The Milkmaid, by Johannes Vermeer, 1660.
Food safety hazards are increasingly recognized as a major public health problem worldwide, yet among developing countries, there is limited understanding of the wider-ranging socioeconomic costs of unsafe food and the benefits of remedial or preventative measures. This limited evidence base has led many countries to underinvest in food safety, or invest inefficiently in reaction to serious outbreaks of foodborne illness, other food scares, or trade interruptions. For many countries experiencing rapid urbanization and dietary changes, the growing complexity of food safety hazards is outpacing if not overwhelming prevailing food safety management capacity—both in government and in supply chains.
A new report strengthens the economic case for increased public investment and other policy attention on food safety in developing countries.
The report synthesizes evidence of the economic costs of unsafe food in relation to both domestic markets and trade.
The report positions food safety as an integral part of economic development and food system modernization.
And the report provides guidance on improving food safety awareness and behaviour from farm to fork.
The five authors of the report are Steven Jaffee, of the World Bank; Spencer Henson, of the University of Guelph; Laurian Unnevehr, of the University of Urbana-Champaign; Delia Grace, of the International Livestock Research Institute (ILRI); and Emilie Cassou, World Bank consultant.
Foreword by World Bank vice presidents
Annette Dixon (human development) and Laura Tuck (sustainable development)
‘Every day around the globe, families and friends eat to provide themselves with essential energy and nutrients to lead healthy and productive lives, as well as for pleasure and comfort. Yet every day, on average, unsafe food makes close to two million people sick, keeping them from school and work, and sometimes dramatically degrading or curtailing their lives. Worst of all, foodborne illness disproportionately strikes populations that can least afford to be sick. Low- and middle-income countries in South Asia, Southeast Asia, and Sub-Saharan Africa account for 41 percent of the global population but are afflicted with 53 percent of all foodborne illness, and 75 percent of related deaths. . . . Translated into economic terms using 2016 income data, illness, disability, and premature deaths induced by unsafe food lead to productivity losses of about US$95 billion a year in low- and middle-income countries. Unsafe food undermines food and nutritional security, human development, the broader food economy, and international trade.
‘The Safe Food Imperative argues that much of the burden of unsafe food can be avoided through practical and often low-cost behavior and infrastructure changes at different points along food value chains, including in traditional food production and distribution channels. In many countries, concerted action on domestic food safety has been sporadic and reactive, coming in the wake of major outbreaks of foodborne disease or food adulteration scandals.
‘Yet what is needed are sustained investments in prevention, including ones that build countries’ core competencies to manage food safety risks, and motivate and empower many different actors, from farm to fork, to act responsibly and with consumer health in mind. . . .
‘Countries as diverse as Chile, India, Kenya, Ukraine, Uruguay, and Vietnam have demonstrated that better health and commercial outcomes are possible with the joint involvement of public agencies, businesses, and consumers in food safety. . . . More and better investments in food safety are needed for countries to unleash their full potential to grow their economy inclusively and sustainably.’
The food safety context
‘Food safety is linked in direct and indirect ways to achieving many of the Sustainable Development Goals, especially those on ending hunger and poverty, and promoting good health and well-being. . . .
‘Well-functioning markets can provide incentives for farmers and food business operators to supply products that match the safety characteristics consumers demand. Even so, there are many circumstances stemming from problems of information and costs where pure market signals fail and additional measures are needed. . . .
For many developing countries, food safety has, until recently, received very little policy attention and only modest investment in capabilities to manage risks.
‘Two main groups of factors contributed to this. The first group includes the weak empirical base for the country-level incidence of foodborne hazards and disease, the economic costs of unsafe food, and the efficacy of food safety interventions. The second group includes institutional factors: the fragmentation of food value chains and public institutional mandates, and the absence of effective consumer representation in most developing countries.
Because of scarce data and thematic leadership, food safety tends to appear on national radar screens only during crises.
‘A typical crisis would be a major outbreak of foodborne disease (FBD) causing death, scandals involving deliberate food adulteration, trade bans, or widespread consignment rejections because of noncompliance with standards. In developing countries, these episodes have tended to spur reactive and defensive damage control, resulting in a flurry of regulatory actions or investments. When these are taken in crisis management mode, they often differ in target, content, approach, and lasting efficacy from when food safety measures are developed and adopted in a more deliberative, evidence-based, forward-looking, and consultative manner.
