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It’s time to end malnutrition in South Asia

Idah Z. Pswarayi-Riddihough's picture
Chronic malnutrition remains prevalent across the region as many poor South Asians cannot afford nutritious foods or don’t have the relevant information or education to make smart dietary choices.
Chronic malnutrition remains prevalent across South Asia as many poor South Asians cannot afford nutritious foods or don’t have the relevant information or education to make smart dietary choices.

In Sri Lanka, as in the rest of South Asia, improving agricultural production has long been a priority to achieve food security. 

But growing more crops has hardly lessened the plight of malnutrition. 

Chronic malnutrition remains prevalent across the region as many poor South Asians cannot afford nutritious foods or don’t have the relevant information or education to make smart dietary choices. 
And children and the poorest are particularly at risk.

South Asia is home to about 62 million of the world’s 155 million children considered as stunted-- or too short for their age. 

And more than half of the world’s 52 million children identified as wasted—or too thin for their height—live in South Asia. 

Moderate-to-severe stunting rates ranged from 17 percent in Sri Lanka in 2016 to a high 45 percent in Pakistan in 2012–13, with rates above 30 percent for most countries in the region.

Moderate-to-severe wasting rates ranged from 2 percent in Bhutan in 2015 to 21 percent in India in 2015–16, with rates above 10 percent for most countries in the region. 

The social and economic cost of malnutrition is substantial, linked to impaired cognitive development, chronic disease, and lower future earnings.

And sadly, much remains to be done to ensure children across South Asia can access the nutritious foods they need to live healthy lives. 

Promoting better nutrition in Bhutan

Izabela Leao's picture
 Izabela Leao / World Bank
School children singing and dancing in Samtse Dzongkhag. Photo Credit: Izabela Leao / World Bank

Bhutan is no ordinary place.

A landlocked Himalayan kingdom tucked in a mostly rugged mountainous terrain between India and China, it measures prosperity by assessing its citizens’ level of happiness by way of a Gross National Happiness index.

Equally striking, Bhutan’s constitution mandates that 60 percent of its national land be preserved under forest cover, making Bhutan the world’s only carbon-negative country.

Bhutan’s geography – with land rises ranging from 200 meters in the southern foothills to 7,000 meters in the high northern mountains – consists of three major agro-ecological zones that allow for a rich biodiversity and seasonal foods.

This natural wealth, however, comes with its caveats as Bhutanese living in isolated rural areas can’t access a reliable diverse diet throughout the year.

"Many families in rural Bhutan practice two meals rather than three meals a day," reports Ms. Kinley Bidha, Tarayana Foundation Field Officer in Samtse Dzongkhag. "Some for cultural reasons, others due to a shortage of food, others due to a shortage of land too farm," she adds.

Overall socio-economic development in the last three decades has led to a rapid improvement in health and nutrition outcomes in Bhutan – the country’s infant mortality rate declined to 30 per 1,000 live births in 2012 down from 90 per 1,000 in 1990; while the rate of stunting in children under 5 years declined 24 percent from 1986 levels.

Nonetheless, the lack of variety of foods in diet remains a key concern, especially for pregnant and nursing women as well as young children. And while most families feed their children complementary food, fewer than a quarter of parents provide them nutritious meals essential to their health.

In addition, 67 percent of Bhutanese adults consume less than the recommended five servings (or 400 grams) of fruits and/or vegetables per person a day [National Nutrition Survey (NNS) 2015].

When consumed, vegetables consist for the most part of two national staples, potatoes and chilies, which hardly provide essential vitamins and minerals.

Keeping regional variations in mind, between 16 and 34 percent of children under 5 are stunted—or too short for their age—seven percent of children are underweight, 35 percent of children of age 6-59 months and 44 percent of women of reproductive age are either anemic or iron deficient. Exclusive breastfeeding rates for six-month-old children remain at a low 50 percent (NNS, 2015).  

Damages caused by malnutrition during pregnancy and the first years of a child’s life are irreversible and contribute to stunting and lower immunological and cognitive development, and predispose to adult-onset diseases (including metabolic syndrome).

Thankfully, the negative impact of malnutrition on Bhutan’s economy is now better understood and has become a priority to promote its national development.

Can cash transfers solve Bangladesh’s malnutrition?

