Povrete ak Malnitrisyon an Ayiti: Rezilta ki soti nan Depatman Nòdès ak Sant

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 Nord-Est and Centre 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 in 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 Chicago 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 Nord-Est and Centre Departments. Research Technical Assistance Center: Washington, DC. 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 the age of five were stunted and 3.7 wasted. Based on the index, the level of hunger in the country was considered serious/alarming. 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 departments, Nord-Est and Centre. In Nord-Est, 49 percent of the population lives in the two lowest quintiles of the asset distribution, compared to 56.7 percent in Centre. Section 1 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 if rural), commerce and petty trade (27 percent), tourism and travel (14 percent), and construction (8 percent). In Nord-Est, about 20 percent of HHs engage in professional/clerical jobs, 37 percent in sales, and 23 percent in agriculture. Eighteen percent are unemployed. In Centre, 18 percent of HHs engage in professional/clerical jobs, 46 percent in sales, and 14 percent in agriculture. Twenty-one 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). In Nord-Est, 13 percent migrate to other communes, 30 percent to other departments, 51 percent to the Dominican Republic, 10 percent to Latin America, and 10 percent to the United States. There is relatively little internal migration from Centre, but 32 percent migrate to the Dominican Republic, 46 percent to the US, and 15 percent to Latin America. 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. Sixty-five percent of HHs in Nord-Est and 69 percent in Centre have access to land usable for agriculture. Gender: About 41 percent of HHs in Nord-Est are headed by women, as are 36 percent of HHs in Centre. At the national level, 12 percent of women reported having experienced domestic violence at Poverty and Malnutrition in Haiti 2 least once in their lives. Recent anecdotal evidence suggests this percentage may have increased, particularly in Nord-Est. In Centre, transit on the border with the Dominican Republic presents many risks to women, including violence (physical, sexual, economic, verbal/psychological), and illicit human smuggling and trafficking, including for purposes of forced sex work. 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. Livelihoods 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). Two such livelihood zones encompass the departments of interest to this analysis. Both departments contain zones designated as HT02 (North tubers and horticulture) and HT03 (Central Plateau maize and tubers). In Nord-Est, Fort-Liberte and Ouanaminthe are entirely designated as HT02, while the remaining arrondissements, Trou-du-Nord and Vallieres, are split across HT02 and HT03. The Centre department is entirely in the HT03 zone. Agricultural production : HHs in HT02 areas engage in the production of tubers such as sweet cassava, yams, and sweet potatoes as staple crops and horticulture such as bananas, black beans, and pigeon peas as cash crops. HHs in HT03 areas engage in the production of tubers and maize as staple crops and some horticulture as cash crops. High elevation regions of Centre also produce citrus fruits and coffee. Market and food access : The main local market in HT02 zones is Ouanaminthe, which is in Nord-Est. In HT03 zones, rugged terrain makes market access difficult, particularly during the rainy season. Staple foods: The main staple foods in HT02 zones are maize, peas, and beans, yams and potatoes, rice and flour, and avocado. The main staple foods in HT03 zones are rice, maize, and beans. Food insecurity: Based on the Consolidated Approach to Reporting Indicators of Food Security approach established by the World Food Programme (WFP), 50.7 percent of the Haitian population is either moderately or severely food insecure. In Nord-Est, 40.2 percent of the population is food insecure, compared to 54.1 percent of the population in Centre. This also translates into low food diversity, low intake of vitamin A, and low consumption of iron-rich foods. 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 interventions in Haiti. Main lessons learned stress the importance of building government capacity, being prepared 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: HHs 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: Report | October 2020 3  In Nord-Est, HHs who own radios or mobile phones are less likely to be poor, while those who own gas/petrol lamps or live in houses with dirt/mud walls are more likely to be poor.  