Years of inadequate policy attention and underinvestment have stunted the development of coherent national food safety management systems in many low- and middle-income countries (LMICs).
‘Most of these countries have weak food safety systems in terms of scientific evidence, necessary infrastructure, trained human resources, food safety culture, and enforceable regulations. Governance of national food safety systems in LMICs—whereby stakeholder roles and accountabilities are well defined and understood—is also weak. While many LMICs have islands of strong food safety management capacity, these support only segments of the agri-food system and consumers (often the wealthiest).
An especially weak area is the infrastructure and services needed to mitigate the food safety risks faced by the poor. Their FBD burden is often invisible and voiceless.
‘The dominant discourse on food safety in LMICs has focused on trade, but this needs to change. . . . Changing demographics and dietary patterns are creating new commercial opportunities in domestic food markets, but these are also increasing the exposure of LMIC populations to food safety hazards. Although statistically invisible, the domestic economic costs of unsafe food are significant and growing in many LMICs.
‘In recent years, various major international initiatives have given increased attention and resources to mitigate risks from unsafe food in LMICs. Examples include the work of the World Health Organization’s Foodborne Disease Burden Epidemiology Reference Group (FERG), CGIAR’s food safety research under its Agriculture for Nutrition and Health program, the Global Food Safety Partnership’s country and regional initiatives, the Partnership for Aflatoxin Control in Africa, the World Bank Group’s expanded investment lending and advisory services, and the African Union’s initiative on food safety; the continued technical support provided to countries by the Food and Agriculture Organization, World Health Organization, and the Standards and Trade Development Facility; support by the U.K.’s Department for International Development, the U.S. Agency for International Development, and the Bill & Melinda Gates Foundation for research on FBDs and their control in developing countries; and various regional initiatives.
The public health burden and economic costs of unsafe food
‘Research is shedding new light on the global burden of FBD. . . . FERG has been working on global estimates of the incidence of FBD since 2006. This work covers 31 of the most important foodborne hazards in 14 regions. The estimates are expressed in terms of disability-adjusted life years (DALYs) associated with ill-health and premature death.
For 2010, the base year, the global burden of FBD is estimated at 600 million illnesses and 420,000 premature deaths.
This aggregates to the equivalent of 33 million DALYs (Havelaar et al. 2015).
For comparison, the estimated 2015 global burden of tuberculosis was 40 million DALYs, and 66 million for malaria.
These FBD estimates are considered to be highly conservative.
‘. . . The global burden of FBD is unequally distributed. Asia and Sub-Saharan Africa have the highest incidence of FBD, as well as the highest rate of deaths due to FBDs and the greatest loss of DALYs. LMICs in South Asia, Southeast Asia, and Sub-Saharan Africa, which make up 41 percent of the global population, are estimated to account for 53 percent of all foodborne illnesses, 75 percent of FBD-related deaths, and 72 percent of FBD-related DALYs.
A disproportionate share of the burden falls on children under the age of five, who account for 9 percent of the global population but 38 percent of all cases of illness and 40 percent of the DALYs.
An estimated 30 percent of premature deaths due to FBD are in children under the age of five.
Geographically, children are most likely to die from FBD in Sub-Saharan Africa, followed by South Asia.
Epidemiological studies show that the people most vulnerable to foodborne disease are the young, old, malnourished, poor, pregnant, and those who are immuno-compromised.
‘The economic costs of unsafe food take multiple forms and have both short- and long-term dimensions. Valuing these costs is challenging because of data and methodological limitations. . . . This report estimates the cost of FBD on the basis of “productivity losses,” as measured by gross national income per capita and associated with disability or premature death captured in DALYs. The report uses FERG’s DALYs by country or subregion for 2010 and the gross national income per capita estimates for 2016 from the World Bank’s World Development Indicators Database.
