South Asia’s malnutrition conundrum

The Oxford Advanced Learners Dictionary (8th edition) definition of malnutrition is ‘a poor condition of health caused by a lack of food or a lack of the right type of food’. Malnutrition in infants and children results in underweight babies and stunted growth, deficits in height for age in children and deficits in weight for age.

Researchers have decisively linked malnutrition and poverty, the one feeds the other and vice versa. At a conservative estimate, malnutrition is said to bring about GDP losses of at least 2-3% and leads to a potential reduction in lifetime earnings for each malnourished individual. Stunting among children is linked to a 4.6 cms loss of height in adolescence, 0.7 grade loss of schooling and a seven-month delay is starting school.

Clearly, improved nutrition is a driver of enhanced economic growth. Paradoxically, rapid weight gain after the second year in a child has been linked to impaired glucose tolerance and obesity, in turn linked to lifetime diseases such as diabetes and hypertension.

A conundrum is defined by the same dictionary as ‘a confusing problem or question that is very difficult to solve’.

Sri Lankan example

Why is malnutrition a conundrum for South Asia? Let us take Sri Lanka as an example, although it is one of the better performers in South Asia. For a middle income country, Sri Lanka’s maternal mortality of 46.9 per 100,000 live births, infant and under five mortality rates of 13 and 15 per 1,000 live births and life expectancy at birth, 73 years, are good world class indicators.

However, under nutrition, 29% underweight, is high. This is the measure of the non income face of poverty, the proportion of people who suffer from hunger. It has two indicators, the prevalence of underweight among children under five and proportion of the population below a minimum level of dietary energy consumption.

In India it is estimated that nearly half of the small children are malnourished, this is higher than in most parts of sub-Saharan Africa. More than one third of the world’s malnourished under-fives live in India.

Millennium Development Goals

The first of the eight Millennium Development Goals is to eradicate poverty and hunger by 2015. Sri Lanka, a MDG study concluded, may be among countries able to achieve several of health MDGs and the income poverty MDG, under certain conditions, i.e. to halve the proportion of people living on less than a $ 1 a day, but not the non income poverty target, the nutrition MDG.

Recently Meera Shekar of the South Asia Division of the World Bank, had an interactive discussion connecting Sri Lanka, India, Nepal, Pakistan, Bangladesh and Afghanistan, in which some interested Sri Lankans were fortunate to participate courtesy the excellent video conference facility at the Distance Learning Centre in Colombo, on Scaling Up Nutrition (SUN) in South Asia.

Worldwide 29 countries have alarming levels of malnutrition, primarily in Asia, Africa and Latin America. In five South Asian countries the percentage of underweight children among the under fives are over 40 per cent, taking into account data from 1960 to 2007. For Sri Lanka, one of the better performers, it reduces very gradually from 38% in 1977 to only 21% in 2006. This is with our other social indicators being at virtual First World levels! (See graph)

One of Sri Lanka’s Ministers of Health has gone on record that ‘policy makers are baffled as they cannot pinpoint the cause for weak nutritional levels in mothers and children’.

Double jeopardy

Sri Lanka is, paradoxically, faced with double jeopardy of both under nutrition and overweight, which is on the rise among high income groups and this makes the population susceptible to the high risk of cardiovascular diseases, diabetes and other non communicable diseases. Over 20% of Sri Lankan women are overweight and the trend is increasing.

There is a clear correlation between nutrition and poverty, so with poverty levels supposedly going down, malnutrition should also reduce, in theory. The conundrum is that the crisis on the ground does not reflect the theory! It’s the converse of the crack about the economist, who is puzzled as to why what works in practice does not work in theory!

Under nutrition in Sri Lanka affects very young children and mothers, often during pregnancy, leading to low birth weight. Early damage caused to children’s cognitive and growth potential is tragically, irreversible, whatever is tried as remedies thereafter.

Shekar, in her excellent presentation, showed that the window of opportunity for improving nutrition standards is very small. It ranges between the pre-pregnant mother and until the new born is 18 to 24 months old. Recent research shows that a large part of the damage is caused to the foetus while in the womb, before birth.

Shekar emphasised that what has to be done is known, it is not rocket science. The mother to be must be given supplements of multiple micro nutrients, iron foliate and iodine through iodised salt, calcium supplements and protection from air pollution caused by cooking fires.

For the newborn baby, compulsory breast feeding. For the baby and child, improved supplementary feeding, zinc supplementation, zinc in management of diarrhoea, vitamin A fortification and supplementation and insecticide-treated mosquito nets. The interventions are known, the delivery is the problem.

The Nutrition Fund

Fortunately, Sri Lanka has a well proven model for delivery. The Nutrition Fund of the Sri Lanka Poverty Alleviation Project, funded by the World Bank (CREDIT 2231-CE), managed by the Jansaviya Trust Fund (JTF) from 1991 to 1998, focused on training mothers to recognise malnutrition in them and their children, sensitised them to long-term debilities which it caused and trained them to prepare more nutritious foods to combat malnutrition.

The Director of the Nutrition Fund Dr. Priennie Ranatunga and her team trained mothers to recognise under nutrition and to appreciate that a malnourished mother will give birth to an underweight girl child, who in turn, due to lack of nourishment, will give birth to malnourished children in the future and that it was within their power to take action to break this vicious cycle.

