Malnutrition in Zambia. Quick wins for government in months. For The Attention of His Excellency The President of Zambia Mr. Edgar Chagwa Lungu

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1 Malnutrition in Zambia. Quick wins for government in months For The Attention of His Excellency The President of Zambia Mr. Edgar Chagwa Lungu

2 A Zambia Where every mother and child is assured of sufficient Nutrition

3 Background Malnutrition in Zambia stands at embarrassingly high levels for a middle-income country, and the persistent rates are undermining social development and national economic growth1. Chronic malnutrition, manifesting as stunted growth, stands at 40% of all Zambian children under age five; stunting in childhood is strongly associated with impairment in cognitive function and lower educational attainment2 and lower earnings in later life3. Acute malnutrition, manifesting as clinical wasting and requiring medical treatment, affects 5% of children; wasting brings high risk of death, and costs the health system a significant amount each year4. Not only is investing in reducing malnutrition the moral thing to do, it also makes sound social and economic sense5. Malnutrition is not just a problem of food. It is caused by three main factors: the lack of sufficient, diverse foods in the diet; the lack of access to clean water, improved sanitation and hygienic environments; and limitations in infant feeding and health services. This means that tackling malnutrition is not the responsibility only of the health sector; it requires the combined and coordinated action of multiple sectors (health, agriculture, water, social protection, education among others), and over sustained periods of time. However, there are some vital actions that can be taken by government now that would start to address some key limitations to reducing malnutrition numbers in Zambia. Starting to take steps on the road towards full resolution of malnutrition now will be seen as a very positive sign by the international community and national organisations working in nutrition. It will also set Zambia on its way to eventual policy coherence and effective implementation and enforcement in the longer term that could see stunting reduced to 25% by the end of the next full Presidential period, in Below are noted five major problems which are blocking reductions in child malnutrition in Zambia currently, and ten short-term actions that can be taken by the government to start to resolve these. Problem 1 When almost half of all children are stunted, the problem of malnutrition becomes invisible to the population, because it becomes the norm6. Malnutrition can also be invisible to those who make policies which affect young children, because policymakers are not exposed to the realities of malnutrition day-to-day. This lack of awareness of the extent of child malnutrition, of its consequences, and of what can be done to address it, is limiting action to resolve it. What the Government can do: 1. Bringing awareness of the issue of malnutrition needs to start at the top: If the President mentions malnutrition in key speeches-including the scale of the issue, and what needs to be done to resolve it- then his goverment will understand that reducing the numbers of malnourished children in 1 World Bank (2014): Zambia loses over US$186 million in GDP annually to vitamin and mineral deficiencies alone. IFPRI (2014): Undernutrition lowers GDP for Egypt by 1.9%; Ethiopia, 16.5%; Swaziland, 3.1%; and Uganda, 5.6% 2 Hoddinott et al (2011): Absence of stunting at 36 months is causally linked to leaving school at an older age and with higher grade attainment in Guatemala; Alderman, Hoddinott and Kinsey (2006): The loss of 0.7 grades of schooling due to malnutrition translates into a 12% reduction in lifetime earnings in Zimbabwe. 3 Hoddinott et al (2011): A one-standard deviation increase in height-for-age at 36 months raises hourly earnings by 20 percent in Guatemala; Thomas and Strauss (1997): 1% increase in height leads to a 2-2.4% increase in earnings in Brazil. 4 Black et al (2013): Malnutrition (fetal growth restriction, sub-optimal breastfeeding, stunting, wasting and deficiencies of vitamin A and zinc) is responsible for 45%of all child deaths. 5 Horton and Steckel (2013): Investing in nutrition can increase a country s gross domestic product (GDP) by at least 3 percent annually. World Bank (2014): Zambia s financing gap for nutrition-specific interventions is between US$ 20 to 24 million; full investment in nutrition would add US$123 million to GDP annually once the interventions have reached scale. 6 It is not, however, normal: The richer sections of Zambian society suffer far less from stunting than the poorer sections, showing that malnutrition can be avoided in this population: Central Statistical Office DHS (2009). Zambia Civil Society Scaling Up Nutrition Alliance (CSOSUN), 21 Mwambeshi road, Northmead, Lusaka - Zambia Tel: , ONE

4 Zambia is a priority for him. This will provide motivation for policy-makers in all relevant sectors to properly address the determinants of malnutrition, and will start to hold those charged with implementing policy account able for their actions. The President could in addition launch a campaign, with the House of Chiefs, the CSO SUN and allies in the donor community and media, to urge action to prioritize and tackle child malnutrition. Problem 2 Changing attitudes and practices related to nutrition requires all stakeholders to work together (as happened with the HIV/AIDS pandemic 10 years ago), including the ealth sector (MOH and MDCMCH) for providing nutrition education to all sections of the population, and treatment of acute malnutrition; the agriculture sector for encouraging production of and access to a wide range of food types; the education sector for providing healthy school meals and educating children on good nutrition; the water sector for ensuring households have access to clean water and improved sanitation; and the social protection sector for ensuring families have the resources to access good diets and health services. While different sectors that influence malnutrition are becoming more aware of their respective roles due to the work of the National Food and Nutrition Commission (NFNC), the SUN Civil Society Alliance, and others, Ministries cannot undertake these roles without proper resources 7. What the Government can do: 2. Each of the 5 key line ministries should have their budget lines for nutrition fully resourced according to need stated in their multi-sectoral district nutrition plans, including at least doubling the budgetary allocations for the nutrition-specific budget lines under MCDMCH (Man agement of Acute Malnutrition, IYCF, CBGMP, micronutrient program), ensuring that funds are reaching this level, and are being disbursed as per the districts multisectoral nutrition plans. The National Food and Nutrition Commission (NFNC)is the body which oversees nutrition in Zambia, but the NFNC is currently placed under the Ministry of Health, and therefore has no convening or enforcement power over the various Ministries which play a role in reducing child malnutrition. Stakeholders in the Nutrition sector have recommended a new placement for the NFNC 3. The President should follow these developments and seriously consider the recommendations. Problem 3 In order to grow and thrive, children need a variety of different foods in their diets after six months of age. Zambian diets are based heavily on maize as a staple foodwhich is filling, tasty, and provides energy, but does not provide the vitamins and minerals children need. Households often struggle to find and afford foods that provide diverse diets for their children. 7 World Bank (2014): Zambia s financing gap for nutrition-specific interventions is between US$ 20 to 24 million (total government budget for nutrition was $1.5 million in 2014) TWO

