1.2 Progress in accelerating improvements for nutrition
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
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
Comprehensive surveillance was
instituted through growth monitoring. All pre-school children were weighed and
checked every three months at community weighing posts. Those with severe growth
failure were given food supplements.
Nutrition was incorporated into
relevant health, education and agriculture policies at national, regional, local
and community levels.
Costs were minimized by retraining
existing staff, using volunteers at the community level and allocating funds to
selective measures with maximum impact. Each group of about 10 households chose
a suitable volunteer to engage in a national training programme and then monitor
both mothers and children in their communities.
A programme of nutrition education and
communication encouraged breastfeeding and the timely introduction of
complementary foods and proper hygiene. Information was disseminated about food
beliefs and taboos. School lunch programmes were established in 5,000 schools in
poor areas and salt was iodized.
Household and community food security
was strengthened by promoting home gardening, fruit trees, fish ponds and
preventing infectious disease in poultry.
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
the need to establish
broad-ranging, integrated food and nutrition programmes as part of poverty
the need for some form of local
organisation through which village-level workers or volunteers encourage and
support the families of children who are lagging.
the potential for very rapid progress
against undernutrition, especially after periods of economic growth that may
have neglected human development.
Costs were minimised by retraining
existing staff, using volunteers at the community level and allocating funds to
selective measures with maximum impact. Thailand improved its Human Poverty
Index (a measure of deprivation in a country) from 34% in 1970 to 12% in
In spite of these impressive advances,
the Asian economic crisis of 1997-99 has led to a serious resurgence of poverty
although malnutrition is held at bay by a food safety net with a national drive
for household self sufficiency in food.
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,
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
How Costa Rica brought about accelerated achievement in
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
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
Costa Rica has a strong tradition of
community participation and a technical capacity for research and training at
both the local and regional level.