Pauvreté et malnutrition en Haïti: Résultats des départements du Sud et de la Grand'Anse

October 2020 R E S E A R C H T E C H N I C A L A S S I S T A N C E C E N T E R USAID Haiti Poverty and Malnutrition in Haiti Findings from Sud and Grand ’ Anse Departments Angelino Viceisza, Kodjo Aflagah, Atabanam Simbou, Dixita Gupta, Kodjo Koudakpo This report is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of contract no. 7200AA18C00057, which supports the Research Technical Assistance Center (RTAC). This report was produced by Angelino Viceisza, Kodjo Aflagah, Atabanam Simbou, Dixita Gupta, and Kodjo Koudakpo under the RTAC contract. The contents of this report are the sole responsibility of RTAC and NORC at the University of Chicago, and do not necessarily reflect the views of USAID or the United States Government. Acknowledgments We are grateful to the RTAC team — in particular, Dr. Gabriela Alcaraz Velasco, Jack Devine, and Samantha Wasala — for their advice and assistance while preparing this report. We would also like to thank several teams at USAID (in particular, members of the Bureau for Humanitarian Assistance) for their feedback and suggestions. Research Technical Assistance Center The Research Technical Assistance Center is a network of academic researchers generating timely research for USAID to promote evidence-based policies and programs. The project is led by NORC at the University of Chica go in partnership with Arizona State University, Centro de Investigacio ́ n de la Universidad del Pacifico (Lima, Peru), Davis Management Group, the DevLab@Duke University, Forum One, the Institute of International Education, the Notre Dame Pulte Institute for Global Development, Population Reference Bureau, the Resilient Africa Network at Makerere University (Kampala, Uganda), the United Negro College Fund, the University of Chicago, and the University of Illinois at Chicago. The Research Technical Assistance Center (RTAC) is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of contract no. 7200AA18C00057. This report was produced by Angelino Viceisza, Kodjo Aflagah, Atabanam Simbou, Dixita Gupta, and Kodjo Koudakpo. The contents are the sole responsibility of RTAC and NORC at the University of Chicago, and do not necessarily reflect the views of USAID or the United States Government. Suggested Citation Viceisza et al. 2020. Poverty and Malnutrition in Haiti: Findings from Sud and Grand’Anse Departments. Research Technical Assistance Center: Washington, DC. Poverty and Malnutrition in Haiti 1 Executive Summary The 2019 Global Hunger Index, a composite measure of undernourishment, child wasting, child stunting, and child mortality, ranks Haiti 111th of 117 countries included in the index. Fifty percent of the country’s population were found to be undernourished, while 21.9 percent of children under five years of age were stunted and 3.7 percent wasted. Based on the index, the level of hunger in the country was considered serious/alarming. In 2016 Hurricane Matthew battered the south of the country, leaving lasting effects on health and livelihoods. These problems are likely to be exacerbated by the COVID-19 pandemic. The main purpose of this Food Security Desk Review and Data Analysis report is to provide an overview and synthesis of the poverty and food security situation in Haiti, with a particular focus on two of the country’s ten administrative de partments, Sud and Grand’Anse , both in the southwest. Grand’Anse is the poorest department of the country, with 70 percent of the population living in the bottom two quintiles of asset distribution, compared to 50 percent in Sud. Section 0 of the report primarily relies on desk research (i.e., review of academic literature, project documents, and policy reports) and to some extent, stakeholder consultations. Section 2 quantitatively explores determinants of poverty and malnutrition using the 2017 round of the Haiti Demographic and Health Survey (HDHS). Key findings (also summarized in Table 1) are: Politics: After the 29-year autocratic dynasty of the Duvalier family fell in 1986, Haiti underwent a cycle of ill-fated presidencies and coups. In recent years, political leaders have attempted to establish a more democratic political system. Those efforts have been partly derailed by natural disasters, including the 2010 earthquake and Hurricane Matthew in 2016, and social unrest driven by corruption scandals and rising prices of fuel and other key commodities. Socioeconomics: Key pillars of the Haitian economy, and thus sources of income for households (HHs), are: agriculture (as high as 51 percent in rural areas), commerce and petty trade (27 percent), tourism and travel (14 percent), and construction (8 percent). In Sud, about 17 percent of HHs engage in professional/clerical jobs, 44 percent in sales, and 16 percent in agriculture. Twenty percent are unemployed . In Grand’Anse, about 16 percent of HHs engage in professional/clerical jobs, 54 percent in sales, and 14 percent in agriculture. Another 14 percent are unemployed. The nationwide unemployment rate of 13.5 percent continues to drive migration by a substantial part of the Haitian population, particularly from the areas of interest (AOIs). Internal migration from Sud and Grand’Anse significantly exceeds the national average. This is not surprising, given the significant distance between the AOIs and the border with the Dominican Republic. Twenty percent of migrants from Sud move to other communes, 69 percent to other departments, four percent to the Dominican Republic, two percent to Latin America, and two percent to the United States. Twenty percent of migrants from Grand’Anse move to other communes, 58 percent to other departments, three percent to the Dominican Republic, five percent to Latin America, and 12 percent to the US. Land, Environment, Climate Change, and Natural Disasters: With 30 percent of Haitian HHs engaged in farming activities, access to land for cultivation and productive purposes is key. At the national level, 61 percent of HHs own or have access to agricultural