Rubaba Anwar's picture
Silvi and her mother arrive with Silvi’s birth certificate to enroll into Jawtno. a cash transfer program aimed to help 600,000 poor families in Bangladesh access prenatal and child care.
Silvi and her mother arrive with Silvi’s birth certificate to enroll into Jawtno. a cash transfer program that aims to help 600,000 poor families in Bangladesh access prenatal and child care. Credit: World Bank


Silvi is eight months old. She lives in a remote village in one of the poorest regions of Bangladesh.
 
Her mother Maya often reflects on her pregnancy and worries about her daughter’s wellbeing as she recalls her morning sickness, the uncertain and painful birth, and the long nights at Silvi’s side as the baby lay wide awake wailing, fighting one illness after the other.
 
She remembers, too, the thrills of hearing Silvi giggle at the sound of her rattle, and when she began to crawl.
 
Despite the little joys that her baby brings to Maya, Silvi’s early childhood was marked with apprehension: Shouldn’t she be a little heavier? When will she learn to walk? Will she be healthy and intelligent enough to earn a decent living when she grows up? Or would she be handed down her parents’ poverty and get married like Maya had to, at only sixteen?
 
But with the right kind of support, Silvi can have a chance at a better life and bring her family out of poverty.
 
Growing evidence has shown that adequate nutrition before birth and the two years after – or in the first 1,000-days – has lasting effects on a child’s intelligence and brain development.
 
When they’re properly fed and exposed to learning, children can reach their full potential and break the poverty trap.
 
Thus, investing in early childhood nutrition and cognitive development (CNCD) is critical to curbing poverty in a country like Bangladesh, where 36 percent of children below the age of 5 are stunted —or too short for their age--, low birth weight is prevalent, and maternal nutrition remains poor.
 
Sadly, poor families like Maya’s are not utilizing services available to them.  

Rural Bangladeshis filming their way to better nutrition

Wasiur Rahman Tonmoy's picture
Local communities in the Chittagong Hill Tracts have created awareness videos to encourage the consumption of nutritious foods, including indigenous foods, threatened by packaged food products with low nutritional value
Local communities in the Chittagong Hill Tracts of Bangladesh have created awareness videos to encourage the consumption of nutritious foods, including indigenous foods, threatened by packaged food products with low nutritional value.

In Bangladesh, chronic and acute malnutrition are higher than the World Health Organization’s (WHO) thresholds for public health emergencies—it is one of 14 countries where eighty percent of the world’s stunted children live.
Food insecurity remains a critical concern, especially in the Chittagong Hill Tracts (CHT).
 
Located in the southeastern part of Bangladesh, CHT is home to 1.7 million people, of whom, about a third are indigenous communities living in the hills. The economy is heavily dependent on agriculture, but farming is difficult because of the steep and rugged terrain.
 
With support from the South Asia Food and Nutrition Security Initiative (SAFANSI), the Manusher Jonno Foundation (MJF) conducted a food and nutrition analysis which finds that more than 60% of the population in CHT migrates during April – July when food becomes harder to procure.
 
Based on these findings, MJF helped raise awareness through nutrition educational materials and training.  The foundation staff also formed courtyard theatres with local youth to deliver nutrition messages, expanded food banks with nutritious and dry food items, and popularized the concept of a “one dish nutritious meal” through focal persons or “nutrition agents” among these communities.

Tackling India’s hidden hunger

Edward W. Bresnyan's picture
India’s National Dairy Development Board (NDDB)
With India’s rapidly growing dairy industry, large-scale milk fortification of Vitamins A and D is a robust vehicle for increasing micronutrients intake across the population. Credit: India’s National Dairy Development Board (NDDB)  
Micronutrient deficiencies, especially Vitamin A and D, are prevalent in India. 
 
Yet, these deficiencies -- often referred to as ‘hidden hunger’ -- go largely unnoticed and affect large populations.
 
Night blindness, a condition afflicting millions of pregnant women and children, stems from low intake of foods rich in essential nutrients like Vitamin A.
 
Budget constraints limit access to nutrient-rich foods for many families, who are unaware or unable to afford a nutritious diet.
 
National programs help supplement diets with Iron and Vitamin, but their scope is too narrow to adequately address these deficiencies.
 
