Elsevier

The Lancet

Volume 371, Issue 9611, 9–15 February 2008, Pages 510-526
The Lancet

Series
Maternal and child undernutrition: effective action at national level

https://doi.org/10.1016/S0140-6736(07)61694-8Get rights and content

Summary

80% of the world's undernourished children live in just 20 countries. Intensified nutrition action in these countries can lead to achievement of the first Millennium Development Goal (MDG) and greatly increase the chances of achieving goals for child and maternal mortality (MDGs 4 and 5). Despite isolated successes in specific countries or for interventions—eg, iodised salt and vitamin A supplementation—most countries with high rates of undernutrition are failing to reach undernourished mothers and children with effective interventions supported by appropriate policies. This paper reports on an assessment of actions addressing undernutrition in the countries with the highest burden of undernutrition, drawing on systematic reviews and best-practice reports. Seven key challenges for addressing undernutrition at national level are defined and reported on: getting nutrition on the list of priorities, and keeping it there; doing the right things; not doing the wrong things; acting at scale; reaching those in need; data-based decisionmaking; and building strategic and operational capacity. Interventions with proven effectiveness that are selected by countries should be rapidly implemented at scale. The period from pregnancy to 24 months of age is a crucial window of opportunity for reducing undernutrition and its adverse effects. Programme efforts, as well as monitoring and assessment, should focus on this segment of the continuum of care. Nutrition resources should not be used to support actions unlikely to be effective in the context of country or local realities. Nutrition resources should not be used to support actions that have not been proven to have a direct effect on undernutrition, such as stand-alone growth monitoring or school feeding programmes. In addition to health and nutrition interventions, economic and social policies addressing poverty, trade, and agriculture that have been associated with rapid improvements in nutritional status should be implemented. There is a reservoir of important experience and expertise in individual countries about how to build commitment, develop and monitor nutrition programmes, move toward acting at scale, reform or phase-out ineffective programmes, and other challenges. This resource needs to be formalised, shared, and used as the basis for setting priorities in problem-solving research for nutrition.

Introduction

Each of the first three papers in this Series on maternal and child undernutrition has important but different implications for those working at national and subnational levels in countries where the burden of undernutrition is high. Black and colleagues report1 that more than a third of deaths of children under the age of 5 years and disability-adjusted life-years worldwide can be attributed to undernutrition. These estimates make undernutrition the largest risk factor in any age-group for the global burden of disease.2

Victora and colleagues' findings3 are a wake-up call to finance ministries and development agencies in countries with a high burden of undernutrition, showing that adequate nutrition in early life is essential for human capital formation. Undernourished children are more likely to be below average height when they reach adulthood, to have lower educational achievement, and to give birth to smaller infants than are those who are nourished adequately. Maternal and child undernutrition is also associated with lower economic status in adulthood, with effects that spill over to future generations.3 These findings reinforce existing assertions about the positive economic outcomes of good nutrition and its importance as a prerequisite for economic development.4, 5

In the third paper, Bhutta and colleagues summarise6 the evidence about interventions with proven effectiveness in addressing undernutrition. These actions span interventions directed at mothers, babies, and young children, and include direct nutrition interventions (eg, provision of micronutrients) as well as behaviour change interventions directed at feeding practices and accompanied by supportive measures such as conditional cash transfers. Together these interventions could reduce the burden of undernutrition in young children by about 25% in the 36 countries with the highest burden of undernutrition if implemented universally.

There are some surprises in these findings for national nutrition leaders. For example, interventions to reduce malaria infection in pregnant women are effective in reducing undernutrition and should be addressed in national and subnational nutrition strategies. Some long-standing strategies promoted as benefiting nutrition, such as school feeding and stand-alone growth monitoring, are not supported by evidence showing a direct effect on undernutrition.6 Programme managers can review their strategies in light of this new evidence, taking local needs, contextual factors, and opportunities into account.

This paper seeks to define strategies for improving maternal and child undernutrition in countries where the burden of undernutrition is high. The challenge is to make recommendations that are specific, actionable, and based on the best evidence, while recognising the limitations in the available evidence, the distinctions between efficacy, effectiveness, and transferability, the need to adapt action strategies to national contexts, and the dynamics of the nutrition policy process.

Section snippets

Learning from success

Over the past 50 years, countries of low and middle income have witnessed many changes in international thinking with regard to strategies for reducing malnutrition, driven by a variety of forces beyond their control. During the past half century, we have had the protein era, the energy gap, the food crisis, applied nutrition programmes, multisectoral nutrition planning, nutrition surveillance, food insecurity and livelihood strategies, and the micronutrient era, among others. These fashions

Key challenges for effective nutrition action at national level

The central message of this Series is that effective nutrition actions exist but have not been implemented at scale and assessed, especially in countries where high proportions of the burden of disease are attributable to undernutrition. This section presents seven challenges that must be met to achieve this goal.

The role of the international nutrition system

Results from the country assessments, supplemented by qualitative interactions with nutrition policymakers and programme managers in selected countries, documented the effect of international agreements, resources, and priorities on national nutrition actions. One example of this influence is the role of poverty reduction strategy papers (PRSPs) in national nutrition actions. PRSPs were established in 1999 by the World Bank and the International Monetary Fund as a prerequisite for concessional

What can be done at national level to address maternal and child undernutrition?

The problem of maternal and child undernutrition at national level is multifaceted. The burden is high, and concentrated in poor communities in poor countries facing hugh burdens of disease and low capacity and human resources. Coverage rates for interventions and support strategies found in this Series to be effective in addressing undernutrition are often not being widely measured or monitored, and those that are monitored suggest that, with the exception of vertical, centrally driven and

Search strategy and selection criteria

A systematic search of PubMed and Cochrane databases, as well as World Bank websites, for programmes with a nutrition component that were intended to reach large populations was commissioned for the Series (see webextra material associated with Bhutta and colleagues' contribution to this Series). Inclusion criteria were based on the quality of the evaluation design, and a full report is available at www.lancet.com. 28 programmes in 18 countries were identified and reviewed.

Survey of

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