land — 37 percent in urban areas and 77 percent in rural areas. Eighty percent of HHs in Sud and 84 percent in Grand’Anse have access to land usable for Report | October 2020 2 agriculture. The southern region of Haiti is particularly prone to natural disasters, such as droughts, floods, hurricanes, and earthquakes. These volatile agroclimatic events have been linked to the El Niño phenomenon in several areas of the country, particularly the AOIs. Gender: About 41 percent of HHs in Sud and 39 percent in Grand’Anse are headed by women. At the national level, 12 percent of women reported having experienced domestic violence at least once in their lives. Among women in Sud, 17.6 percent have experienced physical violence from their husbands. In Grand’Anse 18.2 percent have experienced such violence. Youth: In Haiti, 54 percent of the population is under 25, with 31 percent between 10 and 24 years old. Of women between the ages of 15 and 19, 84.2 percent have not worked (likely for pay) in the last 12 months, while 60 percent of men have. Among women between the ages of 20 and 24, 58.4 percent have not worked, while 34.6 percent of men have not. Food security context: Most of our analysis utilizes the livelihood zones classification established by the Famine Early Warning Systems Network (FEWS NET) created by USAID in 1985. As established by FEWS NET, livelihood zones are geographic areas of a country where people generally share similar options for obtaining food and income and similar access to markets. In Haiti, the zones are numbered on the FEWS NET map from HT01 (dry coastal maize and charcoal) to HT09 (urban). Three of those livelihood zones cover the AOIs in this report. Both Sud and Grand’Anse contain zones designated as HT07 (South beans, bananas, and petty trade) and HT08 (Southwestern coast maize, manioc, and bush products). Most of the northern and western coasts of the two departments are designated as HT08. The eastern part of Sud is classified as HT01 (dry coastal maize and charcoal). Agricultural production: The Sud HT01 zone produces maize and charcoal. The HT07 zones in both departments produce beans and bananas and are also marked by petty trade. Farming in both departments is mostly traditional, with very little production of cash crops. The HT08 zones in both departments produce maize, cassava, and bush products. Fisheries in those areas produce conch and lobster. Market and food access: Trade networks in HT07 areas are characterized by departmental and local supply centers. Members of poor HHs are unable or barely able to meet minimal energy needs, possibly due to weak production capacity. As a consequence, 60 to 70 percent of HHs resort to purchasing food, although there is some evidence wealthier HHs consume dairy products from their own animals. In HT08 areas, imported food prices are the highest in the country. This is likely because those areas are isolated and access is hindered by inadequate roads. Staple foods: In HT01 zones the main staple foods are maize, pearl millet, beans, rice, and flour. In HT07 zones, staple foods are rice, maize, and beans. In HT08 zones, staple foods are rice, maize, and beans. Food insecurity: Based on the Consolidated Approach to Reporting Indicators approach established by the World Food Programme (WFP), 50.7 percent of Haiti ’s population is food insecure, either moderately or severely. In Sud, 46.4 percent of the population is food insecure, compared to 77.9 percent of the population in Grand’Anse. This also translates into low food diversity, low intake of vitamin A, and low iron-rich food consumption. Lessons from food security and nutrition programs: A diverse set of actors, both local and international, are conducting a range of interventions, among them are agricultural insurance, cash transfers, job training, and school feeding programs. Collectively, their findings offer insights into effectively designing Poverty and Malnutrition in Haiti 3 interventions in Haiti. Main lessons learned stress the importance of building government capacity, preparing for disasters, being ready to target and reach beneficiaries (e.g., rosters and financial inclusion/access through bank accounts or mobile wallets), engaging the community, being gender responsive, and enhancing coordination between all actors, stakeholders, and partners. Poverty analysis: Households defined as poor fall in the bottom quintile of the wealth-index distribution within a department, based on the 2017 HDHS. Results from the econometric analysis suggest that:  In Sud, HHs who own radios or mobile phones or have a fixed or mobile place for handwashing are less likely to be poor. Those who live in houses with cane/palm or dirt/mud walls are more likely to be poor. HHs who own sheep are more likely to be poor, whereas HHs who own chickens are less likely to be poor.  Similar to Sud , in Grand’Anse, HHs who own radios or mobile phones and those who have access to solar energy are less likely to be poor. Those who access drinking water through (protected or unprotected) springs or live in houses with cement floors are more likely to be poor. Child malnutrition analysis: A child is considered stunted (wasted) if the z-score of height-for-age (weight for-height) is below -2 standard deviations (SD), based on the 2012 and 2017 HDHS. Results from the econometric analysis suggest that: Stunting: In both departments, children living in HHs with a large number of members under 15 years of age are more likely to be stunted. Stunting decreases with the size of the child at birth. Children whose mothers are fully literate are significantly less likely to be stunted. Additionally, in Sud, both children in HHs headed by women and children whose pregnancy was unwanted are less likely to be stunted. Stunting is generally more prevalent in HHs with a larger number of members older than 65. Wasting: Wasting is less prevalent among girls, children whose pregnancy was unwanted, and children whose mothers are divorced, separated, or widowed. Children who were very small at birth, recently had a