade which slowed efforts to extend the admittedly inadequate population coverage of these services. In an effort to stabilize the economy and resume economic expansion, a structural adjustment program, which has been supported by Bank loans since 1983, has addressed issues related to fiscal reform, trade and finance, public enterprise, education, and agriculture. Government macroeconomic policies to reduce deficits, promote fiscal reform and increase the efficiency of production have been accompanied by efforts to improve living standards and enhance the income-earning capacity of the poor. The last in a series of structural adjustment and agriculture sector adjustment loans will be completed during the first half of the 1990s. These loans, which focus primarily on macroeconomic policy reforms, have included measures to ensure the expansion of compensatory feeding programs to offset the impact of the phase out of food price subsidies and, more recently, measures to protect the investment and recurrent budgets of the social sector ministries. The government is now faced with the need to reformulate policies and restructure programs which are intended to alleviate poverty to target them to the most vulnerable population groups in order to control their cost and ensure their sustainability. 6.03 The Moroccan government, with donor assistance, has supported several programs which are intended to increase the supply of affordable food and protect the health and nutrition status of the population (See Table 13). Major investments have been made in the food price subsidy program and in the distribution of food through school feeding programs, informal education, training and employment programs. The Ministry of Health has implemented a series of nutrition programs which have included the delivery of vitamin and iron  - 33 - Table 13 Population Coverage of Food and Nutrition Programs Program' | Target Pop. Beneficiaries Compensatory Feeding Programs J , 1.8-3.4 million2 ' 1,651,750 Compensatory Feeding - Schools 300 - 600,0003 816,000 SMB - Orphanages 35,000 CET - Vocational Training Female Students 125,000 AC - Urban Artinan Coops 50,000 CFP-Trade Schools - Students 96,500 Urban Sanitation Unemployed Poor 93,750 Reforestation Rural Unemployed Poor 62,500 Reforestation Small farmers 75,000 Mountain Reservoirs Rural poor 534,000 MSA - Mothers: 200 -400,0004 150,000 NSA - Children: 280 - 500,0005 300,000 MOH - Children (Actamine) n 130,000 Maternal-Child Health Services - NOR Growth Monitoring 4.0 million 320,000 Vitamin D injections 344,000 Basic Immunizations 2,880,000 Family Planning 5.8 million 2,400,000 Prenatal Care & Attended Delivery 924,0006 582 00 Tetanus Toxoid for MWRA 7 5.8 million 3,126,000 Source: Catholic Relief Services, Morocco; DHS 1992, Preliminary Results, Ministry of Health; Ministry of Education I/ Feeding programs are financed by USAID and Wortd Food Program. MCH programs are financed by a large number of donors including the UN agencies, the World Bank, WHO, USAID and other bilateral donors. 2/ Estimated population in 1992, 26.4 mitlion. Number of poor, based on results of the 1991 LSMS, 7-13X = 1.8-3.4 million. 3/ Children 6-11 years of age = 4.2 mitlion, of which 7-13% are poor. 4/ Married Wonen of Reproductive Age - 5.8 million, of which 2.9 mitLion pregnant or lactating, of which 7-13% poor. 5/ Children 0 - 4 years bf age = 4.0 mitlion, of which 7-13% are poor. 6/ Crude birth r-atu ..timite i at 36! 1o9U populatimn - 924,000 births. Z/ Married WoTen u' Pepriduccive Age  - 34 - supplements, growth monitoring for children 0 to 5 years of age, the distribution of a fortified weaning food (Actamine) to children under five whose growth was faltering, and nutrition education. Other interventions supported by the health sector which have contributed to improvements in nutrition status include the basic immunization program, the control and treatment of diarrheal disease, family planning, and promotion of breastfeeding. 6.04 Food price subsidies have been used by the Moroccan government to ameliorate the impact of economic difficulties and more recently, to soften the negative impact of the structural adjustment program which began in the early 1980s. The subsidies were introduced in the 1970s, when a wide variety of commodities including cereals, sugar, and edible oils, as well as such relative luxuries as meat, butter and milk were subsidized in an effort to stabilize food prices, maintain low wages, and transfer income to the poor. The urban areas benefitted most, and the effect in agricultural areas was to depress domestic production. About 3W of GDP, which amounted to 11 of the government's recurrent expenditures, was used to support food prices in the early 1980s. These food price subsidies were not targetted to commodities consumed more frequently by low income groups, and in fact, the policy has been widely regarded as a general income subsidy compensating to some extent for lower wages. 6.05 Several analyses of social expenditures in 1985-87 revealed that the subsidies, which were expensive to government, were of greater absolute benefit to higher and middle income groups than to the poor because the former's consumption levels were higher. Only 16W of the value of the cereals subsidy was estimated to have been captured by the 301 of the population in the lowest income groups. Although these findings suggested that the program might have been phased out entirely on efficiency grounds, the negative impact of abolishing the remaining food price subsidies, which was expected to result in the equivalent of a 20* reduction in income for the 3.5 million poorest households, who spent as much as 601 of income on food, underlined the relative importance of the program to the poor in Morocco. It was expected that low income urban households would reduce their consumption by 6.4W, while agricultural households which derive their incomes from food production would experience an increase in production prices which would offset the negative effects of an increase in the price of purchased foods. An analysis of the dietary effect of the food subsidies suggests that their impact on consumption may have been less than is indicated when only expenditures are considered (See Table 14). 6.06 The government began to phase out the food price subsidies in 1987 in the context of agricultural sector reforms which were supported by an agriculture sector adjustment loan approved in 1986. By 1989, only three commodities, a high extraction wheat flour, sugar, and edible oils were still subsidized, at an annual cost to the government of about DH 230 million, less than 21 of government recurrent expenditure or 0,5% of GDP. The subsidy on soft wheat flour represents more than half of total food subsidies. However, much of this cost is covered by a tax on imports of soft wheat. The subsidized wheat flour is a high extraction flour, of a lower quality than standard flour (rich households prefer better quality flour). The production of this flour is controlled by quotas, with a limited quantity allocated to the mills in each  - 35 - region, and the resulting flour is distributed under the control of the regional authorities. Some leakages seem to occur as the flour is appropriated by the food industry, but overall this subsidy has a limited economic impact, and it is targeted to poor consumers. 