Meera Shekar

India's undernourished children: a call for reform and action

The prevalence of child undernutrition in India is among the highest in the world; nearly double that of Sub-Saharan Africa, with dire consequences for morbidity, mortality, productivity and economic growth. Drawing on qualitative studies and quantitative evidence from large household surveys, this book explores the dimensions of child undernutrition in India and examines the effectiveness of the Integrated Child Development Services (ICDS) program, Indias main early child development intervention, in addressing it. Although levels of undernutrition in India declined modestly during the 1990s, the reductions lagged behind those achieved by other countries with similar economic growth. Nutritional inequalities across different states and socioeconomic and demographic groups remain large. Although the ICDS program appears to be well-designed and well-placed to address the multi-dimensional causes of malnutrition in India, several problems exist that prevent it from reaching its potential. The book concludes with a discussion of a number of concrete actions that can be taken to bridge the gap between the policy intentions of ICDS and its actual implementation.

Delivery sciences in nutrition.

Although we continue to gain knowledge on what works bio logic ally to improve nutrition, much less is known about the issues that determine the eff ective ness of large-scale pro gramming and the strategic actions needed to build political com mitment. We strongly reiterate Geert Tom Heikens and colleagues’ state ment of the need to “enter the realm of eff ectiveness and operational research” (Jan 19, p 181). Reducing malnutrition requires an ex panded research agenda of “delivery science” to understand implementation and cost eff ective ness at scale. For example, although much is known about the effi cacy of vitamin A supplementation, little fi nancing or re search has focused on optimising delivery: a capsule costs only US

Vitamin A supplementation in Tanzania: the impact of a change in programmatic delivery strategy on coverage.

0·02, but the delivery still costs 25–75-fold more per child. Even less is known about the optimum delivery of infant feeding interventions within various health systems contexts. Where effi cacious inter ventions are introduced at scale, the limited commitment and in sti tutional capacities at national levels to deliver, manage, and assess these pro grammes has posed a serious obstacle to achieving results. Inadequate capacities are traced largely to the vicious cycle of absence of explicit training in these competencies in leading universities, absence of research on the delivery sciences including operational research, lack of or poor-quality assessments, scarce funding for delivery research, and the reluctance of journals to publish it. Thus, only 3% of health research goes into improving the delivery sciences—the rest goes to developing technologies, even though better delivery alone would save 62·5% of child deaths and improved technology at present delivery levels could save only 22%. Journals such as The Lancet have a role to play in strengthening delivery science. We know a lot about what to do; we know much less about how to do it, and how to do it at scale in the countries where it is needed most. We urge The Lancet to give its support to breaking this vicious cycle of neglect through a conscious eff ort to publish and recognise such essential research.

What difference do the new WHO child growth standards make for the prevalence and socioeconomic distribution of undernutrition

BackgroundEfficient delivery strategies for health interventions are essential for high and sustainable coverage. We report impact of a change in programmatic delivery strategy from routine delivery through the Expanded Programme on Immunization (EPI+) approach to twice-yearly mass distribution campaigns on coverage of vitamin A supplementation in TanzaniaMethodsWe investigated disparities in age, sex, socio-economic status, nutritional status and maternal education within vitamin A coverage in children between 1 and 2 years of age from two independent household level child health surveys conducted (1) during a continuous universal targeting scheme based on routine EPI contacts for children aged 9, 15 and 21 months (1999); and (2) three years later after the introduction of twice-yearly vitamin A supplementation campaigns for children aged 6 months to 5 years, a 6-monthly universal targeting scheme (2002). A representative cluster sample of approximately 2,400 rural households was obtained from Rufiji, Morogoro Rural, Kilombero and Ulanga districts. A modular questionnaire about the health of all children under the age of five was administered to consenting heads of households and caretakers of children. Information on the use of child health interventions including vitamin A was asked.ResultsCoverage of vitamin A supplementation among 1–2 year old children increased from 13% [95% CI 10–18%] in 1999 to 76% [95%CI 72–81%] in 2002. In 2002 knowledge of two or more child health danger signs was negatively associated with vitamin A supplementation coverage (80% versus 70%) (p = 0.04). Nevertheless, we did not find any disparities in coverage of vitamin A by district, gender, socio-economic status and DPT vaccinations.ConclusionChange in programmatic delivery of vitamin A supplementation was associated with a major improvement in coverage in Tanzania that was been sustained by repeated campaigns for at least three years. There is a need to monitor the effect of such campaigns on the routine health system and on equity of coverage. Documentation of vitamin A supplementation campaign contacts on routine maternal and child health cards would be a simple step to facilitate this monitoring.