cough, or live in HHs headed by their maternal grandparent are more likely to be wasted. Wasting also decreases with the mother’s education. In Sud, children whose mothers are married or fully literate are less wasted. Wasting increases with the number of dependents in a HH under 15 years of age. Table 1 . Summary of Findings Theme Grand’Anse Sud Source Poverty rate (HHs in lowest two quintiles) 70 percent 50 percent 2017 HDHS Stunting 21.6 percent 22 percent 2017 HDHS Wasting 3.6 percent 2.1 percent 2017 HDHS Migration destination Other communes (13 percent), other departments (30 percent), Dominican Republic (58 percent), Latin America (5 percent), United States (12 percent) Other communes (20 percent), other departments (69 percent), Dominican Republic (4 percent), Latin America (2 percent), United States (2 percent) CNSA (2019) Report | October 2020 4 Theme Grand’Anse Sud Source Access to land usable for agriculture 84 percent 80 percent DHS (2017) Main production HT07: beans, bananas, HT08: maize, cassava, bush products HT01: maize, HT07: beans, bananas, HT08: maize, cassava, bush products FEWS NET (2015) and CNSA (2019) Staple foods HT07 and HT08: rice, maize, and beans. HT01 zones: maize and pearl millet, beans, and rice and flour, HT07 and HT08: rice, maize, and beans. FEWS NET (2015) and CNSA (2019) Food insecure 77.9 percent 46.4 percent CNSA (2019) Food diversity and nutrition Low food diversity Low intake of vitamin A Low food diversity Low intake of vitamin A CNSA (2019) Low iron-rich food consumption Low iron-rich food consumption Poverty determinants Radios, mobile phones (-), drinking water through (protected or unprotected) springs (+), solar energy (-), cement floors (+) Radios, mobile phones or have a fixed/mobile place for handwashing (-), houses with cane/palm or dirt/mud walls (+) sheep (+), chickens (-) 2017 HDHS Child malnutrition determinants: stunting Number of HH members under 15 (+), Size at birth (-), mother fully literate (-), 2017 HDHS Sud only: Mother is HHH (-), pregnancy unwanted (-), number of HH members over 65 (+) Child malnutrition determinants: wasting Girls (-), pregnancy unwanted (-), mother is divorced, separated or widowed (-), child was very small at birth (+), child recently had a cough (+), mother’s education ( -), 2017 HDHS Sud only: mother is married (-), fully literate (-), number of HH members under 15 (+) Note: HT07 stands for South beans, bananas, and petty trade; HT08 stands for Southwestern coast maize, manioc, and bush products; and HT01 for Dry coastal maize and charcoal. Poverty and Malnutrition in Haiti 5 Table of Contents Executive Summary ........................................................................................................................................................... 2 1. Desk Review ............................................................................................................................................................ 11 1.1 Country and Regional Context .................................................................................................................. 11 1.2 Food Security Context ................................................................................................................................. 17 1.3 Lessons Learned: Programs and Initiatives .............................................................................................. 26 2. Data Analysis ........................................................................................................................................................... 34 2.1 Poverty in Sud ................................................................................................................................................ 34 2.2 Poverty in Grand’Anse ................................................................................................................................. 39 2.3 Child Malnutrition ......................................................................................................................................... 44 3. References ................................................................................................................................................................ 51 4. Annexes .................................................................................................................................................................... 55 Report | October 2020 6 List of Tables Table 1. Summary of Findings ......................................................................................................................................... 4 Table 2. Surplus/Deficit of Food Production by Food Group and AOI .............................................................. 22 Table 3. Food Security and Food Diversity by Sex of the Household Head ..................................................... 24 Table 4 . HH Assets and Poverty in Sud (2017 HDHS) ........................................................................................... 35 Table 5 . House Materials and Poverty in Sud (2017 HDHS) ................................................................................ 36 Table 6. Water Access, Sanitation, Hygiene, and Poverty in Sud (2017 HDHS) ............................................. 36 Table 7 . HHH Characteristics, HH Structure, and Poverty in Sud (2017 HDHS) ........................................... 37 Table 8 . HH Assets and Poverty in Grand’Anse (2017 HDHS) ........................................................................... 40 Table 9 . House Materials and Poverty in Grand’Anse (2017 HDHS) ................................................................. 41 Table 10 . Water Access, Sanitation, Hygiene, and Poverty in Grand’Anse (2017 HDHS) ............................ 41 Table 11 . HHH Characteristics, HH Structure, and Poverty in Grand’Anse (2017 HDHS) ......................... 42 Table 12 . Mother’s Characteristics and Stunting in Sud and Grand’Anse (Pooled) Departments ............... 