|Ending Malnutrition by 2020: An Agenda for Change in the Millennium - Final report to the ACC/SCN by the commission on the nutrition challenges of the 21st century (ACC/SCN, 2000, 104 p.)|
|1. Recent Progress|
Dramatic progress has been made in some areas of nutrition in recent years, especially in reducing iodine deficiency disorders and clinical vitamin A deficiency (see Section 2.3). The goal of virtual elimination of iodine deficiency disorders by 2000 is beginning to look achievable. Several countries have succeeded in eliminating severe, clinical vitamin A deficiency, although sub-clinical deficiency is still a major challenge. Over the last two decades, the prevalence of underweight and stunting in preschool children has declined in all regions of the world except for parts of Sub-Saharan Africa (ACC/SCN, 1996b and 1997a). In Thailand, preschool underweight fell at the exceptional rate of about 3 percentage points per year (ACC/SCN 1996a). In five other countries - Indonesia, Malaysia, Pakistan, Tanzania and Zimbabwe - the decline was at about one percentage point per year, and in three others - India, Brazil and Egypt - at 0.7 to 0.8 percentage points. In all these cases, the rate of improvement in nutrition was substantially better than the average rate within the region over the 1980s (ACC/SCN, 1996a). ACC/SCN analysis of WHO data on stunting (ACC/SCN, 1997a) confirms these findings, but setbacks are likely in the 1997-99 period as a result of the Asian crisis and global slowdown in economic growth.
The elements of policy and strategy underlying these successful experiences differed considerably among countries. There was no single recipe for success, but common points were identified in the ACC/SCN synthesis How Nutrition Improves, which concluded:
"The interplay of complex factors in development benefiting nutrition can begin to be disentangled. Economic growth is important, but improvement can move ahead of that caused by growth - indeed must do so to tackle nutrition problems within a reasonable time-frame. Observations tend to confirm that investments in health and education, when reaching the undernourished, can help improve nutrition; again this feeds back into better health potential and educability. Finally, deliberate policies to improve nutrition through community-based programmes do appear to accelerate nutritional improvement." (ACC/SCN, 1996a, p 92)
There are examples of achievements that, if sustained over time, can have significant impact. However, policy-makers should not shy away from aiming for more dramatic change.
1.2.1 Thailand: a remarkable success story
The impact of a coherent national policy in Thailand with explicit actions and changes in governmental support for community-based improvements is shown in Figure 1.1. A wide range of social, educational, health and agricultural issues was coordinated at every level of government with a drive to galvanise grassroots involvement (Box 1.1). The remarkable early fall in the prevalence of preschool underweight shows how effective coherent, explicit and determined action on the part of governments can transform the health of the nation within a five-year period (ACC/SCN, 1992a).
The requirement for achieving rapid reductions in undernutrition is purposeful action: a determined political commitment, clear goals, good strategic and programme planning, sustained action, and systematic monitoring within a physical and administrative infrastructure. To this must be added a process for mobilising the public at large. Community participation and consumer demand need to be promoted by a three-way communication between the people, the community's non-governmental organisations and its government. Experience with undernutrition and micronutrient deficiencies in developing countries, and with diet-related chronic disease of adults in the industrialised world, shows that rapid progress is possible if these elements are in place.
Figure 1.1 Progress in reducing underweight in preschool children in Thailand from 1982 to 1995
Source: Division of Nutrition, Ministry of Public Health, Thailand (1998)
How Thailand tackled undernutrition
In 1982 more than half of Thai pro-school children were underweight. Over the ensuing eight-year period, severe and moderate underweight, as well as severe vitamin A deficiency, were virtually eliminated. Mild underweight was significantly reduced. Maternal mortality declined from 230 in 1992 to 17 per 100,000 live births in 1996. Thailand achieved these results through a programme of accelerated action that focused on nutrition.
Underweight was identified as the most important nutrition problem and for the first time the National Economic and Social Development Plan included a separate national plan for food and nutrition. The plan set explicit goats to eliminate severe, moderate and mild underweight.