6.07 The effectiveness of the program to subsidize a single variety of coarse wheat flour is being monitored by the Ministry of Agriculture and the Ministry of the Interior. The quality of the flour is difficult to control as it is often blended. Despite the program's shortcomings, and given the drought conditions of the past two years and the apparently effective targeting to the lowest income groups, it is unlikely to be phased out or significantly modified in the short term. Barley flour has been identified as a possible low cost substitute for the coarse wheat flour but this alternative has not been tested. The nutritional effect would be minimal because the nutritional quality and energy content of barley is equal to that of soft wheat. The consumption impact would depend more on consumer preferences and the substituability between a less expensive barley flour and an all-wheat flour. No other efforts have been made to identify commodities which are consumed primarily by low income groups or to measure the potential benefits of alternative targeted food price subsidies. 6.08 Comoensatorv feedina proarams, using donated commodities, began in the 1960s and increased significantly in the 1970s and 1980s. The food aid served a variety of purposes - charity, salary supplement or income transfer, and nutritional supplement. Large numbers of the urban and rural population have counted on food aid to supplement household income and increase consumption. Small amounts of food aid have traditionally been allocated to orphanages and homes for the handicapped and the aged. The value of food aid total over US$60 million from USAID, US$113 million from the Government of Morocco, and US$64 million from the World Food Program for the 1987 to 1993 period and the average cost per beneficiary ranged from $20 to $65. (See Tables 16 & 17). By 1991, 2.5 million Moroccans were estimated to be receiving food aid distributed through employment and training programs which, though targeted to the poor, do not give preferential access to the individuals or groups who have the highest priority from a nutritional standpoint. The programs have fallen short of the goals established as part of the Medium Term Agricultural Sector Adjustment Program, which called for an increase in the coverage of the existing programs from 1.9 million to 3.5 million beneficiaries by 1991 as a means of compensating for the phase out of the food price subsidies. 6.09 The monetization of food aid began on a pilot basis in 1987 as an effort to make the food aid programs self-sustaining. A portion of the food aid is sold to wholesalers and the proceeds are used to finance food distribution- development programs. A Development Support Fund of US$2.5 million is being used to finance 24 model vocational training centers which have non-traditional training programs for barbers and hairdressers, for instance, which are designed to meet the needs of the local labor market. Another $2.3 million is being used to provide potable water, sanitation and health education to villages in two provinces in southern Morocco. These programs should be monitored and their expansion considered if they prove successful. Other means will have to be found to make them self-sustaining when the food aid program has been phased out at the end of 1993.  - 36- Table 14 Dietary Effect of Subsidies 1959-60 1971-72 1984-85 Urban Rural Urban Rural Urban Rural 1. Daily Calories 2,889 3,937 3,059 3,609 3,3;8 3,464 2. Cereals as X of daily calories 61.7 73.7 48.0 63.1 46.5 64.9 3. Soft Wheat as % of daily calories 52.4 18.2 40.8 15.8 39.5 16.2 a) Subsidy Rate % 49.0 49.0 b) Subsidy X cowpared resulting from daiLy calories intake 19.0 7.9 4. Sugar as X 10.4 9.9 9.7 9.1 7.2 8.6 of daily calories a) Subs'idy Rate X -54.0* -54.0* b) Subsidy % compared resuLting from daily calories intake 0.0 0.0 5. Oils as % of daily 10.6 5.9 12.7 7.4 8.3 7.4 calories a) Subsidy Rate X 67.0 67.0 b) Subsidy % compared resulting from daily calories intake 5.5 5.0 X Total Calories Subsidized 24.5 12.9 Total Calories Subsidized (Kcal) l 596 322 * A negative subsidy has been assumed to contribute nothing to intake nor detract from it. Note, however, that in subsequent years the subsidy rate became positive. Source: McGuire, Judy, "Nutrition in Morocco" April, 1989. Background paper from the 1991 World Bank report, Reaching the Disadvantaged: Social Expenditure Priorities in the 1990s.  - 37 - Table 15 COMPENSATORY FEEDING PROGRAMS U.S. PL480 Title II 1988 - 19911 Distribution by Commodity Per Year Distribution Value Quantity % (in US$ 000's) (in MT) Flour 10.4 2.0 8,850 Wheat 17.3 3.2 36,561 Oil 12.1 2.3 3,183 Milk 2.8 .5 4,779 Monetized Wheat2 24.9 4.7 Freight 32.5 6.1 100.0 18.83 Distribution by Program Food for Work Distribution Value _____ _ D (in USS O0O's) Promotion Nationale 12.3 2.30 Reforestation and Water .7 .14 Social Assistance 27.7 5.20 Weaning Food (Actamir,e) 1.9 .35 Monetization 24.9 4.70 Freight 32.5 6.10 100.0 18.80 Beneficiaries 1.1 million (see Table 17) Source: Ministry of Economic Affairs I/The program has been extended through 1992. 2/Wheat which has been imported is sold on the local market and the proceeds are used for development projects such a- ab training. 3/The USS value of the program for four years 1* $ 60 million. The program was designed to provide approximately USS 20 miliih.n per yed. for futr years.  38 - Table 16 COMPENSATORY FEEDING PROGRAMS WORLD FOOD PROGRAM 1989 - 1993 Promotion Nationale 5 years 1989 - 1993 Value Quantity (in USS 000's) (in MT) Wheat 6.8 48,750 Vegetable Oil 2.8 2,925 Sugar .6 1,950 10.2 Beneficiaries: 534,000 low income laborers in rural areas. Education - School Lunch Program 4 years 1988 - 1992 Value Quantity (in USS 000's) (in MT) Wheat flour 16.9 73,586 Vegetable Oil 10.6 12,263 Powdered Milk 11.6 12,263 Dates 14.7 18,396 53.8 rotal Program 64.06 Beneficiaries: 816.000 children Source: Ministry of Economic Affairs  - 39 - 6.10 The annual cost of food per beneficiary for the period 1987-1992 ranged from $12 for the MOH Actamine program to $126 for the orpl:nages, with an average of about $55 for the employment and training programs, reflecting wide variations in the daily calorie transfer per person from 198 calories (NOPH) to 2,120 calories for the orphanages. The Dirham value of the food provided averaged slightly over 100 Dirhams per year per beneficiary (about US$12.00), which, for the lowest income groups in Morocco, represents an average income supplement of less than 101. The U.S. food aid program ended in early 1993 when all of the final shipment of commodities was exhausted. Rations had been reduced in many feeding programs in order to prolong the life of the program. In 