In Centre, HHs who own radios or mobile phones are less likely to be poor while those who live in houses with dirt/mud walls are more likely to be poor. Additionally, those who access drinking water from wells or live in houses with cane/palm walls or leaf roofs are more likely to be poor. The same holds for those who lack access to a fixed or mobile place for handwashing. Finally, HHs that own sheep or chickens, have more members above 65 years of age, and live in houses with cement walls or have access to solar energy are less 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, based on the 2012 and 2017 HDHS. Stunting: Econometric analysis suggests that in the Nord-Est and Centre departments, children are less likely to be stunted if their mother has a post-secondary education or they are boys. They are more likely to be stunted if their mother is married. In Centre, children in HHs headed by women are less likely to be stunted, whereas children with average birth size are significantly more likely to be stunted compared to those who were very large at birth. Wasting: Pairwise comparisons suggest that children are more likely to be wasted if the mother is not literate or divorced or separated. They are less likely to be wasted if the father has a professional or managerial job. Table 1 . Summary of Findings Theme Nord - Est Centre Source Poverty rate (HHs in lowest two quintiles) 49 percent of HHs 56.7 percent of HHs 2017 HDHS Stunting 21 percent 30 percent 2017 HDHS Wasting 1.5 percent 2.9 percent 2017 HDHS Migration destination Other communes (13 percent); other departments (30 percent); Dominican Republic (51 percent); Latin America (10 percent); United States (10 percent) Dominican Republic (32 percent); United States (46 percent); Latin America (15 percent) CNSA (2019) Access to land usable for agriculture 65 percent 69 percent DHS (2017) Main production Tubers, horticulture, maize Tubers, horticulture, maize FEWS NET (2015) and CNSA (2019) Staple foods HT02: Maize, peas, beans; yam and potatoes; rice and floor; avocado Rice, maize, beans FEWS NET (2015) and CNSA (2019) HT03: rice, maize, beans Food insecure 40.2 percent 54.1 percent CNSA (2019) Poverty and Malnutrition in Haiti 4 Theme Nord - Est Centre Source Food diversity and nutrition Low food diversity Low intake of vitamin A Low iron-rich food consumption Low food diversity Low intake of vitamin A Low iron-rich food consumption CNSA (2019) Poverty determinants Radio, mobile phones, or gas/petrol lamps (-); dirt/mud walls (+) Radio, mobile phones (-); dirt/mud walls (+); no hand- washing place (+); ownership of sheep or chicken (-); number of HH members over 65 (-) 2017 HDHS Child malnutrition determinants: stunting Mother has post-secondary education (-); mother is married (+); boys (-) 2017 HDHS Child malnutrition determinants: wasting Mother not literate (+); mother divorced or separated (+); Father has a professional or managerial job (-) 2017 HDHS Note: HT02 stands for North tubers and horticulture livelihood zone and HT03 for Central Plateau maize and tubers livelihood zone. Report | October 2020 5 Table of Contents Executive Summary ........................................................................................................................................................... 2 1. Desk Review ............................................................................................................................................................ 11 1 .1 Country and Regional Context .................................................................................................................. 11 1 . 2 Food Security Context ................................................................................................................................. 18 1 . 3 Lessons Learned: Programs and Initiatives .............................................................................................. 26 2. Data Analysis ........................................................................................................................................................... 34 2.1 Poverty in Nord-Est ...................................................................................................................................... 34 2.2 Poverty in Centre .......................................................................................................................................... 39 2.3 Child Malnutrition ......................................................................................................................................... 44 3. References ................................................................................................................................................................ 51 4. Annexes .................................................................................................................................................................... 55 Poverty and Malnutrition in Haiti 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 Nord-Est (2017 HDHS) ................................................................................ 35 Table 5. House Materials and Poverty in Nord-Est (2017 HDHS) ...................................................................... 36 Table 6. Water Access, Sanitation, Hygiene, and Poverty in Nord-Est (2017 HDHS) ................................... 37 Table 7. HHH Characteristics, HH Structure, and Poverty in Nord-Est (2017 HDHS) ................................ 38 Table 8. HH Assets and Poverty in Centre (2017 HDHS) .................................................................................... 