All this was in the context of a poverty alleviation plan for some 7.5 million poor people in the north, north-east and south of Thailand. Thailand improved its Human Poverty Index (a measure of deprivation in a country) from 34% in 1970 to 12% in 1990. The dramatic progress in Thailand shows:
the need to establish broad-ranging, integrated food and nutrition programmes as part of poverty reduction.
Sources: Winichagoon et al (1992); UNDP (1997); Tontisirin and Bhattacharjee, personal communication (1999).
1.2.2 Costa Rica: a success story in the 1970s
Costa Rica is another country which achieved tremendous progress in a relatively short period of time. Infant mortality dropped from 62 to 19 per 1,000 live births from 1970 to 1980 and further to 12 per 1,000 by 1997. Life expectancy increased from 67 years in 1970 to 77 in 1997 (UNICEF, 1998). During the seventies, iodine and vitamin A deficiencies were reduced to the point that they were no longer considered a public health problem. In 1978 the proportion of under fives suffering from undernutrition was 45% (Munoz and Scrimshaw, 1995). By 1982 this had declined to 34%. The latest data indicate that the prevalence of moderate and severe underweight has been reduced to about 2%. The prevalence of low birth weight shows a national rate of 7%, the same as for Singapore and the UK (UNICEF 1998).
The nutrition programme, which started in the 1950s but was strengthened in 1975, targeted children under six years of age, school children and pregnant and breastfeeding women. Five hundred nutrition centres were built to facilitate the implementation of the health and nutrition programmes.
The nutrition programme included:
warm meals to pre-school children, pregnant and breast-feeding women, and undernourished children who had been referred to the nutrition centres by health posts
powdered milk distribution to pre-school children, pregnant and breast-feeding women
distribution of food rations (dried skimmed milk, corn-soya blend, vegetable oil and flour) from the World Food Programme and the Costa Rican Mixed Institute of Social Aid to families showing nutritional vulnerability, chosen by health centre staff
nutrition education including: home visits to families with severely undernourished children; educational talks targeted at pre-school children, mothers and organised groups; demonstrations of how to prepare different meals; magazines and radio programmes
school cafeterias serving a mid-morning snack (both local food and that donated by international agencies) and a hot meal at breakfast and lunch for 2-13 year-olds. Food for the school meals was obtained from the National Production Council stores and authorised co-operatives, with the school gardens programme providing much of the vegetables, fruit and eggs needed. By 1985,69% of schools provided lunch, while 30% provided both lunch and breakfast (Novigrodt Vargas, 1986).
iodization and fluoridation of salt and fortification of sugar with vitamin A.
These improvements were brought about by a dramatic increase in health services to cover 84% of the population, with emphasis on the prevention of communicable diseases, on maternal and child health, water and sanitation and health education. (Expansion in health services was made possible by major improvements in the economic situation in Costa Rica -Box 1.2.) Within four years of the start of the programme, 125,000 children were being screened and 10,000 pregnant women were enrolled in pre-natal clinics (UNICEF, 1984). By the 1990s, 96% of the population had access to safe water, 84% had access to adequate sanitation and over 90% of one-year-old children were fully immunised (UNICEF, 1997a). Around 400 health posts established in rural areas and urban health centres adjusted their activities to concentrate on the high-risk, deprived areas.
Costa Rica's health and nutrition improvements were achieved rapidly within a democratic framework, and serve as an inspiring challenge to other developing countries (Munoz and Scrimshaw, 1995). Costa Rica experienced a significant decline in the rate of improvement in health indicators during the 1980s. This was due to the economic crisis and a decline in investment in public health. However, the slowdown in the pace of improvement was not as severe as expected.
How Costa Rica brought about accelerated achievement in nutrition
In 1948 Costa Rica abolished its armed forces to redirect resources to social welfare and development.
Funds were diverted from curative to preventive medicine with a real commitment to reach both rural and urban communities, targeting the most vulnerable.
Costa Rica was politically stable and government motivation and commitment to the health service and social reforms was high.
In the 1970s a National Health Plan was drafted and implemented to provide health care to the entire population and to control or eliminate undernutrition and common infections. Community participation in all activities pertaining to the health care system was seen as central.
Costa Rica has a strong tradition of community participation and a technical capacity for research and training at both the local and regional level.