1990, the NSA program rations were cut to half of the 1987 level and by 1992 were at only 25* of the 1987 level (Table 17). The flour, oil, and milk rations were altered slightly to include flour, oil and soy-fortified corn meal. In 1992, the program provided the equivalent of about 125 calories per beneficiary per day. 6.11 Nutritional status or risk are used as criteria for food benefits in the Maternal and Child Health programs of the Ministries of Social Affairs and Public Health. In 1987, the Mother-Child Healthcare Centers of the MSA provided nutrition and health education and the equivalent of 510 calories a day, equal to about forty percent of energy requirements and eighty per cent of protein requirements, for the mother and two children under five years of age per family. About 300,000 children and 150,000 mothers benefitted. The implicit pronatalist message of the NSA program has been acknowledged, and in recent years, mothers, who receive health and nutrition education as part of the program, are also referred to the KOH for family planning services which are routinely provided in the context of its primary health care program. 6.12 Unti] 1993, the Maternal Child Health program of the MOH supported the production and iistribution of a nutritious weaning food, Actamine, a fortified cereal which was developed in Morocco during the 1980s. Actamine was distributed to children under five years of age identified through growth monitoring as under weight for age. Actamine was available in the primary health care facilities and through the ministry's outreach programs, which served rural areas where there are no health facilities. Health, nutrition, and family planning education was included in the program. In 1989, 414 tons of Actamine were produced and 354 tons were distributed to approximately 133,000 children who were under weight for age. In 1992, a media campaign to promote breastfeeding and nutrition surveillance for children up to five years of age was being prepared, food warehouses were being repaired, disinfected and equipped with assistance from the USAID Title II compensatory feeding program. Actamine is no longer being produced in Morocco because its production was dependent on the availability of donated food commodities, which were phased out at the end of 1992. To date, the government has not made a decision about the continuation of the program without food aid.  - 40 - Table 17 CRS FEEDING PROGRAM Morocco 1987 - 1990 Number of Food Cost Local Value Calo::ies Annual Food Beneficiary per Year $ Food DH per Person Cost per (Million) per Day Beneficiary SMB 35,000 4.4 52 2,120 $ 126 CETs 125,000 6.5 101 808 52 ACs 50,000 2.6 101 808 52 CFPs 96,500 5.0 101 808 52 CSEs 450,000 12.9 49 510 29 Urban Sant. 93,750 5.6 176 1,761 60 Reforest-PN 62,500 3.8 176 1,761 61 Reforest-EF 75,000 3.1 97 994 41 MOPH 130.000 1.5 25 198 12 TOTAL 1,117,750 45.4 $ 41 5MB Socilt6s Musulnanes de Bienfaisance (orphanages) (264) CET Centres de t'Education et du Travail (vocational education for girls (388). AC - Artisanal Cooperatives for 'low income artisans" in urban (191). (405 total In Morocco; 191 with extremely low incomes). CFP - Centres de Fonmation Professionnelle (trade schools for "poor" boys and girls (347). CSE * MCH Centres. Centres Socio-Educatifs (300) "Most Destitute" Carte Indigence. Urban Sant. * Prom. Nat. urban unemployed poor. Reforest PN a Promo. Nat. 12 provinces unemployed landless laborers. Raforest EF a Eaux et Forts - small farmers (<25 ha) in mountainous regions (14 provinces). HOPH - Malnourished Children 0-5 concentrated In rural areas. Source: CRS/Morocco. Title II Compensatory Feeding Program Operational Plan 1987-1990. September 21. 1987.  - 41 6,13 Growth monitoring for children from birth to 5 years of age is part of the MCH program of the Ministry of Health. In 1989, the MOH weighed and measured 320,000 children, which represented slightly more than 8* of the population 0 to 5 years of age. A MOH study of 7 provinces in 1987 revealed that children in urban areas were weighed an average of 5 times during the first 2 years of life, ano children in rural areas were weighed 3.5 times. Few children are brought for growth monitoring after they reach 2 years, which suggests a need for additional efforts to inform and educate parents about the importance of continuing to monitor their children's growth up to 5 years of age. About 344,000 children received a long-acting Vitamin D injection as newborns, but only 143,000 returned at six months of age for a second injection. In contrast, the annual nationwide immunization campaigns have achieved coverage of more than 90% of the children under five, thanks to intensive efforts by the MOH, extensive cooperation including logistical support at the national and provincial level from the military and other ministries and active participation of local government officials. These campaigns are an excellent example of what can be accomplished in Morocco when objectives are clear, political commitment is strong, resources are made available, and planning and coordination are good. 6.14 Family planning has significant nutritional benefits for women of reproductive age and their children. In Morocco, infant mortality is reduced by half when children are born two years apart, and by almost half again when they are born more than four years apart. One of the major causes of these reductions is that the mother has more time to rebuild her health status and her stores of essential nutrients in preparation for the next child. The infant is better nourished in the womb, and the woman is better able to withstand the stress of pregnancy, childbirth and breastfeeding. Virtually all women in Morocco (98% in 1992) are aware of a least one modern method of contraception and 42% of married women of reproductive age are using contraception. The gap between knowledge and practice remains wide, however, and in rural areas, only 28% of women are using contraceptives in comparison to 54* in urban areas. 6.15 Iron supplements are distributed to pregnant women through the Ministry of Health's MCH-FP program, however, only 60% of the population is reached by the Ministry of Health's combined efforts in urban and rural areas, and only 3% of women in some of the rural areas receive any prenatal care. The iron supplements are distributed through the family planning outreach program which in theory extends the coverage well beyond the 32% of pregnant women who receive prenatal care, but no evaluation of the program's coverage or benefits has been undertaken. There are indirect nutritional benefits in the Moroccan family planning program which is heavily dependant on oral contraceptives. A study in Asia found that women who use oral contraceptives have 45% less iron deficiency anemia than women using other methods of birth control because of the combined benefits of reduced fertility and lower menstrual blood losses. 