45 Table 13 . Father's Characteristics and Stunting in Sud and Grand’Anse (Pooled) Departments ................. 46 Table 14 . Child's Characteristics and Stunting in Sud and Grand’Anse (Pooled) Departments ................... 47 Table 15 . Mother’s Characteristics and Wasting in Sud and Grand’Anse (Pooled) Departments .............. 48 Table 16. Father's Characteristics and Wasting in Sud and Grand’Anse (Pooled) Departments ................ 49 Table 17 . Child’s Characteristics and Wasting in Sud and Grand’Anse (Pooled) Departments .................. 50 Table 18. Predictors of Poverty in Sud and Grand ’Anse Departments Based on OLS Regression (2017 HDHS) ................................................................................................................................................................................ 55 Table 19. Predictors of Stunting in Sud and Grand’Anse Departments Based on OLS Regression (2017 and 2012 HDHS) .............................................................................................................................................................. 58 Table 20. Predictors of Wasting in Sud and Grand’Anse Departments Based on OLS Regression (2017 and 2012 HDHS) .............................................................................................................................................................. 60 Poverty and Malnutrition in Haiti 7 List of Figures Figure 1. Areas of Interest ............................................................................................................................................. 12 Figure 2 . Flood Risk for Sud and Grand’Anse ........................................................................................................... 15 Figure 3 . Main Livelihood Zones in Sud and Grand’A nse ...................................................................................... 18 Figure 4. Primary and Secondary Roads in Haiti and AOIs ................................................................................... 19 Figure 5. Market Accessibility ....................................................................................................................................... 19 Figure 6 . Mode of Accessing Food in Sud and Grand’Anse by Livelihood Zone .............................................. 21 Figure 7 . Food Diversity in Southern Departments by Livelihood Zone (# of food groups) ....................... 25 Figure 8 . Frequency of Vitamin A Intake in Southern Departments by Livelihood Zone .............................. 25 Figure 9 . Frequency of Iron-fortified Food Consumption in Southern Departments by Livelihood Zone26 Report | October 2020 8 List of Acronyms ACF Action Contre La Faim International AOI area of interest AVSF Agronomes et Vétérinaires Sans Frontières CLM Chemen Lavi Miyò CNSA Coordi nation Nationale de la Sécurité Alimentaire CRS Catholic Relief Services DHS (2017) Report for the 2017 Demographic and Health Survey for Haiti (see reference list) EFSA Emergency Food Security Assessment FAO Food and Agriculture Organization FDI I ndustrial Development Fund FEWS NET Famine Early Warning Systems Network FFP Food for Peace FTF Feed the Future GHI Global Hunger Index GII Gender Inequality Index GoH Government of Haiti 2017 HDHS Analysis based on the 2017 Demographic and Heal th Survey Data for Haiti HH household HHH head of household HT FEWS NET livelihood zone for Haiti IFAD International Fund for Agricultural Development IFRC International Federation of Red Cross ILO International Labor Organization in inches I PC The Integrated Food Security Phase Classification KL Kore Lavi LOKAL Limyè ak Organizasyon pu Kolekyivite yo Ale Lwen MARNDR Ministêre de l’Agriculture des Ressources Naturelles et du Développement Rural MBEP Market - Based Emergency Program MAST Min istry of Social Affairs and Labor ( Ministère des Affaires Sociales et du Travail ) Mt metric ton NGO n on - g overnmental o rganization Poverty and Malnutrition in Haiti 9 OLS Ordinary Least Squares pp percentage point(s) SD standard deviation SYFAAH System of Financing and Agricultural Insurance UCT Unconditional Cash Transfer UNDP United Nations Development Programme UNICEF United Nations Children's Fund US United States of America USAID United States Agency for International Development VAC Village Assistance Committee WASH water, sanitation, and hygiene WFP World Food Programme Report | October 2020 10 1. Desk Review 1.1 Country and Regional Context 1.1.1 Overview and Politics Haiti is a Caribbean country that shares the island of Hispaniola with the Dominican Republic. With an approximate population of 11.5 million people, Haiti is often lauded as the first country to abolish slavery and the only nation in history established as a result of a successful slave revolt (e.g., Matthewson 1996). In fact, the Haitian revolution (1791 – 1804) has been credited with spurring political activism in several other Caribbean nations around that time (e.g., Geggus 2001). Despite its successful beginnings in 1804 as an independent nation led by Black people, Haiti has struggled politically and economically, particularly in recent decades (e.g., Hauge 2018). For example:  After the 29-year autocratic dynasty of the Duvalier family, characterized by state-sanctioned violence, fell in 1986, Haiti underwent a cycle of ill-fated presidencies and coups. Since then, Haiti has attempted to establish a more democratic political system; however, such efforts have partly been derailed by natural disasters including the 2010 earthquake and Hurricane Matthew in 2016, and by coup d’états in 1991 and 2004. Between 2011 and 2017, thre e presidents and ten prime ministers succeeded each other, creating political instability. In 2018 – 2019, protests related to corruption and misuse of public funds, particularly the PetroCaribe scandal, threatened the stability of President Jovenel Moise. Further exacerbated by rising petrol prices, high cost of living, and corruption allegations, the events known as “Pays lock” (i.e., country lockdown) led to interrupted water supplies, food price increases, decrease in daily incomes, and disrupted operations by hospitals, schools, humanitarian organizations, businesses, and government institutions, according to a 2019 report by the International Federation of Red Cross and Red Crescent Societies. Moise’s government failed to hold scheduled parliamentary elections in October 2019, and the President has been ruling by decree with no seated parliament since January 2020. Now, the country faces potentially damaging consequences from the spread of the COVID-19 virus.  