STOP STUNTINGSOUTH ASIA HEADLINE RESULTS - 2016 PROGRESS REPORT

  This period - from conception until the child is two years old – is crucial to make a difference for nutrition.

After that, it is very difficult to get back what the child has lost. This time cannot be replaced.”

Aamir Khan
UNICEF Regional Ambassador for Nutrition in South Asia

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Globally, about 25 percent of children under five years of age have stunted growth.
Stunting is the cause of an estimated one million child deaths annually.

For the children who survive, stunting in infancy and early childhood causes lasting damage, including poor cognition
and educational performance, reduced lean body mass, short adult stature, lower productivity, reduced adult wages, pregnancy complications
and – when accompanied by excessive weight gain later in childhood – increased risk of nutrition-related chronic diseases.


In South Asia, 38 percent of under fi ve children are stunted. This high prevalence and the region’s
large population mean that South Asia bears about 40 percent of the global burden of child stunting.

UNICEF SOUTH ASIA TARGET

12 million fewer children with stunted growth and development by 2017

GLOBAL TARGET

40 percent fewer children stunted by 2025

ACHIEVING RESULTS

Theory of change: Programmatic priorities

UNICEF sees the 1,000-day window of opportunity – from conception to two years – as crucial to reduce stunting. Our maternal and child nutrition programmes in South Asia support the scaling-up of evidence-based nutrition-specific and nutrition-sensitive programmes for children under two years and women before and during pregnancy. We place emphasis on greater equity for greater impact.
Nutrition-specific programming: Our programmes support the scale-up of 10 Essential Nutrition Interventions with strong evidence base and high potential to reduce the prevalence of child stunting. These 10 proven interventions are grouped into four Focus Programme Areas:
- Improving child feeding and care practices in the first two years of life
- Improving micronutrient nutrition and anaemia control in young children
- Improving early detection and treatment of severe wasting in young children
- Improving women’s nutrition, especially for adolescent girls and mothers

Nutrition-sensitive programming: As with most development challenges, reduction in the prevalence of child stunting calls for a multi-sectoral response. UNICEF promotes inter-sectoral nutrition-sensitive programmes, with a particular emphasis on three areas:
- Health, hygiene and sanitation
- Education, participation and protection
- Food security, poverty reduction and social protection

Theory of change: Programmatic strategies

UNICEF South Asia uses six interrelated programmatic strategies to accelerate progress towards the goal of reducing the number of stunted under-fi ves by 12 million between 2014 and 2017. These strategies are:
- Analyze the distribution and determinants of child stunting
- Support the scale-up of evidence-based interventions to reduce stunting
- Strengthen human and institutional capacity for maternal and child nutrition
- Foster community participation and community-centred approaches
- Strengthen governance and accountability for maternal and child nutrition
- Manage knowledge to improve policies, programmes, advocacy and research

UNICEF South Asia Nutrition, 2014 to 2017

theory of change

FA= Focus Area
PS= Programme Strategy

DATA PROFILE

Global estimates indicate that about 25 percent of children under fi ve years of age (i.e. 159 million) have stunted growth. Stunting levels in South Asia (38 percent) are comparable to those in sub-Saharan Africa (37 percent) and over three times higher than those in East Asia and the Pacific (12 percent) or Latin America (11 percent). The high prevalence of stunting and the region’s large population mean that South Asia bears about 40 percent of the global burden of child stunting.

Prevalence of stunting in South Asia


Data source: Afghanistan NNS 2013, Bangladesh DHS 2014, Bhutan NNS 2015, India RSOC 2014, Maldives DHS 2009, Nepal MICS 2014, Pakistan DHS 2013, Sri Lanka DHS 2007.

The prevalence of stunting in South Asia declined from about 61 percent in ~1990 to about 38 percent in ~2013, with every country seeing some improvement over the past two decades. However, progress is too slow to achieve South Asia’s share of the global target on stunting.

Prevalence of stunting in children under 5 in South Asia (1990-2013)



Data Source: UNICEF/WHO/World Bank Joint Child Malnutrition Estimates, 2014, Afghanistan NNS 2013, Bangladesh DHS 2014, Bhutan NNS 2015, India RSOC 2014, Maldives DHS 2009, Nepal MICS 2014, Pakistan DHS 2013, Sri Lanka DHS 2007.

Regional and national averages hide important disparities. In South Asia the prevalence of stunting in the poorest wealth quintile is 2.4 times higher than in the richest quintile (59 percent vs. 25 percent, respectively).