6.16 Breastfeeding has always been promoted passively in Morocco for its health and contraceptive effects. Few Moroccan women have had access to infant formula and the equipment required to use it until very recently. The promotion of breastfeeding through the MCH-FP program of the MOH received new impetus after a focus group study indicated that the majority of pregnant women received no counseling or information on breastfeeding from health care providers until after  - 42 - childbirth. The majority of health personnel had received little or no information or trairAing on the health and nutritional benefits of breastfeeding or how to manage breastfeeding and weaning. The N0H has developed new information and education programs in the hopes of increasing the use of appropriate breastfeeding and weaning practices among Moroccan women. Preliminary results of the 1992 Demographic and Health Survey and a comparative analysis realized by the MOH indicate that less than 62t of women oreastfeed their 0 to 4 months old infants (72* in rural areas and 46% in urban areas), and that there is a significant reduction in breastfeeding since 1985, as shown in the household consumption survey. 6.17 The World Bank supports the immunization program and other health, family planning and nutrition programs of the Ministry of Health through two projects, the Health Development Project, SAR No. 5440-MOR, which financed the expansion of these programs in three pilot provinces and the Health Sector Investment Project, SAR No. 8108-MOR, which provides support for the strengthening of health, family planning and nutrition programs on a nationwide basis. 6.18 The Ministry of Education's Food Office manages approximately 4,946 school canteens which provide two meals every school day to about 816,000 children. Food is contributed by the World Food Program and the Ministry of Education pays personnel and the costs of transportation, equipment and materials. The majority of the canteens, 0S in 1989, are in rural areas. The number of girls who participate in the program has increased steadily, from only 16% in 1978 to 28% in 1987 and roughly parallels the increase in school enrollment of girls. Primary school enrollment is estimated at about 60* of the age cohort however, enrollment rates are lower in rural areas where some of the poorest areas still have no schools. Recent studies have shown that the presence of a canteen in a school is an important determinant of enrollment. 6.19 Two projects supported by the World Bank, the Rural Primary Education Project, SAR No. 7434-MOR, and the Rural Basic Education Project, SAR No. 8936- NOR, finance the construction of school canteens. The Rural Basic Education project will also finance canteen scholarships for 100 students per school of 360 students. Scholarships will be awarded to the families who enroll all of their female, as well as all of their male children in school. Improvements in girls' education has important links to delayed marriage, lower fertility and improved maternal and child health and nutrition status. Education modules on health and nutrition have been a part of the curriculum of the secondary schools in Morocco for many years. The Rural Primary Education project supports the development of education modules on health and nutrition and the related in-service training for primary level teachers and students. Examinations for 4th and 5th grade students will incorporate questions related to health and nutrition. 6.20 Government interest in exploring new directions in food and nutrition programs has been stimulated by the phase out of the food price subsidies and compensatory feeding programs. The apparent reductions in poverty revealed by the preliminary results of the LSMS and in infant mortality as revealed by the DHS underline the need to identify vulnerable population groups and direct future program benefits to them, rather than to the entire population in order to reduce  - 43 - costs and ensure program sustainability. Japanese grant funds have been obtained oy the World Bar:k to permit the government to explore the potential for innovative efforts to improve the nutrition status of the population and reduce the prevalence of specific micronutrient deficiencies. Four interventions were identified: the analysis of the nutritional status data and correlations with related socioeconomic indicators based on the results of the 1991 LSMS; a national anemia and iodine deficiency survey; a test of the feasibility of iodizing water in areas where iodine deficiency is prevalent; and technical, financial and market feasibility tests of the fortification of sugar with iron. Several alternative methods of addressing iodine deficiency through the use of community-based interventions are described in Annex V. A summary of information on the costs and benefits of a variety of food and nutrition programs is provided in Annex VI. The studies financed by the Japanese grant funds are expected to provide more specific information on the cost and benefit of some of these interventions in the Moroccan environment, and to provide information which will be useful in the restructuring of the government's food and nutrition programs.  - 44 - VII. Conclusions and Recommendations A. CONCLUSIONS. Economig Growth and Consumption 7.01 The severity of Morocco's food security problems has declined as a result of the economic growth and development of the past three decades. GDP increased to US$900 per capita in 1990, life expectancy rose to 63 years, and by 1992, infant mortality had declined to 57/1000 live births. Nevertheless, two- thirds of the population reported expenditure levels below US$740 per capita in 1990-91, life expectancy is ten years lower than in the industrialized countries and infant mortality remains high. Although poverty has been reduced, poverty and nutritional risk are not necessarily synonymous. The population groups which are at high risk from a nutritional standpoint include most children under five years of age, women of reproductive age, as well as those who occupy the lowest rungs of the socioeconomic ladder in urban and rural areas (See Table 13). 7.02 The overall quantity of foods produced in Morocco and those imported would meet the energy requirements of the entire population if they were evenly distributed and equitably available. The strongest evidence that they are not is provided by data from the 1985 National Consumption Survey, which indicated that the highest income quartile consumed twice as many calories as the lowest income quartile. The average per capita consumption for the lowest quartile of the population of 1542 calories translates to an adult equivalent of about 2000 calories, which is inadequate but not alarmingly low. The 1990/91 LSMS did not collect information on per capita food consumption, consequently it will not be possible to update information by income group or other socioeconomic characteristics. 