|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|
Over the last nine years, major international commitments have been made to reduce malnutrition. Nutrition goals formally adopted include:
The World Summit for Children, 1990. Called for "a reduction in severe and moderate malnutrition among children under 5 to half the 1990 rate by the year 2000". The Sub-Committee on Nutrition (ACC/SCN) conducted a series of country-level reviews, in collaboration with national nutrition institutes, for Brazil, Egypt, India, Indonesia, Tanzania, Thailand and Zimbabwe. These aimed to document a wide-ranging base of national experiences in nutrition policies and programmes, looking specifically at why and how actions were undertaken, and evaluating their effect on nutrition. This work showed that through focused action, accelerated progress against childhood undernutrition can be achieved.
The International Conference for Nutrition, 1992. Reaffirmed the goals set out at the World Summit for Children and other earlier goals, set them in a broader context and also called for the "elimination of death from famine". The Conference - co-sponsored by WHO and FAO -was to be followed by countries writing their own National Plans of Action for Nutrition. Some plans of action were prepared, awareness of nutrition problems increased, a wide range of people with responsibility for nutrition action were brought together, and some strong local networks were created. More recently the Asian Development Bank, in collaboration with UNICEF, has provided funding for implementation of National Plans in selected countries in Asia.
The World Food Summit, 1996. This Summit declared "the commitment to achieving food security for alt, and to an ongoing effort to eradicate hunger in all countries, with an immediate view to reducing the number of undernourished people to half its present level no later than 2015". The summit endorsed the 1992 International Conference for Nutrition recommendations and incorporated them into the World Food Summit Plan of Action and the Rome Declaration on World Food Security. Since 1996, several UN agencies have been driving forward the Plan of Action - monitored by the Committee on World Food Security. FAO has developed a number of country-specific programmes working with national governments to implement the summit recommendations. An inter-agency working group has also been set up to take forward a plan for Food Insecurity and Vulnerability Mapping Systems (FIVIMS).
These conferences emphasised the reduction of undernutrition as part of a broader strategy to eradicate poverty. Reducing poverty is an end in itself and a means to achieve other goals. At the World Summit for Social Development in 1995, governments committed themselves to establish national goals for "substantially reducing overall poverty in the shortest possible time, reducing inequalities and eradicating absolute poverty by a target date to be specified by each country in its national context". In 1996, the Development Ministers of the OECD's Development Assistance Committee proposed a global development and assistance partnership to meet a core of priority goals, including "a reduction by half in the proportion of people living in extreme poverty by 2015". Each conference also emphasised the vital role of the UN family itself: goals should serve as a focus for collaboration among the different agencies and organisations involved in mobilising and monitoring implementation.
The 20/20 Initiative enjoins governments in developing countries and donors to devote 20% of their expenditures to basic social services. This initiative was first suggested by the UNDP's Human Development Report in 1992 and formally approved at the World Summit for Social Development in 1995. Many governments and donor agencies are now involved in working towards this goal. Such commitments will help to provide the needed financial support for community-based programmes.
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.
"Approximately half of the economic growth achieved by the United Kingdom and a number of Western European countries between 1790 and 1980, has been attributed to better nutrition and improved health and sanitation conditions, social investments made as much as a century earlier" (UNICEF, 1997a, p. 17).
The social and economic costs of poor nutrition are huge. Investing in nutrition makes good economic sense because:
it reduces health care costs. Preventing low birthweight and stunting reduces childhood mortality and morbidity and their substantial health costs. Pelletier et al. (1993) estimated that over half the child deaths in developing countries can be attributed to underweight and its effect on infectious disease. Children hospitalised for severe undernutrition experience a higher case-fatality rate and a longer duration of stay than children in hospital for other reasons (Atakouma et al., 1995).
it reduces the burden of non-communicable diseases. Diabetes, heart disease and cancers in adult life are very costly conditions to diagnose, manage and treat, and are already distorting the health budgets of the developing world. Preventing early undernutrition may reduce the risk of these conditions in later life (as reviewed by Scrimshaw, 1997). Public health programmes to reduce the dietary contribution to these diseases are also cost-effective.