Prevalence of stunting in children under 5 by wealth quintile, different regions, 2006-2012



Data source: Adapted from UNICEF. 2013. Improving Child Malnutrition: The achievable imperative for global progress.
Note: Excludes China.



Prevalence of stunting in children under 5 in South Asia by wealth quintile



Data source: Afghanistan, NNS 2013; Bangladesh, DHS 2014; Bhutan, NNS 2015; India, RSOC 2014; Maldives, DHS 2009; Nepal, MICS 2014; Pakistan, DHS 2013; Sri Lanka, DHS 2007.

In summary, the situation in South Asia is marked by a high prevalence of stunting, a large burden of stunted children, slow rate of improvement and significant disparities between and within countries.

ACCELERATING CHANGE IN SOUTH ASIA

1 - AFGHANISTAN

UNICEF supported the design and roll out of a harmonized training package to build the capacity of NGOs to deliver nutrition specific interventions in 11 provinces. The package places emphasis on the provision of quality services aiming to improve breastfeeding, complementary feeding, micronutrient nutrition and the integrated management of acute malnutrition.

2 - BANGLADESH

UNICEF efforts were centered on mainstreaming a package of proven nutrition interventions in public health services. Data indicate that the coverage and quality of services are improving: 58% of facilities report providing counseling on maternal and child feeding, and nutrition supply gaps were reduced by 36%. A new National Nutrition Policy and a costed Action Plan will strengthen multi-sectoral efforts to reduce stunting.

3 - BHUTAN

UNICEF supported the design and implementation of the National Nutrition Survey (NNS-2015), which generated disaggregated data on nutrition, anemia, child feeding, water, hygiene and sanitation. In addition, UNICEF supported the development the National Guidelines on Complementary Feeding and the National Food and Nutrition Security Strategy and Action Plan.

4 - INDIA

UNICEF supported national and state nutrition programmes, focusing on stunting reduction. In eight of the 14 states where UNICEF works, the state government has created a State Nutrition Mission or equivalent, to improve governance, coordination and funding for nutrition, with a priority focus on districts with the highest burden.

5 - MALDIVES

UNICEF is supporting the implementation of the national standards and programme on infant and young child feeding (IYCF). Simultaneously, UNICEF is contributing to build the capacity of health staff to counsel mothers on IYCF while supporting the roll out of a behavior change communication strategy on maternal and child nutrition.

6 - NEPAL

UNICEF is supporting the implementation of Nepal’s Multi Sector Nutrition Plan (MSNP) to reduce child stunting. The MSNP counts with high level political commitment as indicated – among others – by the fact that the newly endorsed National Health Sector Strategy includes the reduction of child stunting as a key objective, with clear indicators and time-bound targets.

7 - PAKISTAN

UNICEF supported several provincial and regional governments in finalizing and implementing their multisectoral nutrition strategies. UNICEF also supported the development of the National Infant and Young Child Feeding Strategy and related communication strategy. Finally, UNICEF initiated an integrated Nutrition-WASH programme for the reduction of stunting in Sindh province.

8 - SRI LANKA

UNICEF supported a field survey to identify nutritionally vulnerable households as well as the establishment of village-level multisectoral nutrition teams in nine districts.
In addition, UNICEF supported the review of the National Nutrition Policy and Micronutrient Strategy, which will be the basis for the development of the National Action Plan 2017-2019.

As mentioned in the previous section, national average figures on the prevalence of child stunting hide important disparities. One of the most important and potential disparities is the rural-urban differential. The prevalence of stunting is still high in urban areas; however, in all countries, without exception, child stunting is significantly more prevalent in rural areas.

Prevalence of stunting in children under 5 in South Asia


Data Source: Bangladesh DHS 2014, Bhutan NNS 2015, India RSOC 2014, Maldives DHS 2009, Nepal MICS 2014, Pakistan DHS 2013, Sri Lanka DHS 2007.


How many children are benefitting from the 10 Essential Nutrition Interventions?