‘The total productivity loss associated with FBD in LMICs is estimated at US$95.2 billion a year. Of this, upper-middle-income countries account for US$50.8 billion, or 53 percent of the total. Lower-middle-income countries account for US$40.6 billion (43 percent), and low-income countries for US$3.8 billion (4 percent). By region, LMICs in Asia account for US$63.1 billion, and those in Sub-Saharan Africa for US$16.7 billion. The cost of treating foodborne illnesses should be added to this. These are estimated at US$15 billion a year in LMICs.
Even without factoring in the hard-to-measure costs of domestic food market disruptions and consumer product avoidance, the domestic costs of unsafe food would aggregate to at least US$110 billion among LMICs.
‘. . . All LMICs are experiencing changes in diets, food sourcing and preparation patterns, and in the structures and governance arrangements in food value chains. But where they are positioned in this process of food system transformation varies considerably. . . .
‘While low-income countries certainly face a significant burden of food-related illness, diets in these traditional food markets tend still to be dominated by starchy staples, and policy attention is focused on the availability and affordability of these foods and on other public health issues (for example, malaria, HIV/AIDS, and waterborne diseases).
Food safety concerns generally become more important in transitioning lower-middle-income countries that are experiencing rapid demographic and dietary change, giving rise to dynamic and visible food safety hazards, which typically overwhelm latent food safety management capacities.
‘And because of greater access to media, improving wealth and a variety of psychological mechanisms, consumers become ever more concerned about food safety. The gap between need and capacity begins to close as countries advance through and beyond upper-middle-income status, as a result of which the relative economic burden of FBD subsides in the modernizing stage of the food safety life cycle. . . .
The status of food safety management
‘No representative and comprehensive benchmarking program exists for food safety management capacities in LMICs. . . . Food safety metrics and targets are generally not covered in development planning and monitoring initiatives.
‘A review of often non–publicly disclosed assessments points to common shortcomings in the national food safety systems of LMICs. These include:
- The absence of a comprehensive national food safety policy, translating into a lack of prioritization of investments
- A focus on hazard rather than risk, often leading to the misallocation of resources
- The presence of many regulations and standards, yet a lack of clarity on the extent to which these are voluntary or mandatory
- The fragmentation of institutional responsibilities, especially for market surveillance and inspecting food production, processing, and handling facilities
- Fragmented systems for laboratory testing that do not function as a system and fail to reveal comprehensive inferences on the causes of FBD
- The lack of effective food safety engagement with consumers, whether in relation to education, risk communication, and other matters
- The failure to empower and incentivize the private sector to deliver food safety and
- The lack of consistent and transparent border measures to address growing food imports.
‘Data and information gathered for this report are consistent with this picture of underdeveloped food safety management systems, especially in the public sector.
For example, animal source foods account for a high proportion of FBD in many LMICs, yet underlying capacities to manage food safety hazards from animal sources are generally weak.
‘This is especially true for functions that are considered critical public goods. Among the 34 Sub-Saharan African countries for which assessment data are available, only four are deemed to have adequate capacity for identifying and tracing animals and animal products, and only a similar number can adequately inspect abattoirs. Capacities for quarantine and border security are somewhat better, yet these are deemed adequate in only 21 percent of the 34 countries. Among the 35 lower-middle-income countries worldwide assessed by the World Organisation for Animal Health, only 6 percent were found to have adequate capacities for animal product identification and traceability, and 11–17 percent were deemed to have adequate capacities for inspecting abattoirs or meat distribution facilities, had effective regulations for veterinary drugs, or were able to ensure the quality of laboratory testing of animal products. The situation is different among upper-middle-income countries, where 30–45 percent of 29 rated countries had adequate capacities in these areas.
‘For the private sector, the situation is more varied in low- and lower-middle-income countries and, again, substantially more advanced in countries in later stages of economic development. . . . [I]nformal distribution channels and traditional community markets continue to play a predominant role, at least in Africa and Asia. . . .
‘The widest gaps between needed and actual food safety management capacity are in lower-middle-income countries. Especially the larger of these countries are important food safety “hot spots,” where the exposure of populations to hazards is increasing, consumer food safety confidence is waning, and neither decentralized food safety regulatory capacity nor the governance arrangements of the formal private sector food industry are able to match the emerging challenges.