7.03 Living conditions in Morocco vary significantly from one region of the country to another, and this has not always been considered in the design and implementation of surveys which are based on regional samples or food and nutrition pS.ograms (See Annex VII). Although the most vulnerable population groups in terms of gender, age cohort, and economic circumstances may be similar throughout the country, there are other conditions such as _naccessibility during the winter months, extreme heat during the summer, seasonal water shortages, the absence of sources of iodine or the presence of certain diseases such as bilharzia which have major consequences for the food security, health and nutrition status of the population. 7.04 The quantity and mix of foods consumed has changed very little between 1985 and 1991; cereals, oils and fats, and sugar, still constitute about 83* of calories consumed. Although iron intake is theoretically high in Morocco because of the cereal-based diet, the bioavailability of iron in cereal grains is low. The consumption of tea w'.th meals, which is known to inhibit the  - 45 - absorption of iron, further reduces effective iron intake, which is estimated at only half the level needed to maintain good health. This is a particular problem for women, who are especially vulnerable to iron deficiency anemia during pregnancy. 7.05 The rural diet, which is high in cereals, low in other sources of protein and highly dependent on the seasonal availability of other foods, does not always meet the nutritional requirements of infants and young children. Exclusive breastfeeding is generally recommended for the first four to six months of life followed by the gradual introduction of a weaning food with a high nutrient content. Breastfeeding is nearly universal among Moroccan women, who breastfeed for an average of 14.4 months. Weaning is abrupt, however, and malnutrition peaks between 12 and 23 months of age, when most children are weaned from breast milk to other foods which are frequently nutritionally inadequate and contaminated. Nutrition Status and Micronutrient Deficiencies 7.06 The weight deficits found in 8t of urban children and 20% of rural children under five years old are evidence of diets which do not meet the nutritional requirements of growing children and periodic bouts of diarrhea and other infections. Height deficits which were found in 17% of urban and 30% of rural children the same age reflect the cumulative effect of undernutrition and malnutrition experienced early in life which persists to maturity. According to a 1989 survey which contains the most recent data currently available on the nutritional status of children below the age of five years, malnutrition was one of the major contributing factors to infant mortality. The leading cause of death for children aged 28 days to five years was malnutrition associated with diarrhea. Mortality rates were twice as high in rural as in urban areas. Poor sanitary conditions in rural areas, where only 14* of the population has access to piped water, combined with unsatisfactory breastfeeding and weaning practices, accounted for the predominance of malnutrition, diarrhea, and acute respiratory infections among the leading causes of death of infants under one year of age. 7.07 Information on fertility, the health status of the population, food consumption patterns, and environmental conditions indicate the presence in Morocco of micronutrient deficiencies which can be easily prevented. High fertility, especially in rural areas, and the cereal-based diet contribute to iron deficiency anemia, a condition which affects an estimated 30% to 40* of the total population. Half the Moroccan population lives in provinces where environmental conditions and dietary patterns predispose the population to iodine deficiency and goiter. A 1990 survey in the province of Azilal which found goiter prevalence rates of 60% among school children and adults and the importance of goiter as a major cause of arrested physical and mental development suggest that this problem should not be ignored. Compensatorv Food and Nutrition Programs  - 46 - 7.08 The Moroccan government has addressed food and nutrition concerns through a variety of programs which have included food price subsidies, supplementary feeding programs, micronutrient supplementation of infants and pregnant women, growth monitoring, diagnosis and treatment of malnutrition, family planning, the promotion of breastfeeding and health and nutrition education. These programs are notable for the unevenness of their coverage of the population groups which should be the beneficiaries, and for the progrem gaps which have beer. identified in the preceding chapters. The majority of the programs were designed to meet the needs of a population which was predominantly rural, employed primarily in subsistence level agricultural pursuits, and for the most part, poor and illiterate. Some of these programs have not been altered substantially in twenty years. With the exception of the food price subsidy program and the nutrition programs of the Ministry of Health, their relevance to the current situation in Morocco and the extent to which they respond to the needs of the population have not been reviewed. 7.09 The impact of the substitution of compensatory food supplementation programs for general food price subsidies hae not been measured. The nutritional effect of consumer shifts to coarser grain cereals as the cost of more refined flours rises should be monitored because the protein quality of the diet may deteriorate dangerously when people eat only one coarse grain. Adverse nutritional consequences may also result if increased prices cause cereal consumption levels to fall. Given the importance of sweetened tea in Morocco, higher sugar prices might lead some to reduce their intake of more nutritious foods to compensate for increased expenditures on sugar, which has limited nutritional value. Food habits tend to persist and consumers may sacrifice total calorie intake in order to maintain dietary patterns. In summary, the nutritional impact of shifts between subsidized commodities and compensatory food supplementation will depend on resource allocation strategy within the household and the net consumption effects for the nutritionally at risk members of the household. B. RECONMENDATIONS. Need for Additional Analysis 7.10 The data gathered in the LSMS will leave several important questions unanswered with respect to food consumption patterns in Morocco and dietary adequacy. The value of food purchases, gifts, and home-production are not disaggregated, therefore the relative importance of each in household consumption patterns cannot be determined. The absence of data on the quantities of food purchased makes it impossible to estimate the nutritional adequacy of the diet. If average prices are used to calculate quantities purchased, the quantity consumed by the poor will be underestimated because the poor usually purchase lower quality lower price foods, and the quantity consumed by the rich will be overestimated for the same reason. Given these important data gaps, additional work will be required to determine the nutritional adequacy of the food consumption habits of vulnerable population groups. The validity of the survey results will need to be tested as well, in order to confirm that data aggregated  - 47 - at the regional level is statistically significant at the provincial and local level. Information about the frequency of food purchases would be a useful addition to future surveys, as it could guide practices in public distribution systems. 