 India’s National Dairy Development Board (NDDB)  
Food fortification is a relatively simple, powerful and cost-effective approach to curb micronutrient deficiencies. It is in general socially accepted and requires minimal change in existing food habits. Credit: Credit: India’s National Dairy Development Board (NDDB)


Fortified Milk Helps Increase Vitamins Intake
 
When fortified with vitamin A and D, milk, which remains a staple for many Indians, can help alleviate dietary deficiencies when supplementation is not available.

Food fortification is a relatively simple, powerful and cost-effective approach to curb micronutrient deficiencies. It is in general socially accepted and requires minimal change in existing food habits.

The process is inexpensive and costs about 2 paisa per liter or about one-tenth of a cent.  And because it only adds a fraction of daily recommended nutrients, the process is considered safe.

For these reasons, food fortification has been successfully scaled up in some emerging economies.

However, except for salt fortification with iodine, India has not yet achieved large-scale food fortification. 

With India’s rapidly growing dairy industry, large-scale milk fortification of Vitamins A and D is a robust vehicle for increasing micronutrients intake across the population.

Engaging communities in the Golden 1,000 Days in Nepal

Kaori Oshima's picture
Field survey team in Nepal
A field survey team for the qualitative study holding a focus group discussion with women in one of the SHD project communities. Photo credit: World Bank

In Nepali, “Sunaula Hazar Din” means, “Golden 1000 Days” – which is a critical window of opportunity between conception and the age of two years that, with good health and nutrition, can mitigate the risks of malnutrition that hamper a child’s long-term physical and cognitive development.

Sunaula Hazar Din (SHD) is also the local nickname of the Government of Nepal’s recently completed “Community Action for Nutrition Project”, implemented by the Ministry of Federal Affairs and Local Development and  financially supported by the World Bank from 2012 to 2017. The project aimed to improve practices that contribute to reduced under-nutrition of women of reproductive age and children under the age of two and to provide emergency nutrition and sanitation response to vulnerable populations in earthquake affected areas.

The project used a “Rapid Results Approach (RRA)”, where target communities formed groups of nine members that would collectively select and work on an activity to address malnutrition for 100 days. RRA focused especially on the “1000 days” households– namely, households with children under 2 years and pregnant and/or lactating women and also had community -wide interventions targeted to address malnutrition.  

To better understand the local dynamics around the SHD design and activities, a qualitative study was conducted, with support from the South Asia Food and Nutrition Security Initiative (SAFANSI).

The study team gathered the voices of various stakeholders, including the community members, facilitators, and the village and district-level authorities. Listening to the voices of these stakeholders makes development practitioners and project teams recognize how participatory designs may work as expected – or not – in a specific context.

A path toward better health for India’s women

Parvati Singh's picture
 World Bank
In India, Members of a self-help group (SHG) like this one discuss women’s  health issues with female health workers. Credit: World Bank

A little over six years ago, Neelam Kushwaha’s first daughter was born weighing 900 gm at birth, severely underweight. Neelam went into labor while working at the local construction site in Jori village, Rewa, Madhya Pradesh, India. Many people work at such local construction sites in rural areas for daily wages ranging from INR 150-280 (about $2- 4$) per day. Her daughter Manvi, was preterm, and Neelam spent months recovering from child birth complications.

Three years later, when Neelam was pregnant with her younger daughter, Sakshi, she quit wage labor and sought employment at an incense manufacturing unit established by World Bank’s Madhya Pradesh District Poverty Intervention Project (MPDPIP) in 2011. At her new role, she earned more and did not engage in labor intensive work during the final months of her pregnancy. Sakshi was born a healthy 3 kilos.

In the course of my field work supported by South Asia Food and Nutrition Security Initiative (SAFANSI) in 2015, I came across several similar stories.

MPDPIP’s livelihood based approach offered several opportunities towards income supplementation for women self-help groups (SHGs) and rural households through agriculture, dairy/poultry farming and local enterprises, among others.

As evident by Neelam’s experience, MPDPIP’s benefits went beyond income and spilled over into health improvement as well.

I learnt that prior to MPDPIP, childbirth in hospitals was difficult due to prohibitively high costs of travel and hospital stay. Pre-existing government schemes such as the Janani Suraksha Yojana (JSY) offer about INR 1,400 ($20) to rural women who opt for hospital deliveries. However, this payment occurs post-partum, and pre-delivery costs have to be borne upfront by pregnant women.

