Ending Malnutrition in Lao PDR: What’s Holding Back Progress on Child Nutrition?

The World Bank policy note Determinants of Child Malnutrition in the Lao PDR, authored by Sutirtha Sinha Roy and Tanida Arayavechkit, with contributions from the Lao Statistics Bureau, the Government of Lao PDR, and development agencies like UNICEF and OPHDI, outlines a troubling paradox. Despite strong economic growth, rising life expectancy, and declining poverty, from 39 percent in 1998 to 18 percent in 2018, the Lao PDR continues to face persistently high levels of child malnutrition, especially stunting. From 2011 to 2017, stunting rates in children under five dropped from 44 percent to 33 percent, but progress has since stagnated. These rates remain far above those of regional peers such as Vietnam, Indonesia, and Cambodia. Alarmingly, underweight prevalence rose from 21 to 24 percent, and wasting climbed from 9 to 11 percent between 2017 and 2023. The implications are not merely developmental; they are economic. Malnutrition costs the country $212 million annually, equivalent to 1.2 percent of its GDP, in lost productivity and health burdens linked to stunting and anemia.

The Nutrition Convergence Projects: A Multisectoral Response

To address this crisis, the Lao government, with World Bank support, has rolled out the Nutrition Convergence Projects across 882 villages in the four most affected northern provinces: Huaphan, Oudomxay, Phongsaly, and Xieng Khuang. These interventions integrate cash transfers (RRPM), healthcare services (HANSA), livelihood support (PRF III), and clean water and sanitation upgrades (WASH). According to evaluation surveys from 2020 and 2022, this multisectoral approach has buffered the effects of both COVID-19 and inflation. Without these programs, the prevalence of stunting and wasting in children under two would have been 7.7 and 3.4 percentage points higher, respectively. However, the sustained high levels of malnutrition indicate deeper structural issues, ranging from inadequate dietary diversity to entrenched cultural misconceptions, that require broader and more targeted reforms.

Poor Diets, Poor Outcomes: Food Insecurity and Low Protein Intake

One of the most potent determinants of child stunting is dietary diversity. Only 40 percent of children aged 6–59 months met the minimum dietary diversity threshold, and just 35 percent of those under two years old did. Among poor households, 82 percent of per capita expenditure goes to food, yet they consume fewer than 15 different food types weekly, compared to 30 among wealthier families. These diets are dominated by cereals, starches, and vegetables, with limited access to meat, eggs, or dairy. Even when protein-rich foods are consumed by other household members, young children are often excluded. The data reveal that children between 24 and 59 months are 11 percentage points less likely to consume dairy compared to their younger peers. Medical experts recommend introducing complementary feeding around six months of age, but many caregivers wait much longer, depriving children of essential nutrients during critical growth periods.

The analysis also finds that children's diets are heavily influenced by household norms and beliefs. For instance, around 40 percent of caregivers believed that eating more during pregnancy would lead to a difficult delivery, while 38 percent did not know the recommended age to introduce foods beyond breast milk. These misconceptions are frequently perpetuated by influential family members rather than medical professionals. Encouragingly, when caregivers are exposed to nutritional education or growth monitoring tools, the likelihood of children consuming fruits, vegetables, and protein increases significantly. This suggests that targeted behavioral change campaigns, when combined with better food access, can have a meaningful impact.

Sanitation, Disease, and the Diarrhea-Stunting Link

Stunting is not only about food. Poor sanitation and exposure to diarrheal diseases are equally damaging. Although national diarrhea rates have declined, children in rural, road-inaccessible, or low-education households remain at greater risk and are less likely to receive treatment. In convergence provinces, nearly 60 percent of the poorest households still practice open defecation or share facilities, compared to just 3 percent among the wealthiest. This gap exposes vulnerable children to fecal bacteria and gastrointestinal diseases that impair nutrient absorption. The World Bank’s analysis found that a one percent increase in village-level toilet coverage reduces stunting by 8 percent among children aged 24–59 months. Moreover, access to sanitation is often determined by household wealth, meaning the poorest face compounding risks from poor diet and poor hygiene.

Maternal Health and Intergenerational Influences

Children’s nutritional outcomes are also strongly tied to the health and knowledge of their caregivers. Those whose mothers received four antenatal care visits or were attended by skilled birth professionals were significantly less likely to be stunted. The likelihood of stunting decreases by 6.4 percent and 5.5 percent for these two factors, respectively. Moreover, children cared for by someone with at least a secondary education are 4.6 percent less likely to be stunted. Household wealth, again, plays a role: children in the richest quintile are 13 percent less likely to be stunted than those in the poorest. Deep-seated cultural beliefs around pregnancy, feeding, and sanitation continue to undermine progress, especially in ethnic minority communities where education levels are lower and access to health services remains patchy.

Across ethnic groups, stark disparities persist. While 30 percent of Lao-Taï children aged 6–59 months are stunted, that figure nearly doubles to 60 percent among Hmong-Iumien children. Using Blinder-Oaxaca decomposition methods, researchers attributed these gaps to differences in maternal healthcare access, sanitation, diet, and household assets. Encouragingly, 46 percent of the disparity in older children’s stunting rates can be explained by these measurable factors, offering a roadmap for targeted, equitable policy intervention.

The policy note concludes with an urgent call to action: stabilize macroeconomic conditions, expand conditional cash transfers tied to health behaviors, enhance health service quality, promote protein-rich diets, and invest in sustainable sanitation solutions. Only through sustained, inclusive, and multisectoral efforts can the Lao PDR offer all its children an equal opportunity to grow, thrive, and contribute to the nation’s future.