Essential Nutrition Intervention 1:
Minimum weight at birth
Percentage of children who were born with a birth weight > 2,500 g

Essential Nutrition Intervention 2:
Early initiation of breastfeeding
Percentage of children who were breastfed within one hour of birth

Essential Nutrition Intervention 3:
Exclusive breastfeeding under six months
Percentage of infants under six months who are fed exclusively with breast milk

Essential Nutrition Intervention 4:
Timely introduction of complementary foods
Percentage of infants 6-8 months old who are fed complementary foods

Essential Nutrition Intervention 5:
Minimum meal frequency
Percentage of children 6-23 months who are fed the minimum number of times per day or more

Essential Nutrition Intervention 6:
Minimum dietary diversity
Percentage of children 6-23 months old who are fed foods from a minimum number of food groups

Essential Nutrition Intervention 7:
Micronutrient-rich foods
Percentage of children 6-23 months old who are fed iron-rich foods

Essential Nutrition Intervention 8:
Minimum adequate nutrition for adolescent girls
Percentage of adolescent girls 15-19 years old with a BMI>18.5 kg/m2

Essential Nutrition Intervention 9:
Minimum adequate nutrition for adult women
Percentage of women 20-49 years old with a healthy BMI (18.5-24.9 kg/m2)


Essential Nutrition Intervention 10:
Safe hygiene and sanitation practices in the household
Percentage of households using improved sanitation facilities


Data Source for Essential Nutrition Interventions 1 and 10: UNICEF State of the World’s Children 2015. Data Sources for Essential Nutrition Interventions 2-9:Afghanistan, NNS 2013; Bangladesh, DHS 2014; Bhutan, NNS 2015; India, RSOC 2014; Maldives, DHS 2009; Nepal, MICS 2014; Pakistan, DHS 2013; Sri Lanka, DHS 2007.

Child stunting is increasingly recognized as a marker and a maker of poor development, so reducing child stunting has become a global development priority. The World Health Assembly has adopted a global target to reduce by 40 percent the number of children under fi ve who are stunted by 2025. Continued progress in South Asia will be needed for this global target to be met. Evidence shows three ‘make-or-break’ areas to reduce child stunting post-2015 in South Asia:
- Child feeding: Improving the quality of complementary foods for children aged 6-23 months, with emphasis on nutrient density and diet diversity while breastfeeding continues.
- Women’s nutrition: Improving women’s food intake (quantity and quality) along the lifecycle as well as the gender determinants of women’s nutrition and social status.
- Household sanitation: Improving family and community hygiene practices, with a particular emphasis on washing hands with soap after defecation and before child feeding.

In pursuit of these aims, the South Asia Regional Action Framework on Nutrition – adopted by the South Asian Association for Regional Cooperation (SAARC) in 2014 – encourages the eight member-countries to apply a four-pillar approach:
- High-level political commitment to improve nutrition governance and programmes.
- Evidence-based, nutrition-specifi c and nutrition-sensitive interventions delivered at scale.
- Stronger institutional and human capacity to manage nutrition programmes.
- Coherent monitoring frameworks and knowledge-management systems.

RESEARCH, KNOWLEDGE, EVALUATION

Víctor M. Aguayo and Purnima Menon (guest editors), Stop stunting in South Asia, a special issue of the international journal Maternal and Child Nutrition released on May 16th, 2016. This supplement was funded and made open access by UNICEF Regional Office for South Asia.

With more than a third of South Asia's children aged 0–59 months being stunted due to persistent nutrition deprivation, this open access supplement presents the rationale for a focus on improving child feeding, women's nutrition, and household sanitation as priority areas for investment to prevent child stunting in this region.

Víctor M. Aguayo and Purnima Menon, Stop stunting: improving child feeding, women's nutrition and household sanitation in South Asia

Mercedes de Onis and Francesco Branca, Childhood stunting: a global perspective

Kathryn G. Dewey, Reducing stunting by improving maternal, infant and young child nutrition in regions such as South Asia: evidence, challenges and opportunities

Kajali Paintal and Víctor M. Aguayo, Feeding practices for infants and young children during and after common illness. Evidence from South Asia.

Sheila C. Vir, Improving women's nutrition imperative for rapid reduction of childhood stunting in South Asia: coupling of nutrition specific interventions with nutrition sensitive measures essential.

Oliver Cumming and Sandy Cairncross, Can water, sanitation and hygiene help eliminate stunting? Current evidence and policy implications.

Mduduzi N. N. Mbuya and Jean H. Humphrey, Preventing environmental enteric dysfunction through improved water, sanitation and hygiene: an opportunity for stunting reduction in developing countries.

Víctor M. Aguayo, Rajilakshmi Nair, Nina Badgaiyan and Vandana Krishna, Determinants of stunting and poor linear growth in children under 2 years of age in India: an in-depth analysis of Maharashtra's comprehensive nutrition survey.

Tina Sanghvi, Raisul Haque, Sumitro Roy, Kaosar Afsana, Renata Seidel, Sanjeeda Islam, Ann Jimerson and Jean Baker, Achieving behaviour change at scale: Alive & Thrive's infant and young child feeding programme in Bangladesh.

