05 November 2015

Bangladesh Can Become a Beacon for Rapid Malnutrition Reduction—If It Chooses To

One of the welcome pieces of news from the 2015 Global Nutrition Report is that Bangladesh, a country with one of the highest undernutrition burdens in the world, is on course to meet global targets for stunting reduction.

Stunting occurs when a significant proportion of children under the age of 5 don’t grow to a height seen in healthy populations.  For Bangladesh 36% of under 5’s are stunted.  A high number indeed, but a number that is coming down at a pace that is in line with global targets.

As my presentation at the Dhaka launch showed, in general, Bangladesh does better than many other South Asian countries in meeting global targets for malnutrition reduction.  Out of the 8 countries in the South Asian Association of Regional Cooperation (SAARC) only Bangladesh and Sri Lanka meet 2 global nutrition targets.  That is the good news.  The bad news is that there are 6 indicators where Bangladesh is off course: under 5 wasting (low weight for height), anemia in women, exclusive breastfeeding, adult overweight, obesity and diabetes. 

The burden of malnutrition is large: recent estimates put the economic losses at 10% of GNP per year, every year.  At a human level the numbers are even starker: of all the under 5 child deaths in Bangladesh every year, 45% are linked to malnutrition.   

Fortunately, solutions are available and they generate large returns.  There is a proven set of programmes and policies that will work to combat malnutrition.  They range from the promotion of breastfeeding for babies, infants and young children & the provision of vitamin A supplements to under 5’s to the fortification of salt with iodine & the biofortification of rice with zinc, to safety net programmes that transfer income and nutrition knowledge, to interventions that improve access to water, sanitation and hygiene. When these programmes are scaled up the ratio of benefit to cost is 16 to 1.  In other words, for every Taka invested, 16 are returned.  (Actually the Bangladesh specific figures are 18 to 1.) A wonderful investment, in every sense.

These interventions work, but frequently are not implemented due to a combination of deficits: a lack of leadership and commitment, poor coverage of programmes, weak coherence across sectors, insufficient funding, and weak data on the location of malnutrition and the effectiveness of programmes.   The countries and states that have overcome these deficits have seen remarkable decreases in malnutrition rates.  As the Global Nutrition Report shows, Vietnam, Ghana, Kenya, Colombia and the Indian state of Maharashtra have all seen remarkable declines in stunting rates over the past 10 years. Compared to Bangladesh’s stunting rate of 36%, Ghana is at 19%, Kenya is at 26% and Maharashtra is at 24%.

Can Bangladesh get its stunting rate into the teens in 10 years’ time?  At the current rate, no.  It would take a decline of about 2 percentage points a year.  Is this possible?  Absolutely. 

What should give us cause for optimism? First, Bangladesh’s economy is growing steadily at about 6% a year—faster than Kenya’s.  A growing economy is helpful to malnutrition reduction—people can afford to buy better food, water and sanitation and governments have larger tax takes which can be allocated to the provision of better services.  Second, Bangladesh has a strong and vibrant set of NGOs. They provide services in conjunction with the Government and they can also promote the accountability of governments and development partners. If they can be mobilized to focus on nutrition, then anything is possible. Third, Bangladesh has a strong and committed set of development partners.  With their enhanced financial and technical support, rapid declines in malnutrition are possible.  Finally, the Government of Bangladesh is very open to independent empirical evaluation of its programmes and policies. This is admirable.  In fact, Bangladesh has one of the best records in the world for collecting nutrition data. This is important because data help us maximize the nutrition impact of resources allocated to nutrition.

So, how can the Government of Bangladesh reduce malnutrition faster? 

First, it should revitalize its intersectoral mechanisms for reducing malnutrition.  Malnutrition is caused by a powerful set of forces, and an even more powerful alliance of actors from different sectors is needed to overcome it.  The health and family planning sectors cannot do it all by themselves through the National Nutrition Services.  They need an agricultural sector that is promoting greater productivity in healthy foods such as pulses, fruits, vegetables, fish and small animals to lower the price to consumers and improve the returns to farmers.   They need an education sector that is doing all it can to keep teenage girls in school to delay the age of first pregnancy until they are women and more ready to be mothers.  They need safety net programs that worry as much about nutrition as poverty and they need water and sanitation interventions that are more focused on the hygienic environment experienced by babies in the first two years of life.  At the moment it is not clear how strong these cross sectoral alliances really are.  

Second, the coverage of nutrition relevant programmes needs to increase.  The 2014 National Demographic and Health Survey shows: only 23% of infants are fed appropriately; the percent of babies under 6 month of age that are being exclusively breastfed is actually declining; 38% of children under 5 did not receive a vitamin A supplementation in the last 6 months; and less than half of all children with diarrhea receive zinc supplements.  These programs and practices need to aim for 90% coverage. 

Finally, the government needs to identify a very senior member of the government as a “Nutrition Czar”--someone with the authority to draw people together to implement a well-developed nutrition plan and who is accountable for the implementation of that plan. That person should report directly to the Prime Minister because, make no mistake about it, malnutrition is a national threat: to lives, livelihoods and lifestyles. 

In the future, the nutrition picture is only going to get more challenging as Bangladesh urbanizes, as overweight and obesity increase and as climate change exerts a strong and ever changing grip on its food production and infection cycles.  More than ever, Bangladesh needs to make the rapid reduction of malnutrition a national mission—before it is too late.

When it comes to efforts to reduce malnutrition, Bangladesh is already burning brighter than most other countries in South Asia, but the flame is fickle and it could fizzle out through complacency.  With more commitment, the flame can become a beacon, showing the way to reduce malnutrition quickly: not just for South Asia, but for the rest of the world.     

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