7.11 A more comprehensive understanding of consumption behavior and the food and nutrition problems faced by Moroccans must be combined with a review of the coverage, impact and costs of ongoing programs to guide the design of the next generation of food and nutrition policies and programs. A comprehensive review of these programs, their objectives, design including targeting mechanisms, administration, implementation, costs and benefits should be undertaken. The results of this review should be compared with the analysis of the living conditions of the Moroccan population as revealed by the LSMS to determine the best match between needs and resources. In view of the considerable variation in living conditions among regions, it might be appropriate to consider the design of a series of food and nutrition program interventions or modules which could be implemented as a whole or in part depending on the requirements of a province or geographic region. The technical expertise of national and international experts when combined with the knowledge of local conditions residing in each community has the potential to contribute much to the potential effectiveness of such a program. 7.12 Japanese grant funds have been obtained by the World Bank to permit the government to explore the potential for innovative efforts to improve the nutrition status of the population and reduce the prevalence of specific micronutrient deficiencies. Four interventions were identified: the analysis of the nutritional status data and correlations with related socioeconomic indicators based on the results of the 1991 LSMS; a national anemia and iodine deficiency survey; a test of the feasibility of iodizing water in areas where iodine deficiency is prevalent; and technical, financial and market feasibility tests of the fortification of sugar with iron. The studies financed by the Japanese grant funds are expected to provide more specific information on the cost and benefit of some of these interventions in the Moroccan environment, and to provide information which will be useful in the restructuring of the government's food and nutrition programs. Food and Nutrition Policies and Programs 7.13 A national food consumption policv should be developed together with a menu of food and nutrition programs which can be used to prevent f?eid insecurity and improve the nutrition status of the population. General guidelines with respect to criteria for the identification of nutritionally vulnerable population groups could be established at the national level, and target populations Identified and quantified at the provincia' level where most programs are implemented. The target population at the nati. l level could be expected to include all women of reproductive age, children under five years of age, and low income population groups from other age cohorts. The cost, benefits and targeting mechanisms of the ongoing programs need to be reviewed and the programs modified in accordance with the findings of the review in order to ensure their quality, relevance, cost-effectiveness, and sustainability.  - 48 - 7.14 TarcetinQ of social orocrrams is a major policy and program issue because effective targeting has the potential to limit program costs, respond to fiscal constraints and focus limited resources on the most needy segments of the population (See Annex VII). A review of 30 social programs in 11 Latin American countries with GDPs per capita ranging from US$590 to US$2,560 came to three major conclusions: (i) targeted programs have much more progressive incidence than general food price subsidies and are even slightly more progressive than primary education and health care; (ii) the cost of targeting is a minor share of administrative costs for most programs, and greatly increases the share of total program resources delivered to the poor despite the increased administrative burden; and (iii) there is no significant difference in the effectiveness of one targeting mechanism over another. Programs which used individual assessment, geographic and self-targeting all had a similar range of benefits - 71 to 73*- going to the poorest 40% of the population. There is no single best way to target; program success will depend to a large extent on the efforts invested in making any targeting mechanism work well. Annex VII provides a description of a variety of methods which can be used to target social programs, their advantages, disadvantages, circumstances under which each one is appropriate, and the information required to use each targeting mechanism. 7.15 Because of the interrelationship of fertility, morbidity, mortality and nutritional status, the nutritional recuirements of women of reproductive age should be given hicher 1riority. Nutrition education has the potential to inspire voluntary changes in eating habits and other behavior which can make a significant contribution to the well-being of the population. Nutrition education should be considered a topic of interest to everyone, for it encompasses not only the nutritional requirements of infants, adolescents, and women during pregnancy and breastfeeding; but also micronutrient deficiencies which affect mental development, reproductive health and labor productivity; food safety and hygiene; and the effects of smoking and alcohol consumption on health and nutrition status, especially during pregnancy, middle age, and beyond. 7.16 The inadequate coverage of children's health and nutrition DroQrr.1s in Morocco is one of the major gaps in Morocco's well-conceived public health strategy which remains to be filled. The already successful immunization and family planning programs should be accompanied by increased population coverage of programs which provide growth monitoring and nutrition education, prenatal care and attended deliveries, and vitamin and mineral supplements as needed, to reach all children under four years of age. 7.17 The classification of employment and training/feeding programs as development programs, (which has a positive connotation), and maternal-child health/nutrition programs es welfare programs, (which has a negative connotation), does nothing to build support for the latter, which are as important to the nation's development as the former. The routine financing of maternal and child health/nutrition programs in advanced developing and industrialized countries is indicative of the priority given to these investments, their effectiveness, and the continuing need for these programs regardless of the level of development. 