With a Gross Domestic Product per capita of US$756 in 2019, Haiti is classified as the poorest country in the Western Hemisphere, according to the World Bank. 1 It ranked 111th of 117 countries included in the 2019 Global Hunger Index, jointly published by the International Food Policy Research Institute, Concern Worldwide, and Welthungerhilfe. According to the Global Hunger Index, almost 50 percent of the population is undernourished, 21.9 percent of children under five are stunted, and 3.7 percent of children under five are wasted. Haiti’s level of hunger is classified as serious/alarming. This has led to significant migration, both from rural to urban areas and across international borders, in particular to the Dominican Republic and other Caribbean countries, the United States of America, and Latin America. 1 See overview at https://bit.ly/31dTHyD . Accessed on August 3, 2020. Poverty and Malnutrition in Haiti 11 According to Léon (2019), local governments Figure 1 . Areas of Interest were formally established in Haiti between 1987 (with a Constitutional change) and 1996 (through additional laws), although there are still movements in that direction (e.g., Laurent and Pierre 2012 and Hauge 2018). The country has 10 departments (Artibonite, Centre, Grand’Anse, Nippes, Nord, Nord -Est, Nord- Ouest, Ouest, Sud-Ouest, and Sud), distributed over 42 arrondissements and 140 communes/municipalities. A representative is appointed by the government in each department, and a mayor is elected in each municipality. Municipal councils are elected every four years. Figure 1 indicates the AOIs, which for this report are Sud and Grand’Anse. Sud has an approximate population of 720,443, according to the 2019 Integrated Food Security Phase Classification (IPC), with 50 percent living in the two lowest quintiles of the asset distribution (own calculations based on 2017 HDHS). It has five arrondissements: Aquin, Chardonnières, Côteaux, Les Cayes, and Port-Salut. Grand’Anse has an approximate population of 421,504 (IPC 2019), with 70 percent living in the two lowest quintiles of the asset distribution (2017 HDHS). It has three arrondissements: Anse d'Hainault, Corail, and Jérémie. While some indicators suggest local governance across Haiti has improved or at least has the potential to improve (e.g., Hauge et al. 2015) as a result of programs such as the USAID-funded Limyè ak Organizasyon pu Kolekyivite yo Ale Lwen (LOKAL) program implemented by Tetra Tech ARD, which sought to strengthen local governments, previously mentioned developments have likely slowed such progress (e.g., Laurent and Pierre 2012; also see Section 1.3). For example, Hauge et al. (2015) report that the 2010 Haitian elections were marred by violence and irregularities. In Sud, 7.9 percent of ballots were untallied in election results (see their figure 1, p. 276). In Grand’Anse, 5.3 percent of ballots were uncounted. And when it comes to disaster preparedness, management, and risk reduction, local governments have not always been up to the task. Interviews and focus groups in eight communes of Grand’Anse conducted one week after Hurricane Matthew (Marcelin, et. al. 2016) found that local governments did not always apply integrated strategies to preparation efforts. 1.1.2 Socioeconomics, Migration, and Remittances According to CNSA (2019), key pillars of the Haitian economy, and thus sources of income for HHs, are: agriculture (as high as 51 percent if rural), commerce and petty trade (27 percent), tourism and travel (14 percent), and construction (8 percent). For urban HHs, 39 percent rely on petty trade, followed by salaried work at 29 percent. Only two percent of urban HHs appear to rely on agriculture. For rural HHs, agriculture is the main source of income (51 percent), followed by petty trade (33 percent). HHs also borrow quite significantly. Around one-third needed to borrow money in the year before the survey (CNSA 2019) and among those, 87 percent were able to borrow. They borrowed from: friends and family (36 percent), local traders (24 percent), credit unions and informal groups (11 percent), banks (5 percent), and other formal financial institutions (13 percent). This seems consistent Source: OpenStreetMap (2020). Report | October 2020 12 with Ministêre de l’Agriculture des Ressources Naturelles et du Développement Rural (MARNDR) (2012a), which found that many communes have relatively high loan approval rates (greater than 50 percent), except for some parts of Grand’Anse. While the unemployment rate in Haiti has decreased in recent years to about 13.5 percent (World Bank, https://bit.ly/3agYL9z ), concerns remain about labor-market prospects and economic security. As a result, a substantial part of the Haitian population continues to migrate, particularly from the AOIs:  Based on the 2010 Census, the Haitian diaspora comprised approximately 20 percent of the country’s population, primarily living in the United States, the Dominican Republic, and other Caribbean/Latin American countries, although evidence suggests this increased significantly after the 2010 earthquake (e.g., https://bit.ly/3hCq0NT ). At the national level, about 66.2 percent of migrants move to other communes within the same department or to different departments. Others cross international borders, primarily to the Dominican Republic (19.2 percent), the United States (9.2 percent), and Latin America (5.7 percent). The main reasons cited for such migration are work/labor (40 percent), education (26 percent), security (4.6 percent), and health (3.9 percent).  