‘These countries need comprehensive measures to curb what is likely to be a substantially higher health and economic burden of FBD in the coming years. Setting aside upper-middle-income China, the world’s lower-middle-income countries accounted for 70 percent of the estimated human capital productivity loss from FBD of all developing countries in 2016.
The growing attention to domestic food safety has probably had little positive impact on the poor.
‘The consumption of unsafe food by low-income populations stems from a combination of factors, including low access to potable water, the cohabitation of humans and animals, high exposure to environmental contaminants, the suboptimal use of inputs and other practices of semi-subsistence farmers, poor rural infrastructure, poor hygienic conditions in urban community markets, and the widespread presence of food safety hazards in street food. A particularly high investment deficit relates to the physical condition of traditional community markets and small shops, where most poor people shop for fresh produce. Some market-based standards initiatives may be having the unintended consequence of securing safe produce for targeted distribution channels, but leaving the more contaminated, test-failing produce for the markets of lower-income consumers.
For many countries, capacities to manage food safety risks for exports appear to be considerably stronger than capacities to protect domestic consumers.
‘Trade-related compliance with food safety regulations and standards has undoubtedly been the catalyst for the significant upgrading of food safety management capacity in many low- and middle-income countries, especially the latter. Thus, efforts to meet some of the toughest regulations and standards in high-income countries have driven many early and sustained upgrades in laws, control systems, and systems of private value chain governance for food safety.
‘Unfortunately, evidence of substantive spillovers between trade-related capacity development and domestic systems is limited. And as noted earlier, many LMICs are not applying risk-based approaches to managing food imports.
Inconsistent or burdensome border measures do not ensure safer food, but preventive and science-based measures can.
‘Compliance costs are not a big burden for leading LMIC exporters. . . . Compliance costs can be a burden for smaller LMICs. It is in these countries, and their less established and smaller sectors and firms, where the costs of compliance with food safety regulations and standards is more challenging. These costs can potentially be a make or break trade issue. . . .
High-value food imports by LMICs have been growing at double-digit rates since 2000 and were just below US$150 billion in 2016.
For low-income countries, two-thirds of their high-value food exports and imports involve trade with other developing countries.
For lower-middle-income countries, imports from and exports to other developing countries are growing at a fast pace.
Trade among developing countries will account for most future growth in high-value food trade because of higher income elasticities and demand for dietary diversity, especially in middle-income countries.
‘Exporting to other developing countries poses challenges that differ from those in high-income markets. . . . [C]ross-border or longer distance South-South trade is often characterized by a lack of transparency in rules and procedures, limited use of science-based evidence in applying technical barriers to trade and sanitary and phytosanitary measures, high border transaction costs, and rapidly changing consumer demands for quality and safety . . . . In many LMICs, informal or illegal cross-border trade is very common and is perhaps equivalent to formal legal trade in size, and animals and food products following this route lack any structured sanitary inspection.
The way forward
‘A . . . . significant share of food safety problems and associated costs is avoidable. [S]ome countries do considerably better than others in terms of the burden of FBD, despite having similar constraints. With a proactive strategy and a proper prioritization of problems and measures, countries can avoid losses from the burden of FBD amounting to hundreds of millions of dollars a year (and these losses can run up to several billion dollars for larger countries). In doing so, countries can minimize disruptions to markets and livelihoods that come from periodic food safety scares and prevent these episodes from dominating consumer perceptions about the underlying quality and safety of local foods (and the integrity of the food governance arrangements in place).
‘While the safety of food is a “public good,” governments do not and cannot have the primary responsibility for safe food. Rather, food safety needs to become a shared responsibility. Operationalizing this concept effectively is a significant challenge in many LMICs. Governments need to play effective vision-setting and convening roles; provide reliable information to other stakeholders; and effectively deploy a wide set of policy instruments, both carrots and sticks, to involve, incentivize, and leverage the actions of farmers, food business operators, and consumers.
While practitioners once emphasized effective ‘official food control’ systems, the most critical roles for government are now recognized to be facilitative ones that induce investments and behavior changes by actors that share with government the goal of and responsibility for safer food.