40 Table 9. House Materials and Poverty in Centre (2017 HDHS) .......................................................................... 41 Table 10. Water Access, Sanitation, Hygiene, and Poverty in Centre (2017 HDHS) ..................................... 41 Table 11. HHH Characteristics, HH Structure, and Poverty in Centre (2017 HDHS) .................................. 42 Table 12. Mother’s Characteristics and Stunting in Nord -Est and Centre (Pooled) Departments ............. 45 Table 13. Father's Characteristics and Stunting in Nord-Est and Centre (Pooled) Departments .............. 46 Table 14. Child's Characteristics and Stunting in Nord-Est and Centre (Pooled) Departments ................. 47 Table 15. Mother’s Characteristics and Wasting in Nord -Est and Centre (Pooled) Departments ............ 48 Table 16. Father’s Characteristics and Wasting in Nord -Est and Centre (Pooled) Departments .............. 49 Table 17. Child’s Characteristics and Wasting in Nord -Est and Centre (Pooled) Departments ................ 50 Table 18. Predictors of Poverty in Nord-Est and Centre Departments Based on OLS Regression (2017 HDHS) ................................................................................................................................................................................ 55 Table 19. Predictors of Stunting in Nord-Est and Centre Departments Based on OLS Regression (2017 and 2012 HDHS) .............................................................................................................................................................. 58 Table 20. Predictors of Wasting in Nord-Est and Centre Departments based on OLS Regression (2017 and 2012 HDHS) .............................................................................................................................................................. 60 Report | October 2020 7 List of Figures Figure 1. Areas of Interest ............................................................................................................................................. 12 Figure 2. Flood Risk for Nord-Est and Centre ......................................................................................................... 15 Figure 3. Main Livelihood Zones in Nord-Est and Centre Departments ........................................................... 18 Figure 4. Primary and Secondary Roads in Haiti and AOIs ................................................................................... 20 Figure 5. Market Accessibility ....................................................................................................................................... 20 Figure 6. Mode of Accessing Food in Nord-Est and Centre ................................................................................. 21 Figure 7. Food Diversity in Nord-Est and Centre Departments (# of food groups) ...................................... 25 Figure 8. Frequency of Vitamin A Intake in Nord-Est and Centre Departments ............................................ 25 Figure 9. Frequency of Iron-fortified Food Consumption in Nord-Est and Centre Departments .............. 25 Poverty and Malnutrition in Haiti 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 Coordination Nationale de la Séc urité 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 Industrial 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 Health 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 IPC The Integrated Food Se curity 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 Ministry of Social Affairs a nd Labor ( Ministère des Affaires Sociales et du Travail ) Mt metric ton NGO non - governmental organization Report | October 2020 9 OLS Ordinary Least Squares pp percentage point(s) PRRO Haiti Protracted Relief and Recovery Operation RFEO Rassemblement des Femmes Engagées de Ouanaminthe SD standard deviation SYFAAH System of Financing and Agricultural Insurance UNDP United Nations Development Programme UNICEF United Nations Children's Fund UNPF United Nations Population Fund USAID United States Agency for International Development VAC Village Assistance Committee WASH water, sanitation, and hygiene WFP World Food Programme Poverty and Malnutrition in Haiti 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, three 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. Moi se’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 pe rcent 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. Report | October 2020 11 According to Léon (2019), local Figure 1 . Areas of Interest governments 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 1shows the AOIs, which for this report are Nord-Est and Centre departments. Nord-Est has an approximate population of 367,038, according to the 2019 Integrated Food Security Phase Classification (IPC), with 49 percent living in the two lowest quintiles of the asset distribution (own calculations based on 2017 HDHS). The department has four arrondissements: Fort-Liberte, Ouanaminthe, Trou-du-Nord, and Vallieres. Centre has an approximate population of 707,601 (IPC 2019), with 56.7 percent living in the two lowest quintiles of the asset distribution (2017 HDHS). It too has four arrondissements: Cerca-la-Source, Hinche, Lascahobas, and Mirebalais. 