Nancy J. Haselow, Ame Stormer and Alissa Pries, Evidence-based evolution of an integrated nutrition-focused agriculture approach to address the underlying determinants of stunting.

Purnima Menon, Christine M. McDonald and Suman Chakrabarti, Estimating the cost of delivering direct nutrition interventions at scale: national and subnational level insights from India.

Meera Shekar, Julia Dayton Eberwein and Jakub Kakietek, The costs of stunting in South Asia and the benefits of public investments in nutrition.

William Joe, Ramaprasad Rajaram and S. V. Subramanian, Understanding the null-to-small association between increased macroeconomic growth and reducing child undernutrition in India: role of development expenditures and poverty alleviation.

Derek Headey, John Hoddinott and Seollee Park, Drivers of nutritional change in four South Asian countries: a dynamic observational analysis.

S V Subramanian, Iván Mejía-Guevara and Aditi Krishna, Rethinking policy perspectives on childhood stunting: time to formulate a structural and multifactorial strategy.

Commentary pieces also available at http://onlinelibrary.wiley.com/doi/10.1111/mcn.2016.12.issue-S1/issuetoc

REAL LIVES, REAL CHANGE

Child Nutrition Week delivers essential nutrition services to children after the Nepal earthquake

At the end of April 2015, immediately after the devastating earthquake in Nepal, the government declared a state of emergency and requested the United Nations to activate the Humanitarian Clusters. The Nutrition Cluster, led by the Ministry of Health and Population and UNICEF, and comprising 28 national and international partners, devised a three-month emergency response aiming to address the safeguard and improve the nutritional status of affected populations.

As a key part of the response, UNICEF and the Nutrition Cluster held a Child Nutrition Week to deliver micronutrient and other essential nutrition interventions for mothers and children under 5, before the onset of the monsoon rains. In Nepal, an event was planned as a fixed-day, village-based strategy to deliver a package of six nutrition interventions to at least 80 per cent of a target population comprising 467,425 children aged 0–59 months, pregnant women and breastfeeding mothers. The Ministry of Health and Population, supported by UNICEF as Nutrition Cluster lead, developed district-level guidelines for the implementation of the Child Nutrition Week with integrated support from a Health and Nutrition Cluster partner in coordination with the District Disaster Relief Committee, and municipal and village authorities. An onsite coaching approach was used to train over 15,000 health workers, female community health volunteers and volunteers from civil society organizations. Information about the Child Nutrition Week was broadcast through Radio Nepal and 63 local radio stations to raise awareness and encourage participation.

The Child Nutrition Week took place between 28 June and 8 July 2015 and was extremely effective in reaching targets. Among children aged 6–59 months, 314,898 (97.4 per cent of target) received a two-month supply of MNPs, and 360,984 (>100 per cent of target) benefitted from vitamin A supplementation while 24,902 women (88.3 per cent of target) received a two-month supply of iron-folic acid supplements. In addition, 153,478 mothers with a child 0–23 months old (91.4 per cent of target) were counselled on the benefits of breastfeeding and the risks of artificial feeding; 142,026 mothers with a child 6–23 months old (>100 per cent per cent of target) were reached to urge continued breastfeeding and the use of MNPs received, through on-site face to face counselling with mothers of children aged 0–23 months.

Nepal’s Child Nutrition Week successfully delivered essential nutrition services to the most vulnerable children and mothers post-earthquake. This is the first time that a Child Nutrition Week approach has been used in South Asia as part of an emergency response. Based on its results, it presents a viable policy option for emergency-affected countries in South Asia and beyond in the future. Furthermore, the Government of Nepal is now considering the use of bi-annual Child Nutrition Weeks to deliver an integrated package of nutrition services as an extension of the routine services provided by the primary health care system.

Source: Aguayo, Víctor M., Anirudra Sharma and Giri Raj Subedi, ‘Child Nutrition Week in Nepal: Delivering essential nutrition services for children after the earthquake and before the monsoon’, Lancet Global Health, vol. 3, November 2015.

Sources:
United Nations Children’s Fund, The State of the World’s children, 2015, Reimagine the future, Innovation for every child, New York, 2015, accessed 3 April 2015

Updated interactive dashboards enable users to explore the entire time-series (1990–2013) of global and regional estimates of prevalence and numbers affected for stunting, underweight, and overweight, and year 2013 for wasting and severe wasting, by the various country regional and income group classifications. On-line dashboards are available on the following websites:
- UNICEF
- WHO
- World Bank