7.18 The micronutrient deficiencies of iron and iodine should receive official recognition as nutrition problems which merit priority attention at the  - 49 - national, regional, provincial, and community level. There are several alternative interventions available which have been proven safe, effective, and economical in other countries. These should be reviewed and adapted to the Moroccan environment as part of the national food and nutrition strategy. Annexes IV and V contain information on the cost and effectiveness of a variety of strategies for addressing micronutrient deficiencies. In that respect, the surveys and studies being carried out under Japanese Grant financing should provide useful information to decision-makers. 7.19 Morocco' s school feeding Procrams benefit many children who would not be classified as poor using the income criteria established by the government. Children who are poor may benefit far less from the school feeding programs than the middle class because they are more likell to live in areas where the schools do not have canteens, and less likely to be enrolled in school. The inability of the school system to construct a canteen for every school in the country should not prevent the consideration of alternative means of providing a nutritional supplement to all school children, especially in the poorest areas and among underrepresented population groups. Some countries provide a nutritious snack or beverage which can be prepared in the community according to a recipe formulated and tested by nutrition experts. The snack or beverage is usually offered at the beginning of the school day BO that the nutritional status of the child as well as performance in school will be improved. 7.20 The development of a comprehensive food and nutrition strategy for Morocco is unlikely to require the creation of new institutions; there are already several ministries, university faculties, and institutes which have long experience in dealing with food and nutrition problems, policies and programs. More attention needs to be given to the coordination of the efforts of existing institutions, to the relationship between policy formulation and program design, evaluation and cost, and to the periodic review and evaluation of policies and programs co ensure their relevance, quality and sustainability. Additional resources may be required to improve and expand the coverage of existing programs and to plan and implement the interventions which have not yet become a part of Morocco's strategy to increase food security and reduce malnutrition. While international assistance in the form of technical expertise and other resources may be needed to support these programs, it must be considered a complement to national efforts and should be closely linked to the country commitment. Without a strong commitment from the government and the people of Morocco, the success of these programs cannot be assured.  - so - ANNEX I page 1 of 1 Food Consumption Habits in Morocco 1. Tradition provides the foundation for food consumption patterns and the basic diet of cereals and oil has been typical of the Mediterranean region for centuries. The variety and amount of food consumed vary according to family income and the local availability of foods. There are usually three meals a day: an early breakfast consists of either cooked corn meal, bread made from wheat and/or barley flour and/or lentil soup, and tea, with yoghurt occasionally added to the cereal. There may be tea breaks at mid-morning and in the afternoon. The main meal of the day is most often eaten at noon and may include couscous (semolina) cooked with vegetables, oil, and poultry, fish or meat when available, or a tajine, which is a stew of meat, fish or poultry cooked in oil to which vegetables, fruits or nuts are added. In more affluent homes, a pastry-wrapped pigeon pie may be served heaped with powdered sugar. Salads and fruits in season are also served if they are available and affordable, and heavily sugared mint tea ends most meals. The diet is high in calories and low in vitamins and proteins as a result of the excessive use of sugar in foods and beverages, the reliance on oils and butter, and the quantity of tubers and cereals consumed. It is especially bad for small children, who are unable to consume sufficient quantities of the bulky staple foods to satisfy their nutritional requirements. 2. Food is generally served in large bowls or platters which are placed in the center of the table or mat. Families eat together, or, if there are guests, they often eat first with the men and older children while the women and the smaller children eat afterward. Small children often wander freely back and forth between cooking and eating areas during mealtime, and randomly accept food by the mouthful or handful from adults or older siblings. The communal eating patterns mak- the measurement of individual consumption levels almost impossible in Morocco. The nutritional requirements of women and growing children are not always well understood, and since retardation of growth in children is not always immediately apparent, it may not be associated by parents with nutritional deprivation. In general, women's iron requirements are twice the level of men's because of their reproductive cycle. Since iron consumption is directly related to calorie consumption, women often cannot consume enough calories to meet their iron requirements. Pregnancy and childbirth aggravate iron deficiency because of the nutritional demands of the fetus and the loss of blood associated with childbirth.  - 51 - ANNEX II Page 1 of 1 Functional Effects of Essential Micronutrient Defidenckes Iron Iodine Vitamin A Morbidity Immune Function X ? X Prevalence X X Incidence ? X Duation 7 X Severity X Mortality Infant X X X Child ? X X Matemal X ? Other (fetal, early adult) X Mental Development & Larnig Disorders :.ain Development ? X Aptitude X X IQ X Exploratory Bdavior X Attention Span X X Memory ? X School Achievement X X ? L,earing Disabilities (blind, deaf) X X Sensory Imparmnts X X Productivity Spontaneous Activity X X Endurance X Maximum Aeobic Capacity X Occupational Prmductivity X X Disability (blindness, mental retardation, lack of motor coordination X X Growth X X X Reproduction Fertility X X Miscarriage-Stillbirth X X X Intra Uterine Growth Retardation X X Prematurity X Congenital Defbrmities (birth defects) X X Source: Levin, PollUt, Gallo010 ad McaGuir-. Ktoxwtrient Deficiency Disorders. in Disease Priorities in Developing Countries.  NWCICE OF STUNT O N MOROCCO By RB9!i mi Expedi_tw Levb I.Expndrre Group .-South Tensift Cernter North-W est Center-North Oriental Center-South I & 2 quintilo 52.5 31.8 38.7 50.0 34.0 20.5 36.7 3 & 4 quIntlie 38.6 36.4 30.7 44.3 .40.9. 17.2 26.6 6 & 6 qulntio 32.8 23.1 30.3 32.1 24.0 19.6 16.4 7 & 8 qitle 14.7 4.2 23.1 28.9 26.4 5.0 17.5 Lg & 10qidotle 8.3 7.4 26.7 10.7 5.4 3.1 15.4 Total 35.7 26.2 30.3 34.0 28.7 15.3 26.0 3 Nofte: Thes table Indicates the percentage of children of age fouw or younpr, whose anthropometric measurements fall below 2 standard deviations of the correspondin expected height for age measwmements based on intematona standards. The table reflects (unextrapolated) sample data. hlEnw LSMS 1990-91, Directon de to Statistique. _~~~~~~~~~~~~~~~~~~~~~~~ 0 Ph H . 