‘This inclusive concept of food safety management may require a paradigm shift in how emerging countries approach food safety regulation. The traditional model centers on enforcement through inspections of food facilities and product testing, and systems of legal and financial penalties for infractions.
This strict authoritative model is seemingly appealing to the public, media, and therefore political decision makers, yet it is not altogether an effective model and it can be highly misplaced in contexts in which smallholder farmers, micro and small enterprises, and informal food channels predominate, and both surveillance and inspectorate capacities are limited.
‘A shared management model implies a move from a regulator-regulated relationship toward efforts by governments to better incentivize and facilitate safe production, processing, and distribution of food. . . . Governments of LMICs not only need to invest more in food safety but also to invest more smartly. . . . Not all investments that can reduce the burden of FBD are ones typically regarded as “food safety” investments. Critical investments may be ones that address environmental health issues, such as those that increase access to potable water and improve sanitation or lessen environmental contaminants in soil, water, and air. . . .
A call to action
This report offers two sets of recommendations to national governments.
The first is for more effective policy frameworks to govern food safety; the second is for better implementation.
‘The first set of recommendations emphasizes . . . shifting the focus from hazards to risks, addressing risks from farm to fork, changing from a reactive to a proactive orientation on food safety, and adopting a consistent approach to prioritized decision making. To improve implementation, this report offers guidance for reforming food safety regulatory practices, investing more smartly in essential public goods, institutionalizing a structured approach to food safety risk management, and leveraging consumer concerns over food safety.
This report makes tailored recommendations for different stakeholders, and general priorities are highlighted for countries at different stages of the food safety life cycle. . . .
The food safety context
‘[T]he economic case for public investment in food safety systems is generally less well understood in low- and middle-income countries. . . .
In developing countries, most cases of foodborne illness are sporadic rather than occurring as part of a substantive outbreak, making them inconspicuous. . . .
‘Country data are frequently missing or unreliable on the incidence and level of food safety hazards, the occurrence of foodborne illness, and the financial costs to farmers and enterprises from market disruptions because of unsafe food. Food safety hazards and practices within informal food marketing channels are not assessed on a regular basis, despite the great importance of these channels for the food supply to the poor and often to the whole population. . . .
‘Thus, while many policy makers and other stakeholders in developing countries recognize that there are gaps and shortcomings in food safety systems, less well understood are the socioeconomic impacts of these weaknesses and, importantly, the size of the benefits from remedial or forward-looking investments or other measures to influence incentives and behavior.
‘And the playing field is changing. This includes significant demographic and economic changes that are resulting in major shifts in dietary and food purchasing patterns, and a fundamental and rapid process of restructuring domestic agri-food systems. Along with these forces are significant changes in the magnitude and types of hazards associated with the food of developing countries. Different countries are currently at different stages in the processes of dietary and food system structural transformation.
The limited evidence base on the costs of food safety lapses and on the benefits of preventive measures has contributed to underinvestment in food safety management systems in many developing countries.
And the growing complexity of food safety hazards in many urbanizing middle-income countries is straining or outpacing food safety management capacity.
‘This includes regulatory control systems, enterprise and value chain management systems, and associated infrastructure and human resources. In developing countries, investments in food safety are often reactive and defensive, occurring after a serious food safety outbreak or the imposition of a trade ban. Experience has shown that reactive investments turn out to be to be very expensive, not only financially but also in the cost to the reputation of the affected industry and the disruptive impacts on value chain actors. Yet, fragmented structures for food safety governance are common, and these tend to inhibit the development and application of forward-looking, preventive approaches to food safety risk management.
Aims and audiences
‘Developing countries face a multitude of competing demands for limited investment funds. The economic case for more significant and sustained investment in food safety systems needs strengthening. To do this, empirical evidence will need to be compiled on the impacts of foodborne hazards for public health, trade, and domestic market development among countries at different levels of economic development. This will also require additional evidence of the economic benefits of improvements in food safety and how these are distributed. Based on this evidence, recommendations can be made for food safety system investments and other public policy initiatives that lead to safer practices from farm to fork.