This is in stark contrast to the present method of distributing food supplement Thriposha, which is issued to pregnant mothers and underweight babies. In a poor household, this is naturally shared among the whole family if the mother is not sensitised of her and her child’s special needs.

Dr. Ranatunga trained mothers to plant, grow, harvest, produce and process their own alternative food supplements in their home gardens. Thriposha deliveries are never on time; poor pregnant and lactating mothers have to make repeated visits to the clinic to collect their allocation. There is under supply and rationing, timely deliveries are constrained by factors like lorry availability and lack of funds for overtime for drivers. It is a bureaucratic nightmare for DMOs. Some remote areas hardly get deliveries. Mothers turn up for the clinic and go away frustrated.

Successful strategies

The success of JTF Nutrition interventions was based on four new and important strategies.

(1) Involvement of community organisations, which have delivered development packages to poor communities with no disciplinary blinkers for decades in Sri Lanka. Their incisive understanding of the problems of the poor and their holistic approach to development (which includes even areas such as culture, values and spiritual development), gives them credibility and asserts their ‘interiority,’ thus reducing the social distance between themselves and the people. By the end of 1994, around 40 community organisations had commenced in depth nutrition projects in about 160 Divisional Secretary areas.

(2) Innovative approach to human development. The highest powers of a human being are those of ingenuity and creativity. Human development therefore requires that brain development proceeds unimpeded. The human foetus and infant (0-12 months), have the highest state of brain development, with 3.5% of the brain being developed, it is estimated, at around 3.5 years of life.

While brain mass is correlated to nutritional well being, brain stimulation is affected by the child’s environment. The JTF’s Nutrition programme used a simple ‘weight/age’ index to measure the nutritional status of children, trained mothers to source and feed children with supplements and supported early childhood education.

(3) Quantification and use of indicators. Voluntary nutrition workers on the programme carefully monitored the nutrition of status of children in the village, the access to pure water, the access to latrines, etc., and maintained a score card to enable the participants monitor their own household scores and support was provided to take initiatives which would help to improve the score, for example a community water supply scheme through the JTF’s own participatory Community Projects Fund. A base line score card was prepared and communities shown how they could improve their score and at the same time attain higher mother and child nutrition scores, which were predetermined through participatory process.

(4) Implementation in a small homogenous geographic area. Community interventions have to be local. Interventions are multi faceted: adult education, pre schools, latrine construction and use, water supply schemes, agricultural wells, wells for drinking water, cultivating, processing of supplementary foods, etc. These have to be authentic and sustainable community efforts. A classic case of Schumacher’s ‘Small is Beautiful’. The approach of the JTF’s Nutrition programme was participatory with bottom up planning, sequenced and realistic, achievable stage by achievable stage.

Nutrition Fund intervention

The Implementation Completion Report of the World Bank, on Sri Lanka’s Poverty Alleviation Project, implemented by the JTF dated 15 June 1998, has this to say on Nutrition Fund intervention:

“The activities of the Nutrition Fund were the most successful. It covered over one fifth of the population within the conflict-free zones of Sri Lanka, and was operational in 18 of the 25 Districts. About 68 Partner Non Government Organisations were involved, in over 1,600 Grama Niladhari Divisions, with a beneficiary participation of 89% of the target population. The outreach was approximately 700,000 mothers and 2.7 million children, well in excess of the Staff Appraisal Report target. Success can largely be attributed to innovative interventions focusing on behavioural factors. Reliance on participatory approaches succeeded in enhancing nutrition awareness and improving feeding practices.”

At the time of project closure, at over three quarter of the sites at which the nutrition programme was being implemented, serious malnutrition had been reduced by more than 15%, based on reporting and record keeping by the participating community organisations.

This model clearly worked. Sri Lankan women, especially the young, are literate. They can be reached by newspapers, radio and TV. The grandmother, mother and girl child should be targeted by an aggressive outreach programme if this cycle of under nutrition, malnutrition and irreversible damage to children’s cognitive and growth potential is to be broken.

Political landmine

Sri Lanka’s current problems on child and maternal malnutrition are further compounded by fact that a health care system, infrastructure and budget, which has evolved to respond to health hazards caused by communicable diseases, in a young population, is today struggling to treat a rapidly ageing population suffering from non communicable diseases and other geriatric illnesses.

But any overhaul is a political landmine, taking on all the vested interests which no politician, in survival mode, interested in popularity and short term fixes for victory, in a five to six year electoral cycle, will ever dare to touch.

Shekar’s presentation has clearly shown that addressing under nutrition in South Asia in general and in Sri Lanka, in particular, will require strategies to:-

(a)Reduce income inequalities.

(b)Improve access to safe water and sanitation.

(c)Reduce food insecurity.

(d)Scale up direct nutrition interventions.

(e)Use the successful participatory delivery mechanism well proven in the Janasaviya Trust Fund’s Nutrition Intervention.

(f)Revise and reform Government health care expenditure and infrastructure to reflect the preventive and curative health demand realities of today. For the malnutrition conundrum, there is a well proven delivery system for the necessary interventions.

The recent UNGA in New York reviewed the Millennium Development Goals; some nations tapped themselves on the back with some self satisfaction and others admitted that the matter is still ‘a work in progress’. South Asia must get over its conundrum; the path is known, it’s the will which is required.

(The writer is a lawyer, who has over 30 years experience as a CEO in both government and private sectors. He retired from the office of Secretary, Ministry of Finance and currently is the Managing Director of the Sri Lanka Business Development Centre.)