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 Error! Reference source not found. ). For example, Hauge et al. (2015) report that the 2010 Haitian elections were marred by violence and irregularities. According to the report, 21.6 percent of ballots in Nord-Est and 8.2 percent of ballots in Centre were untallied in official election results (see Hauge et al., figure 1, p. 276). Given this and related electoral conflict, one of the study authors discusses the difficulties in institutionalizing elections in a separate paper (Gilles 2014). 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 Poverty and Malnutrition in Haiti 12 Source: OpenStreetMap (2020) . 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 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 Nord-Est. 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 internationally more so than the national average. This should not be surprising given both AOIs share a border with the Dominican Republic (recall Figure 1). Thirteen percent of migrants in Nord-Est migrate to other communes, 30 percent to other departments, 51 percent to the Dominican Republic, 10 percent to Latin America, and 10 percent to the United States. There is relatively little internal migration from Centre. There, 32 percent of migrants migrate to the Dominican Republic, 46 percent to the United States, and 15 percent to Latin America.  The main reasons cited for migration in Nord-Est are work/labor (60 percent) and education (10 percent). For Centre, the main reasons cited are work/labor (90 percent), education (20 percent), and security (22 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 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 Nord-Est, urban HHs constitute 49 percent and rural constitute 51 percent. In Centre, urban HHs constitute 22 percent and rural constitute 78 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 Report | October 2020 13 come from Port-Au-Prince (21 percent) and other areas (12 percent). These remittances are mainly 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, 2020).  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, the practice known as “konbit” combines a farm labor group with a tontine. Wages are paid to the group and members receive this pay to the group on a rotating basis. The group can also work on the land of members who may not pay in cash but by, for example, feeding the workers. 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 heads of household (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, particularly in Centre. 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, 65 percent of HHs in Nord-Est and 69 percent in Centre have access to land usable for agriculture. According to MARNDR (2012a), in most parts of Nord-Est and Centre, no more 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. Poverty and Malnutrition in Haiti 14 Environment and climate change drives the Figure 2 . Flood Risk for Nord - Est and Centre potential for natural disasters and further threatens livelihoods and economic security (also see Section 0). This occurs both directly (e.g., through displacement or destruction of property) and indirectly via degraded land quality and land erosion. For example:  Major natural disasters have affected the country over the years, with the two most recent being the 2010 earthquake and the 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 from August through October.  In 2018, Haiti suffered several natural disasters all at once: a period of severe drought, floods, and an earthquake (FAO, https://bit.ly/3fZgDH j). 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, Nord-Est and Centre. Figure 2 indicates that Nord-Est is considered at high risk of flooding relative to Centre, which is at low risk. A more detailed map of 2012 agroecological zones is 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, 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 both departments, particularly Centre, less than five percent of agricultural land is irrigated. In Nord-Est, communes that border the Dominican Republic (e.g., Ferrier) seem to have more irrigation that the average. 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 (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 losses of income). Forty-two percent of HHs in urban areas and 22 percent of HHs in rural areas have experienced such shocks. While the Government of Haiti (GoH) has attempted to institute a weather index insurance system (World Bank Report | October 2020 15 Source: Integrated Context Analysis (2017). 2013, https://bit.ly/2DLxSP6 ), it is unclear that this mechanism is functioning at scale (also see Section Error! Reference source not found. ). 1.1.4 Gender Based on the 2017 HDHS, about 41 percent of HHs in Nord-Est and 36 percent of HHs in Centre 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 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, Haiti’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 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 criteria for enrollment into microfinance programs, which in turn prevents them from obtaining funds to help their small businesses thrive. Furthermore, since government extension services fail to include women, 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 ).  