For the AOIs, people migrate internally significantly more than the national average. This is not surprising given the significant distance between the AOIs and the border with the Dominican Republic (recall Figure 1). Twenty percent of migrants in Sud migrate to other communes, 69 percent to other departments, four percent to the Dominican Republic, two percent to Latin America, and two percent to the United States. Twenty percent of migrants in Grand’Anse migrate to other communes, 58 percent to other departments, three percent to the Dominican Republic, five percent to Latin America, and 12 percent to the United States.  The main reasons cited for migration in Sud are work/labor (61 percent), education (10 percent), and security (8 – 9 percent). For Grand’Anse, the main reasons cited are work/labor (52 percent) and education (36 percent). A key consequence of, and thus reason for, migration is the ability to send resources to support family and friends, a.k.a. remittances (e.g., Torero and Viceisza 2015). In fact, Amuedo-Dorantes et al. (2010) find positive effects of remittances on children’s education in Haiti. There is also a substantial body of literature documenting the potentially positive effects of remittances on key development outcomes (e.g., Yang 2011 and the references within). According to CNSA (2019):  Eighteen percent of HHs in Haiti had received remittances in the six months prior to August 2019. Remittances are the main source of income for 20 percent of urban HHs and 13 percent of rural HHs. In Sud, urban HHs constitute 17 percent and rural constitute 83 percent. I n Grand’Anse, urban HHs constitute 25 percent and rural constitute 75 percent. Also see discussion further below related to COVID-19.  For urban HHs, remittances from outside Haiti are sent primarily from North America (43 percent), Latin America (13 percent), and the Dominican Republic (10 percent). Internal remittances primarily come from the capital, Port-Au-Prince (18 percent), and other areas (12 percent). These remittances are used to pay for food (65 percent), education (11 percent), rent (five percent), and other basic needs (10 percent).  For rural HHs, remittances from outside Haiti are sent primarily from North America (35 percent), Latin America (14 percent), and the Dominican Republic (14 percent). Internal remittances primarily come from Port-Au-Prince (21 percent) and other areas (12 percent). These remittances are mainly Poverty and Malnutrition in Haiti 13 used to pay for food (66 percent), education (14 percent), rent (two percent), and other basic needs (nine percent). Particularly in light of COVID-19, there are several concerns for the economic security of Haitian HHs:  The World Bank has estimated that certain countries may see declines of as much as 30 percent relative to their typical remittance receipts. In fact, the value of remittances to Haiti in March 2020 was 18 percent smaller than in the same month the year before ( https://bit.ly/3hgEW3T ). Jewers and Orozco (2020) further indicate that host countries with an elevated number of COVID-19 cases are home to the majority of migrants from Latin America and the Caribbean. The case counts in the United States and the Dominican Republic are of particular concern for Haiti, since those two countries host more than 70 percent of its migrants (Jewers and Orozco, Table 6).  While operational, the agricultural sector has been impacted by government restrictions limiting group gatherings to no more than five people, in place from March to mid-July (Cledo 2020). For example, in Grand’Anse informal labor organizations are founded on group collaboration. The group can work on the land of members who may not pay in cash, but instead by feeding them, for example. Clearly, such constructs and practices continue to be at risk due to the pandemic.  Similar concerns regarding the effect of limiting group size apply to other key industries such as construction.  As is the case for most Caribbean countries, international travel restrictions have led to marked decline in tourism and travel. These developments are in addition to pre-existing concerns with regard to potential political instability, climate change and natural disasters, and food insecurity. 1.1.3 Land, Environment, Climate Change, and Natural Disasters According to CNSA (2019), the major forms of land access in Haiti are: inheritance (35.3 percent), purchasing (24.1 percent), leasing (17.3 percent), and sharecropping/metayage (15.5 percent). Overall, male HHHs tend to engage more in sharecropping (17 percent versus 12 percent of women), whereas female HHHs tend to dominate when it comes to inherited plots (40 percent versus 33 percent of men). Despite this and the fact that formal law treats daughters and sons equally with respect to land property, Kelly et al. (2019) find that women feel relatively tenure-insecure on inherited land relative to men. Concerns about land tenure and property rights are further confirmed by initiatives such as “Securing Land Rights in Haiti: A Practical Guide” prepared by the Haiti Property Law Working Group in 2014 ( https://bit.ly/2DLVH9w ) . Given that close to 30 percent of Haitian HHs engage in farming activities ( https://bit.ly/2FfpNTj ), access to land for cultivation/productive purposes is key. At the national level, 61.1 percent of HHs own or have access to agricultural land, with 36.7 percent in urban areas and 77.4 percent in rural areas (DHS 2017 and CNSA 2019). Based on the 2017 HDHS, 80 percent of HHs in Sud and 84 percent in Grand’Anse have access to land usable for agriculture. According to MARNDR (2012a), with the exception of some parts of Grand’Anse and Sud, less than one carreau (1.3 hectares) of agricultural land is available per farmer. This is consistent with an average farm size of 0.5 hectares across the country (e.g., World Bank 2017) and other developing countries — as suggested by, for example, Foster and Rosenzweig (2017), who argue that most farms/land plots around the world are too small to be efficient. Report | October 2020 14 Environment and climate change drives the potential for natural disasters and further threatens livelihoods and economic security (also see Section 1.2.1). This occurs both directly (e.g., through displacement or destruction of property) and indirectly via degraded land and land erosion. For example:  Major natural disasters have affected the Figure 2 . Flood Risk for Sud and Grand’Anse country over the years, with the two most recent being the 2010 earthquake and Hurricane Matthew in 2016. As is the case for most Northern Caribbean islands, hurricanes and tropical storms also remain an annual threat during the Atlantic hurricane season, which tends to occur between August and October.  