The costs of stunting in South Asia and the benefits of public investments in nutrition.

Background The World Health Organization has recently established revised child growth standards. Objective To assess how the use of these new standards affects the estimated prevalence and socioeconomic distribution of stunting and underweight among children in a large number of low- and middle-income countries. Methods We analyzed Demographic and Health Survey data for stunting and underweight in 41 low- and middle-income countries employing these new standards and compared the results with those produced by analyses of the same data using the old growth references. Results For all 41 countries, the prevalence of stunting increases with the adoption of the new standards, by 5.4 percentage points on average (95% CI: 5.1, 5.7). The prevalence of underweight decreases in all but two of the countries, by an average of 2.9 percentage points (95% CI: 2.7, 3.2). The impact of using the new standards on socioeconomic inequalities is mixed. For stunting, inequalities tend to rise in absolute terms but tend to decline in relative terms. The impact on underweight is inconsistent across countries. Poor children suffer most from undernutrition, but even among the better-off children in developing countries, undernutrition rates are high enough to deserve attention. Conclusions These results suggest that the adoption of the new WHO standards in itself is unlikely to affect policies dramatically. They do confirm, however, that different strategies are likely to be required in these countries to effectively address undernutrition among children at different socioeconomic levels.

An investment framework for nutrition : reaching the global targets for stunting, anemia, breastfeeding, and wasting

Abstract South Asia is home to the largest number of stunted children worldwide: 65 million or 37% of all South Asian children under 5 were stunted in 2014. The costs to society as a result of stunting during childhood are high and include increased mortality, increased morbidity (in childhood and later as adults), decreased cognitive ability, poor educational outcomes, lost earnings and losses to national economic productivity. Conversely, investing in nutrition provides many benefits for poverty reduction and economic growth. This article draws from analyses conducted in four sub‐Saharan countries to demonstrate that investments in nutrition can also be very cost‐effective in South Asian countries. Specifically, the analyses demonstrate that scaling up a set of 10 critical nutrition‐specific interventions is highly cost‐effective when considered as a package. Most of the interventions are also very cost‐effective when considered individually. By modelling cost‐effectiveness of different scale‐up scenarios, the analysis offers insights into ways in which the impact of investing in nutrition interventions can be maximized under budget constraints. Rigorous estimations of the costs and benefits of nutrition investments, similar to those reported here for sub‐Saharan countries, are an important next step for all South Asian countries in order to drive political commitment and action and to enhance allocative efficiency of nutrition resources.

Reaching the global target to reduce stunting: an investment framework.

The report estimates the costs impacts and financing scenarios to achieve the World Health Assembly global nutrition targets for stunting anemia in women exclusive breastfeeding and the scaling up of the treatment of severe wasting among young children. To reach these four targets the world needs

Know Your Deficiencies, Know Your Response, Know Your Costs: A Commentary on Micronutrient Program Optimization Modeling.

70 billion over 10 years to invest in high-impact nutrition-specific interventions. This investment would have enormous benefits: 65 million cases of stunting and 265 million cases of anemia in women would be prevented in 2025 as compared with the 2015 baseline. In addition at least 91 million more children would be treated for severe wasting and 105 million additional babies would be exclusively breastfed during the first six months of life over 10 years. Altogether achieving these targets would avert at least 3.7 million child deaths. Every dollar invested in this package of interventions would yield between

An investment framework for nutrition in Afghanistan : estimating the costs, impacts, and cost-effectiveness of expanding high-impact nutrition interventions to reduce stunting and invest in the early years

4 and

Supporting the National Action Plan on Nutrition: Estimating the Cost, Impact, Cost-Effectiveness, and Economic Benefits of Expanding the Coverage of Direct Nutrition Interventions in Bangladesh

35 in economic returns making investing in early nutrition one of the best value-for-money development actions. Although some of the targets -- especially those for reducing stunting in children and anemia in women -- are ambitious and will require concerted efforts in financing scale-up and sustained commitment recent experience from several countries suggests that meeting these targets is feasible. These investments in the critical 1000 day window of early childhood are inalienable and portable and will pay lifelong dividends -- not only for children directly affected but also for us all in the form of more robust societies -- that will drive future economies.