This report aims to increase the awareness of policy makers of the socioeconomic impacts of foodborne hazards in low- and middle-income countries, provide a rationale for greater policy attention and public resources to strengthen food safety capacities and incentives, and provide guidance on how to go about doing this.
‘The report is primarily aimed at policy makers and policy analysts in low- and middle-income countries, both those associated with technical ministries (especially, agriculture, health, and trade) and those involved with economic and development planning and budgetary and fiscal management. The analysis and strategic perspectives offered in this report will also be relevant to development practitioners and partners seeking to devote greater attention to food safety matters in their support for public health, trade, and agricultural and food system transformation in low- and middle-income countries. . . .
Why safe food matters to economic development
‘Unsafe food contains microbiological, chemical, or physical hazards that can make people sick, causing acute or chronic illness that in extreme cases lead to death or permanent disability. Unsafe food reduces the bioavailability of nutrients, particularly for vulnerable consumers, and is associated with malnutrition. The presence of food safety hazards can lead to food losses and reduce availability for food-insecure populations.
For these reasons, food safety is seen as an integral part of food and nutritional security.
‘Food safety hazards that have been addressed by public policies include microbial pathogens (for example, Salmonella spp.); zoonotic diseases (for example, highly pathogenic avian influenza); parasites (for example, intestinal worms); adulterants (for example, melamine); naturally occurring toxins (for example, aflatoxin); antibiotic drug residues; pesticide residues; and heavy metals (for example, cadmium).
‘Food safety hazards are not only a public health issue for low- and middle-income countries (LMICs) but they also affect the growth and modernization of domestic food markets and income and employment opportunities in food production, processing, and distribution. . . .
‘Food safety is an increasingly important determinant of the trade performance of many LMICs, especially those competing in markets for high-value foods, including fresh fruit and vegetables, fish and fishery products, meat, spices, and nuts. . . .
Food safety and the Sustainable Development Goals
‘Of paramount importance for LMICs is the impact of unsafe food and investments in food safety management capacity on efforts to reduce poverty. Food safety intersects with poverty in two critical ways: the poor as consumers of food and as agents in agri-food value chains. A growing body of literature identifies the extent of food safety hazards in informal food markets, which are the predominant source of food for the poor, especially in urban areas (Grace et al. 2008; Feglo and Sakyi 2012; Jarquin et al. 2015). Food safety can affect the livelihoods of poor people employed in agri-food value chains as, for example, small-scale farmers, operators of micro and small food processing and distribution enterprises, and employees in commercial food enterprises.
Thus, even a single food safety event can undercut livelihoods and push people into poverty—or back into poverty—if it causes consumers to shift purchasing and consumption patterns.
Attempts to improve food safety by banning street food vendors can have negative consequences for livelihoods and nutrition.
But there can be significant positive impacts on poverty if investments in increasing the capacity to manage food safety enhances agri-food markets in a way that is inclusive of the poor.
‘Improving food safety and building the capacity to do this will play an important role in achieving the Sustainable Development Goals (SDGs). Indeed, food safety will be integral or highly significant to achieving several SDGs, especially SDGs 1, 2, and 3, while also contributing to achieving several other goals . . . .’
Delia Grace, one of the five authors of this book, is an epidemiologist and veterinarian with more than 20 years of experience in developing countries. She leads research on zoonoses and foodborne disease at the Nairobi-based International Livestock Research Institute. Her research includes food safety, emerging diseases, gender studies, and animal welfare. Her career has spanned the private sector, field-level community development, aid management, and research. She has worked in Asia and Africa, and authored or coauthored more than 100 peer-reviewed publications, as well as training courses, films, articles, and blogs. She has worked at several universities, including University College Dublin, Edinburgh University, the Free University of Berlin, and Cornell University.
Read the World Bank press release
Food-borne illnesses cost US$110 billion per year in low- and middle-income countries, 23 Oct 2018.
Read the AgHealth blog post
New World Bank report says food-borne illnesses cost US$ 110 billion per year in low- and middle-income countries, 26 Oct 2018.
Read the book
The Safe Food Imperative : Accelerating Progress in Low- and Middle-Income Countries, World Bank Agriculture and Health Series, 23 Oct 2018.
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