The southern region of Haiti is particularly prone to natural disasters such as droughts, floods, hurricanes, and earthquakes. According to Schwartz (2018), Hurricane Matthew had a significant impact on assets, reducing phone access by 16 percentage points, radio access by 30 percentage points, and ownership of livestock by as much as 39 percentage points.  In 2018, Haiti suffered several natural disasters all at once: a period of severe drought, significant floods, and an earthquake (Food and Agriculture Organization, https://bit.ly/3fZgDHj ). According to IPC (2019), 568,000 people live in areas at risk of being affected by such natural disasters, and 333,000 people are estimated to be affected by cholera.  These volatile climatic events have been linked to the El Niño phenomenon in several areas of the country, particularly the AOIs, Sud and Grand’Anse. Figure 2 indicates that Sud is considered at medium risk of flooding relative to Grand’Anse, which is at low risk. A more detailed map of 2012 agroecological zones is also available through MARNDR at https://bit.ly/2Hfw7v7 .  While volatile weather is not unique to Haiti, the country’s pre -existing conditions make it particularly vulnerable. Back-to-back crises have contributed to the degradation of livelihoods and living conditions of the most vulnerable populations, who are often the same people affected by several emergencies at once or in succession. In addition, Haiti retains less than one percent of its original primary forest, making it among the most deforested countries in the world (Hedges et al. 2018). This in turn threatens the country’s biodiversity.  From an agricultural and food security standpoint, the potential for environmental degradation and natural disasters is further exacerbated by limited irrigation in the AOIs (MARNDR, 2012a). In all communes of Grand’Anse, less than five percent of agricultural land is irrigated. In Sud, more than 50 percent of the agricultural land in Chantal is irrigated. Communes bordering Chantal on the East, e.g., Torbeck, Cayes, Maniche, also seem to be more irrigated. But in the remainder, irrigation is limited. As Abel et al. (2019) argue, climate change can serve as a driver of conflict, further exacerbating economic and physical insecurity and migration. Continued exposure to negative shocks could impede Haiti’s development and undermine potential benefits from social programs. According to CNSA (2019), 37 percent of HHs have experienced a negative shock in the last six months, either related to climate Source: Integrated Context Analysis (20 17). Poverty and Malnutrition in Haiti 15 (e.g. drought and earthquakes), food and agriculture (e.g., rising food or input prices and livestock diseases), or other adverse events (e.g., deaths, accidents, and loss of income). Almost twice as many urban HHs (42 percent) as rural HHs (22 percent) have experienced such shocks. While the government of Haiti has attempted to institute a weather index insurance system (World Bank 2013, https://bit.ly/2DLxSP6 ) , it is unclear that this mechanism is functioning at scale (also see Section 1.3). 1.1.4 Gender Based on the 2017 HDHS, about 40 percent of HHs in Sud and 39 percent of HHs in Grand’Anse are headed by women. According to the United Nations Development Programme (UNDP, https://bit.ly/31Le5HF ), Haiti ranked 150 out of 162 countries on the 2018 Gender Inequality Index, which measures gender-based inequalities on three dimensions: reproductive health (based on maternal mortality and adolescent birth rates), empowerment (based on the share of parliamentary seats held by women and attainment in secondary and higher education), and economic activity (based on the labor market participation rate of women and men). Based on these and other measures, there are some concerning trends with respect to gender:  About three percent of the parliamentary seats in Haiti are held by women ( https://bit.ly/3bUiXP7 ).  The percentage of women without any level of education is 13 percent and for men, it is nine percent. Six percent of men and only four percent of women have completed secondary school (DHS 2017).  In 2012, Ha iti’s female labor force participation rate was about 47 percent, while its male labor force participation rate was about 60 percent ( https://bit.ly/2E0reom and https://bit.ly/33oCrYz ). A 2015 World Bank study found wages among women to be 32 percent lower than wages among men.  According to MARNDR (2012b), 25 percent of plots representing 20 percent of land in Haiti belong to women. This suggests a relatively small representation of women in agriculture and that women's plots are smaller on average than those of men (0.75 versus 1 ha). About 40 percent of plot owners produce principally for their own consumption, on plots that represent 32.7 percent of all plots. As expected, women are overrepresented among plot owners who produce primarily for their own consumption (28 percent) compared to the share of the plots they own.  Women struggle to gain access to credit, extension services, and inputs (World Bank 2015). Also, they often do not meet the criteria for enrollment into microfinance programs, which in turn prevents them from obtaining funds to help their small businesses thrive. Furthermore, government extension services fail to include women and thus, they are unable to obtain the same agricultural knowledge or inputs as men (Venort and Calixte 2019).  