Based on DHS (2017), 39.8 percent of women in Nord-Est and 39.5 percent in Centre control their own earnings. And only 4.5 percent of women in Nord-Est and eight percent in Centre independently own their dwelling.  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 Nord-Est, this number is 9.9 percent, and in Centre, it is 12.6 percent. Recent anecdotal evidence suggests this number may be even greater, particularly in Nord-Est. According to Rassemblement des Femmes Engagées de Ouanaminthe (RFEO), the number of reported domestic violence cases between March and April 2020 in Ouanaminthe, an arrondissement in Nord-Est, increased from the typical 4 to 13. RFEO attributes this to the economic downturn.  Petrozziello et al. (2012) found migrant women in transit on the Dominican Republic – Haiti border to be at risk of physical, sexual, economic, and verbal/psychological violence as well as illicit human Poverty and Malnutrition in Haiti 16 smuggling and trafficking, including for purposes of forced sex work. The market in Comendador (the Dominican Republic), which shares a border with Belladère (Centre, Haiti) appeared of particular concern. In response to increased concerns about violence against women, the RFEO has been implementing initiatives to combat violence against women and support survivors. The organization has also set up a database to record cases in Ouanaminthe. There also seem to be broader Nord-Est-based initiatives as suggested by a relatively recent terms of reference drafted by the Subgroup on Gender-based Violence in collaboration with the GoH and United Nations Population Fund (UNPF, https://bit.ly/2XTwQaM ). On a slightly more positive note:  Women’s organizations appear actively involved in the fight against COVID -19, particularly in the Ouanaminthe, the shared border with the Dominican Republic and frequent back-and-forth travel increases risk of spread. According to Reliefweb, the Women’s Voice and Leadership project in Haiti has increased its support to six women’s organizations (including the RFEO) in Nord-Est, in an attempt to strengthen awareness of COVID-19 prevention measures. With well-established ties to the communities in which they work, these organizations enjoy great credibility with the local population. That makes them particularly well positioned to transmit health advice to the respective communities in an effort to change behavior and attitudes ( https://bit.ly/36QmgnV ).  Quellhorst et al. (2020) find that, for a sample of 214 farmers across Artibonite, Centre, and Ouest, postharvest management practices were gendered at the lower end of the value chain, where women played a key role in marketing. They argue that addressing postharvest management challenges through targeted interventions to increase food availability can improve food security in Haiti. One way to interpret this is that with proper support women could play an even more substantive role in food security. 1.1.5 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 views (particularly of young people), found 44 percent of youth in Haiti believe their opinion is not considered in their community, 26 percent believe 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 Report | October 2020 17 people (e.g., Pluim 2014 on participation). Some examples include (also see Section Error! Reference source not found. ):  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 (FAO), 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 ). 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 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. About 60 percent of HHs in Nord-Est and 70 percent in Centre are engaged in agriculture. Figure 3 . Main Livelihood Zones in Nord - Est and Centre In Nord-Est, less than two percent Departments of HHs participate in fisheries. In Centre, there seems to be no such activity, likely because the department does not border the Caribbean Sea. Figure 3 shows the livelihood zones (and their corresponding key crops) for the AOIs. Based on FEWS NET’s 2015 livelihood classification, some parts of Nord-Est fall into two zones, also apparent from the figure. Specifically, Fort-Liberte and Ouanaminthe are entirely in HT02 (North tubers and horticulture), which means that they engage in the production of tubers as staple crops (e.g., sweet cassava, yams, and sweet potatoes) and horticulture as cash Source: FEWS NET (2015). crops (e.g., bananas, black beans, and Poverty and Malnutrition in Haiti 18 pigeon peas). The remaining arrondissements, Trou-du-Nord and Vallieres, are split between HT02 and HT03 (central plateau maize and tubers). The southern parts of Trou-du-Nord and Vallieres are considered HT03, similar to Centre. They engage in the production of tubers and maize as staple crops and some horticulture as cash crops. Some highly elevated parts of Centre also produce citrus fruits and coffee. The parts of Nord-Est that are classified as HT02 c