it improves productivity and economic growth. Undernourished children become smaller adults with reduced physical capacity. Productivity of adults who are undernourished - even on a short-term, seasonal basis - is impaired. Better health leads to longer working lives, reduced absence due to illness and more productive days. Such differences at the individual level contribute to a country's economic growth (Spurr, 1987).
it promotes education, intellectual capacity and social development. Undernutrition during fetal life and infancy can damage a child's mental development and impair capacity to learn. Undernutrition is associated with delayed enrollment in school and with absences from school - and it can be difficult for a child to catch up, Healthier children are expected to live longer, healthier lives. They are therefore more likely to capitalise on the benefits of schooling (Pollitt, 1990). Education is the cornerstone of social development.
The cost-effectiveness of preventive programmes is well recognised as far exceeding those of therapy. Even in the USA (a country with low levels of undernutrition, but without universal access to antenatal care) the National Accounting Office concluded that providing the Women, Infants and Children (WIC) supplementation programme to pregnant women reduced first-year medical costs for US infants by $1.19 billion in 1992, offsetting the cost of the programme (Avruch and Cackley, 1995). Evidence from this Commission's Report implies far greater economic gains when undernourished mothers are assisted.
No economic analysis can fully encompass the benefits of sustained mental and physical development from childhood into adult life. Healthy adults with the physical capacity to maintain high work outputs, and with intellectual ability to flexibly adapt to new technologies, are a huge national asset. Figure 1.2 illustrates the links between improving nutrition and boosting economic growth.
Global financial institutions like the World Bank are now clear about the importance of investing in nutrition:
"... resources put into nutrition are an investment with significant returns, today and in the future." (World Bank, 1992, p. 1)
Until 1997, many developing countries were benefiting from both reductions in poverty and improvement in the nutrition and health of their children and adults. The successes illustrated above emphasize the impact of community action even in poor circumstances. The sudden emergence of major financial crises in many Asian countries and in South America, however, may threaten much if not all of the progress made over the last decade if appropriate measures are not taken.
Recent evidence from Indonesia shows the re-emergence of nutrition deficiencies (Helen Keller International, 1998 and 1999). High inflation, massive unemployment and decline in consumer spending power have led both to a fall in the ability to buy expensive but micronutrient-rich foods such as eggs, meat and milk and to a fall in vitamin A and iron intake. Surveys suggest that four-fold increases in anaemia are likely, as well as increases in wasting, night-blindness and diarrhoea in children, adolescents and women. This may herald the emergence of another 'lost generation' unless rapid action, of the type undertaken in Thailand, is taken to minimise the impact of the financial crisis on the most financially insecure.
More effective safety nets to cushion the social and health effects of financial crises are essential. Some action is already being taken. Governments in Asia have sought to establish safety-nets in response to the 1997/8 financial crisis. The World Bank has established a Social Monitoring Early Response Unit to monitor the impact of the crisis in Indonesia. In January 1999, the Bank brought together governments, donor and development agencies, NGOs and others throughout the region to assess the situation and determine how to respond.
The set-backs are not confined to the developing world. In parts of Central and Eastern Europe, there has been a fall in life expectancy in the 1990s (WHO Europe, 1997), coinciding with the sudden change in government and national financial management. This is in marked contrast to the increasing life expectancy in the rest of Europe. The collapse of the command economies in the 1990s led to dramatic changes in the system of food production and consumption in many countries of Central and Eastern Europe. Russia, for example, became a net food importer: until recently Russia was importing one-third of its food requirements. The collapse of the rouble in the 1998 Russian financial crisis means that the country's ability to import foodstuffs has been severely reduced, and the Russian government has asked the European Union and the US government for food aid. The failure to organise specific economic and organisational measures to safeguard the population's health has led to huge societal costs. These issues are dealt with in later chapters.
Figure 1.2 Nutrition, health and economic growth