5 What the Government can do: 4. A majority of the Zambian population (and a majority of households with stunted children) are primarily engaged in farming, and produce most of the foods they eat themselves. The Government s FISP program helps poorer families to produce more maize, which is a great help to many. However, the FISP could contribute more strongly to reducing child malnutrition if it diversified the foods supported with the package, and ensured that the poorest households were able to access the program. The President should order a review to see how good nutrition (rather than just food security) could become a major consideration of FISP, and follow up on recommendations. 5. Most households supplement the foods they grow with foods they buy. The social safety net Cash Transfer Programme helps poor households afford essentials, including food. This programme could be made more sensitive to nutrition by including nutrition information and education for recipients. The President should order a review to see how good nutrition could become a major consideration of the CTP, and follow up on recommendations. Problem 4 There are several reasons why children become acutely malnourished, including giving inappropriate foods when infants should be exclusively breastfeeding in the first six months of life; becoming ill due to dirty water and poor sanitation; and being given poor quality foods and beverages making claim to be appropriate options for young children. Children who become acutely malnourished require treatment, and clear treatment protocols including the provision of Ready to Use Therapeutic Foods (RUTF) exist in Zambia. However, although supplies of RUTF are generally available in Lusaka, these are not finding their way to clinics in other parts of the country. Erratic supply of these foods means malnourished children are not issued with sufficient treatment rations, resulting in multiple re-admission and high relapse and death rates. What that Government can do: 6. Review and reinstate Statutory Instrument #48 of supporting the Code of Marketing on Breast Milk Substitutes, and ensure that legislation has the power to enforce compliance of private sector baby-food and infant formula manufacturers, and that the food safety agency and Ministry of Health officials are aware of the legislation and have the resources and political support to assess the current situation and take action where infringements are found. 7. Assess regional need for and costs of procuring RUTF, as well asavailability at central level, and assess and unblock current supply lines for RUTF from Medical Stores Ltd in Lusaka to local health centres where it is needed. 9 This legislation (regulating which products are considered suitable foods for young children and how these are marketed) was suspended in 2011 after lobbying by certain sections of the food industry, with negative results for child malnutrition. THREE

6 Problem 5 Low capacity in nutrition at all levels has been recognized as a constraint to the full implementation of nutrition plans and policies in Zambia. Recognizing this, UNZA commenced a BSc level qualification in nutrition in 2010, and the first graduates of this program will graduate in However, not enough potential students can afford this vital training, and even for those who can, nutrition is not recognized as a profession in Zambia as it is in many other countries, making it potentially difficult for these graduates to play a meaningful role in leading the improvement in the country s child malnutrition statistics. In addition, capacity at local levels is lacking, with staff and community workers not routinely trained to a high level in preventing, spotting and treating acute malnutrition, or counselling families to avoid chronic malnutrition. What the Government can do: 8. Ensure that the nutrition degree, and nutrition as a profession, is recognized under the Health Professions Council, so that graduates of appropriate courses can enter the system at the appropriate level, and consider providing scholarships for outstanding students each year in order to increase numbers of nutrition leaders in Zambia. 9. Commission a review of government training curricula for local-level health workers to ensure that nutrition is adequately covered, and ensure that budgets and personnel are available for trainings and updates. Key contacts for further action Zambia Civil Society Scaling Up Nutrition (CSOSUN), Tel , References for further information Alderman, Hoddinott and Kinsey (2006): Long-term consequences of early childhood malnutrition. Oxford Economic Papers 58 (3): Black et al (2013): Maternal and Child Undernutrition and Overweight in Low-and Middle-Income countries: Prevalences and Consequences, Lancet Central Statistical Office, Zambia (2009): Demographic and Health Survey 2007, Macro International, Arlington, USA IFPRI (2014): Global Nutrition Report 2014: Actions and Accountability to Accelerate the World s Progress on Nutrition. Washington, DC Hoddinott et al (2011): The Consequences of Early Childhood Growth Failure over the Life Course, IFPRI Discussion Paper Washington, DC. Horton and Steckel (2013): Global economic losses attributable to malnutrition and projections to In "The Economics of Human Challenges", ed B. Lomborg. Cambridge University Press Thomas and Strauss (1997): Health and Wages: Evidence on Men and Women in Urban Brazil, Journal of Econometrics,77(1): World Bank (2014): Costing nutrition interventions in Zambia, World Bank Report, Washington, DC FOUR

7 CSO - SUN ALLIANCE Zambia Civil Society Scaling Up Nutrition Alliance Zambia Civil Society Scaling Up Nutrition Alliance(CSOSUN), 21 Mwambeshi road, Northmead, Lusaka - Zambia Tel: ,

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