By Andrea L Spray
Andrea L Spray is a Nutrition Specialist at The World Bank and supports the SecureNutrition Knowledge Platform. Views expressed here represent my own and not those of The World Bank.
Undernutrition is the single biggest contributor to child mortality, and one of the world’s most serious health and human development challenges. Although the overall trend for undernutrition is improving, there are still 162 million children under-five who are stunted, the vast majority of whom live in Sub-Saharan Africa and South Asia. Poor nutrition causes a range of serious and costly health problems, from impaired cognitive and physical development to illness, disease and death; nearly one-half of all child deaths are attributable to undernutrition. However the implications extend far beyond health outcomes, affecting educational attainment, workforce capacity and productivity, political stability, and economic progress.
The linkages from nutrition status to long-term well-being are clear, and consequently stunting prevalence is regarded not only as a measure of long-term undernutrition but a marker for national economic growth potential. Although the global development community has prioritized nutrition since the inception of the Millennium Development Goals, we are falling short in our commitment to alleviate undernutrition and will continue to do so unless we do something different. To achieve global targets for stunting reduction, it is necessary to both improve coverage of nutrition-specific interventions and massively scale up efforts towards putting nutrition-sensitive principles into practice.
There is a globally recognized package of nutrition-specific interventions – those that address the immediate determinants of fetal and child nutrition and development – spanning the first 1,000 days from pregnancy through the child’s first 24 months. These interventions are by and large delivered through the health sector, and include the promotion of an adequate and diverse diet, supplementation and fortification with essential micronutrients, and management of moderate and severe acute malnutrition. The evidence base for these nutrition-specific interventions dates from our early understanding of the role of essential nutrients and infectious disease in human health in the late 1800s, and has formed the basis for large-scale donor-driven nutrition intervention since at least the 1970s.
However, as the recent Lancet Series on Maternal and Child Nutrition indicates, scaling up this core package of proven nutrition-specific interventions to 90% coverage in high nutrition burden countries would result in a decrease of only 20% in global stunting. And indeed, despite impressive achievement in reducing undernutrition (35% decline from 1990 to 2011), there are still unacceptably high numbers of undernourished children, and in many countries the prevalence of stunting far surpasses the WHO threshold for a severe public health problem.
It goes without saying that any reduction of undernutrition is commendable and 32 million under-five children not undernourished – roughly equivalent to the population of Peru – is nothing to balk at. However, faced by widespread structural, financial, and capacity constraints, most countries are nowhere near 90% coverage of this demonstrably cost-effective package of nutrition services. Even if they were, nutrition-specific interventions are simply not enough to reach global targets for stunting reduction.
So where then do we look for the remaining decrease necessary to achieve the WHA goal of 40% reduction of stunting by 2025?
As a public health nutritionist, nary a day goes by without reference to the UNICEF/Black conceptual framework for the underlying factors driving undernutrition: food insecurity, care practices, and the disease environment and access to health services. As these underlying drivers of nutrition status are multisectoral – spanning agriculture, social protection, health, WASH, and education - so too must be the interventions to address them. Nutrition-sensitive intervention thus calls for applying a nutrition lens to existing sector activities with the goal of improving their impact on nutrition outcomes.
Although given renewed visibility in the 2013 Lancet Series, nutrition-sensitive approaches to improving nutrition outcomes are not new. However, challenges lie both in what to do and how to do it, and early efforts at multisectoral collaboration were deemed too onerous. One commonly cited challenge is the dearth of conclusive evidence for nutrition-sensitive intervention. But given the gravity of the nutrition situation, there is evidence enough to take action. In the case of agriculture, which is arguably the most mature nutrition-sensitive sector, thanks to the collaborative effort of a community of experts supported by institutions such as FAO, World Bank, and USAID, essential work has been done to elucidate the causal chain from agriculture activities to nutrition outcomes, highlighting both what is known and what remains unknown. But we need to take it one step further.
To achieve the ambitious nutrition and human development goals we have collectively set for ourselves – in order to get beyond the potential 20% reduction in stunting afforded by nutrition-specific intervention – we must increase our capacity to translate nutrition-sensitive principles into practice across all key sectors. Sector specialists committed to improving nutrition outcomes must work in conjunction with public health nutritionists to translate these pathways into discrete activities in the context of a specific project. This means becoming more steeped in each other’s respective context, breaking down technical language, melding frameworks, conducting collaborative research and analysis to elucidate the points of intersection, evaluating the impact and reporting on the results to help build the evidence base for what works. In short, we must work together to do things differently in order to achieve a different outcome for nutrition.