Forty percent of girls older than five have received no formal education, relative to 34.5 percent of boys (IHSI 2019, https://bit.ly/3fOEiKp ).  At the national level, 12 percent of women between the ages of 15 and 49 have experienced domestic violence at least once in their life (DHS 2017). In Sud, this number is 10.5 percent and in Grand’Anse, it is 9.6 percent.  Based on DHS (2017):  17.6 percent of women in Sud had been beaten by their husbands versus 18.2 percent in Grand’Anse.  33.6 percent of women in Sud had control over their own earnings versus 31.8 percent in Grand’Anse.  5.4 percent of women in Sud independently own a house versus 3.1 percent in Grand’Anse. Report | October 2020 16  14.1 percent of women in Sud use a bank account versus 9.3 percent in Grand’Anse.  7.1 percent of women in Sud were not involved in major HH decisions versus 7.2 percent in Grand’Anse.  56.6 percent of women in Sud own a cell phone versus 48.6 percent in Grand’Anse. Youth In Haiti, 54 percent of the population is under 25, with 31 percent between the ages of 10 and 24 (CNSA, 2019). Based on DHS (2017), 84.2 percent of women and 60 percent of men between the ages of 15 and 19 have not worked (likely for pay) in the last 12 months. For Haitians between the ages of 20 and 24, 58.4 percent of women and 34.6 percent of men have not worked. These numbers compare to a range from 14.6 to 18.9 percent for women in the 35 – 49 age group and a range from 2.9 to 5.4 percent for men in the same age category. This is consistent with arguments made previously. For example, Justesen and Verner (2007) found that female youth in Haiti need special attention because they are more likely than their male peers to drop out of school and be unemployed or inactive. The difference seems to be due to potential risk factors such as lack of role models, guidance, and expectations, early marriage and/or pregnancy, and domestic violence. An August 2019 poll by U-Report ( https://haiti.ureport.in ), a digital tool that allows for the anonymous and free collection of people’s views (particularly of young people), found 44 percent of youth in Haiti believe their opinion is not considered in their community, 26 percent believe that they are discriminated against or excluded from decision-making, and 44 percent are concerned about unemployment ( https://bit.ly/2UjwYyz ). This is consistent with Eustache et al. (2017), who find a high mental health burden among Haiti’s youth , with many not accessing mental health care. Since a substantial part of the Haitian population is relatively young and more likely than their elders to migrate, many development programs emphasize investing in and creating opportunities for young people (e.g., Pluim 2014 on participation). Some examples include (also see Section 1.3):  Rural development programs, particularly focused on young people. Consistent with Feed the Future and International Labor Organization guidelines (e.g., https://bit.ly/31X1C3L ), Food and Agriculture Organization, International Fund for Agricultural Development, and WFP seem to be implementing such initiatives ( https://bit.ly/2Y1qlCJ ).  Skill-building programs, particularly focused on digital jobs and women. Consistent with this, the Ayitic Goes Global program sought to enhance participation among young Haitian women in the global economy ( https://bit.ly/33ZAfsb ) .  Ad hoc forums on adolescent and youth employability, e.g. by UNICEF ( https://bit.ly/2UjwYyz ). 1.2 Food Security Context 1.2.1 Agricultural Production Agriculture is a main source of income for rural HHs who, not surprisingly, are among the poorest in Haiti. At the national level, the main risks to agricultural production are drought, lack of seed supply, predatory birds/pests for crops, diseases and lack of veterinary services for livestock and other animals, and rising prices, e.g., of imported rice, which affect food security and people’s ability to engage in agricultural activities. According to Oxfam (2012) and World Bank (2015), the main constraints Poverty and Malnutrition in Haiti 17 inhibiting growth of the agricultural sector are neglected rural infrastructure, weak research and extension, poorly defined land tenure, limited access to credit and technical training, soil erosion, under investment in human capital, and climate change. Fifty to 90 percent of HHs in Sud, and 75 to 95 percent of HHs in Grand’Anse are engaged in agriculture. In Sud, anywhere from 1 to 19 percent of HHs participate in fisheries. I n Grand’Anse, t he range is from 1 to 13 percent. Figure 3 shows the livelihood zones (and their corresponding key crops) for the AOIs. Based on FEWS NET’s 2015 livelihood classification, Sud falls into t hree zones and Grand’Anse into two zones. Producers in the HT01 zone, Dry coastal maize and charcoal – found only in Sud, grow maize. Producers in the HT07 zone, which spreads across both departments, cultivate beans and bananas and engage in petty trade. Their farming is mostly traditional, with very few cash crops. The HT08 zone, named Southwestern coast maize, manioc, and bush products, also spreads across both departments. This zone is also marked by fisheries focusing on conch and lobster. The HT01 dry coastal maize and charcoal zones can further be described as:  About 13 miles from the coast.  Coastal plain areas, dry bushes, and savanna grass-covered plateaus.  Little rainfall (16 to 40 inches per year), with rainy season in April, May, and November.  Agriculture primarily rainfed and concentrated in rainiest areas. The HT07 South beans, bananas, and petty trade zones can further be described as:  Moderately fertile area.  Rainy season from April to November, with rainfall of 35 inches per year.  Limited access to land, although landless HHs practice sharecropping.  Lean season and farming from March Figure 3 . Main Livel ihood Zones in Sud and Grand’Anse to August. HHs tend to offer labor to the agricultural market during this time at low wages (likely due to oversupply).  H