2 N a  53 - ANNEX III Page2 of 2 NUTRITION AND SOCIOECONOMIC STATUS: RESULTS OF THE 1990-1991 LSMS Percentage of Children with Low Height for Age According to Residence and Water Source Supply Source of Water Supply J Urban Rural | Total N 1280 125 1405 Piped Water % <-2 15.4 24.8 16.2 N 110 2493 2603 Well, Spring % <-2 18.2 28.4 29.0 N 238 229 467 Public Fountain % <-2 17.2 33.2 25.1 N 44 33 77 Water Seller X <-2.0 13.6 21.2 16.9 N 14 44 58 Water Truck % <-2.0 21.4 25.0 24.1 Other N 24 81 105 X <-2.0 20.8 27.1 25.7 TOTAL N 1710 3005 4715 X <-2.0 15.9 28.4 23.9 Source: ISMS 1990-1991. Direction de la Statistique, Ministry of Planning.  ANNEX IV -54 - Page 1 of 2 Definition of Deficiencies IRON DEFICIENCY: (Individual) - Hemoglobin values below which anemia is likely to be present in individuals living at sea level. Hemoglobin (g/lOOcm3) Children, 6 months - 6 years 11.0 Children, 6 - 14 years 12.0 Adult Males 13.0 Adult Females (non pregnant) 12.0 Adult Females (pregnant) 11.0 At all age levels Serum Ferritin Levels < 10-12 mcg/l indicates depletion of iron stores. IODINE DEFICIENCY: Mild IDD: (Population) - goiter prevalence of 5-20X (Individual) - median urinary iodine levels in excess of 50 mcg/g of creatinine. Moderate IDD: (Population) - goiter prevalence of 21-29Z (Individual) - median urinary iodine (25-50 mcg/g/ of creatinine Severe IDD: (Population) - goiter prevalence > 29X endemic creatinism 1-10l (Individual) median urinary iodine < 25 mcg/g/ of creatinine.  55 ANNEX IV Page 2 of 2 VITAMIN A DEFICIENCY: - Population - X of children <6 years of age with deficiency. Clinical: Nightblindness (XN) 1.0% Bitot's Spots (XIB) 0.5% Corneal Scars, ulceration (X3A) 0.01% Xerophthalmia-related Corneal Scars 0.05% Biochemical: Serum retinol (Vitamin A) < 10 mcg/dl 5.0Z Idividual Serum retinol: Adults - 30 mcg/dl for mild deficiency. Children - 20 meg/dl for mild deficiency. Serum retinol: Adults & Children - <10 mcg/dl for severe deficiency. Liver retinol: Adults & Children - <20 mcg/g for mild deficiency. Adults & Children <10 mcg/g for severe deficiency. Source: Levin, PoLit, Gatloway and McGuire. Hicronutrient Deficiercy Disorders, in Disease Prforities In Developing Countries.  56 ANNEX V page 1 of 1 The Treatment of Iodine Deficiency Using Community-based Interventions 1. The industrial iodation of salt is only one of the methods which has been developed for the introduction of iodine to areas of the world where consumption is below nutritional requirements and goiter is endemic. In India, China and Thailand, community-based programs to increase iodine consumption are being developed. A summary of these experiences is provided here. 2. In the mountainous areas of Thailand, iodine deficiency and the problem of endemic goiter have been addressed through the use of a community level program to iodize water with potassium iodate. Quantities as small as 30 milliliters of iodized water are distributed to villagers for dilution of their drinking water at home. Schools distribute 200 ml of iodized water to each child with their lunch. A simple machine for the slow release of iodine into drinking water supplies has been developed, while in other areas, small quantities of locally produced salt are sprayed with an iodine solution, packaged, and sold in the village store. Kits have been developed for the on-site testing of iodine levels in salt and water to facilitate quality control. The iodination of corn and soybean oil is also being tested for stability and toxicity. Fish sauce, which is widely used for cooking in Thailand, can also be iodized by the direct addition of the potassium iodate to the sauce. This can be premixed at the local fish sauce bottling factory. Field trials of the iodized salt and oil, the school lunch program and the use of the community water iodinator have all demonstrated positive results when compared to the results in control population groups. 3. In China, a government monopoly of salt production has facilitated the introduction of iodination at decentralized facilities throughout the country. Provincial officials are able to adjust the level of iodine dosage according to local consumption patterns. Salt consumption varies by as much as 50 because of the year round availability of fresh vegetables in some provinces in contrast to the consumption of highly salted pickled vegetables during the winter months in others. Salt is packed in plastic crates and protected from heat, light, humidity, and dust. This careful control of storage conditions enables maximum preservation of iodine in the salt. The use of iodized salt has reduced goiter to only 20a of pre-iodination levels, a remarkable achievement for a country whose GDP per capita is only US$370.  57 ANNEX VI Page 1 of 5 Annual Per CaDita Costs of Ihmical Nutrition Programs Food Supplementation $46.00 1 Nutrition Education $ 2.00 2 Food Subsidies $30.00 1 Integrated Health-Nutrition Care $25.00 School Feeding $12.00 1 Iron Supplementation $ 2.00 per pregnancy 3 Iron Fortification $ 0.20 4 Iodine Supplementation $ 0.50 Iodine Fortification $ 0.10 Vitamin A Supplementation $ 0.50 Vit_amin A Fortification $ 0.20 1. Kermedy & Atdefaan, 1987. 2. HoD 1985. 3. Assunes six prenatal visits at S0.39 each Ctarginal cost of Iron counseLllng) pLus 200 iron tablets at S0.001 each. 4. Levin, 1985. Source: Levin, Potlit, GalLoway and McGufre. Micronutrient Deficiency Disorders, in Disease Priorities in Developing Countries.  - 58 - ANNEX VI Page 2 of 5 Nutrition Program Costs for 10.000 PoRulation Cost per Target Annual Benefits Group Program Per Year Cost Food Supplements 46 Pregnant women $ 62,054 0 - 3 years Nutrition Education 2 Pregnant women 2,698 0 - 3 years Food Subsidy 30 Bottom 60,000 Quintille Integrated Nutrition PHC 25 Pregnant women 33,725 0 - 3 years School Feeding 12 5 - 9 years 14,400 Iron: Supp. Pregnant women 2 Pregnant women 800 Fortification 0.20 Pregnant women 2,000 Iodine: Supp. women Repro. Age 0.50 Preg.women 15-49 1,250 Supp. All 0.50 Preg.women 15-49 2,325 Fortification 0.10 Preg.women 15-49 1,000 Vitamin A: Supp. 0.50 0 - 5 years 650 Fortification 0.20 0 - 5 years 2,000 Source: Levin, PoLlit, Galloway and NcGuire. Nicranutrient Deficfency Dfsorders. In Dieas Prioritles fn Developing Countries.  -59 - ANNEX VI Page 3 of 5 Application of AssUzDtions to SDecific Intervertion for 10.000 PeoDle Iron Supplementation of Pregnant Women: 1. Target group - pregnan women (400) (assume age 25) 2. Average rate of anemia: 63% 3. Per capita cost: $2 per pregnancy 4. Program effectiveness: 75% (but prevents single death) 5. Deaths averted: 1 pregnant woman 6. Productivity gains: 20% (immediate only) 7. Program duration: 200 days 8. Costs: $800 9. Discounted wage gains: (0.63x399) x 0.2x500x.75x0.75 - 14140 ' + lx5OOx.75x21.3 - 7988 2 - 22128 10. Discounted healthy life years gained lx24.7 - 24.7 3 + 0.2x0.63x399x.75 -