Post MPDPIP, women were able to opt for hospital deliveries with greater ease due to access to credit from their SHGs. This is particularly relevant for Madhya Pradesh as it has consistently fared poorly with respect to institutional deliveries.

Happy New Year! In Sri Lanka, a time to celebrate many things – and to think

Idah Z. Pswarayi-Riddihough's picture
 Joe Qian / World Bank
A group of women in a Sri Lanka Estate. Credit: Joe Qian / World Bank

Happy New Year to all our Sri Lankan friends and colleagues celebrating the Sinhala and Tamil New Year this month; and Happy Easter to those celebrating it.

This is my first opportunity to celebrate these various holidays in my adopted country. I love the energy, the buzz of excitement everywhere and the decorations coming up in many of the commercial districts. I have been asking so many questions about the importance of the New Year holiday; and at the same time enjoying the preparations for the festivities, the anticipation of the big day as well as the serious messages.

I have learnt that the Sinhala and Tamil New Year, also known as 'Aluth Avurudda' (in Sinhala) and 'Puthandu' (in Tamil) is very important to all Sri Lankans and it celebrates the traditional Lunar New Year. It is celebrated by most Sri Lankans – a point of Unity and a Joyful occasion.

Even more importantly the holiday coincides with the New Year celebrations of many traditional calendars of South and South East Asia – a regional point of unity! Above all, this is also known as the month of prosperity.

So what does the holiday mean to you as a Sri Lankan, or maybe you are someone like me who may not be Sri Lankan but loves the country and its people?    

At the World Bank Group, promoting shared prosperity and increasing the incomes of the poorest 40 percent of people in every country we work in is part of our mission. The first goal is to end extreme poverty or reduce the share of the global population that lives in extreme poverty to 3 percent by 2030.

How protein deficiencies impact the health of communities in India

Parvati Singh's picture
Soybean farmers discuss best practices that can leverage improvement of food and nutrition security in Madhya Pradesh.

The state of Madhya Pradesh in India is largely vegetarian with limited consumption of eggs and meat. 

While these dietary preferences are commonplace in other Indian states, Madhya Pradesh is facing a protein deficiency epidemic which threatens the long term health of its population.

How did it get there?

In 2015 I spent five weeks in rural and tribal areas of Madhya Pradesh evaluating the World Bank’s Madhya Pradesh District Poverty Intervention Project (MPDPIP II), with the support of the South Asia Food and Nutrition Security Initiative (SAFANSI)

Across the 8 districts I visited, families shared how they had improved their agricultural productivity, started backyard kitchen gardening, and supplemented their income through dairy and poultry farming, collective procurement and small scale enterprises.

As I examined local village level health records, Anganwadi Center (AWC) registers, Auxiliary Nurse and Midwife (ANM) registers and Primary Health Center (PHC) documents, I noticed a reduction in severe malnutrition and severe anemia among pregnant women and under 5-year-old children.

However, this decrease did not extend to moderate or mild malnutrition and anemia.

In Bangladesh, changing behaviors for better health

Rokeya Ahmed's picture
A toilet in Chunarughat, Hobigonj reduces fecal contamination for this family (World Bank/M. Monir)
A toilet in Chunarughat in the Habiganj district in Bangladesh has helped reduce fecal contamination for Amena Begum and her family. Credit: World Bank/M. Monir

Amena Begum resides in a village in the Habiganj district in Bangladesh and is a mother to three young children.  Last year Amena spent US$100 to construct a toilet to ensure her three children were hygienically protected from feces.
 
Even though her family members have adapted to using the toilet, exposure to fecal contamination can occur anywhere.  For example, while playing outside, a child may accidentally ingest soil with animal feces, or the child could be exposed when he or she eats food off of dishes washed with pond water.  
 
It is also not uncommon for families without toilets to throw feces into a nearby bush, which remains exposed in their living area. These actions can lead to the contraction of hazardous, lethal diseases and create a traumatizing effect on the lives of many children, not to mention the unfavorable impact on the environment.
 
A new study on early childhood diarrhea in rural Bangladesh found that despite high on-site latrine access, frequent fecal contamination was present along all environmental pathways investigated. Human fecal markers on children’s hands and in soil, and rotavirus in stored water, soil and on hands had been detected. Animal (particularly ruminant) fecal markers were highly prevalent in water, soil and on hands.

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