The way forward: repositioning children's right to adequate nutrition in the Sahel
Sara E. Wuehler, Helen Keller International, Africa Regional Office, Dakar-Yoff, Senegal. E-mail: firstname.lastname@example.org
Efforts to reduce mortality and undernutrition among infants and young children in the Sahelian countries of West and Central Africa have produced limited positive results. A series of recent publications have described the global prevalence and consequences of maternal and child undernutrition (1, 2), effective actions that can reduce undernutrition (3, 4), and the financial commitments that will be required to complete the necessary scaling up of these actions (5). The sporadic progress that has been achieved emphasizes the need for more concerted action to reduce undernutrition in the region. Most countries are not yet on track towards achieving the Millennium Development Goals (MDGs) of reducing mortality by two-thirds and halving underweight among children less than 5 years of age by 2015. Further, exclusive breastfeeding among infants less than 6 months of age is still below 10% in all but two countries.
A recently conceived initiative seeks to achieve optimal nutrition for ≥80% of infants and young children in the Sahel. This issue of Maternal and Child Nutrition presents the objectives of this initiative and describes the findings of situational analyses of existing infant and young child nutrition (IYCN)-related conditions, including relevant national legislation, nutritional status surveys and other research activities, ongoing programmes and related training materials, and monitoring and evaluation activities in six selected countries in the region: Burkina Faso, Chad, Mali, Mauritania, Niger and Senegal (6–12). These analyses identified both notable progress and substantial gaps in regional IYCN activities. Highlights of progress include a substantial foundation of well-conceived national policies, and programmes, focusing on: (i) the promotion of exclusive breastfeeding to 6 months; (ii) vitamin A supplementation (VAS) through twice annual child survival events that are reaching >80% of children; (iii) inclusion of zinc supplements in the treatment of diarrhoea; (iv) management of acute malnutrition through centralized rehabilitation centres and community outreach programmes; and (v) national behaviour change communication strategies in some of these countries. In addition, national-level multi-sector nutrition counsels or working groups have been established in five of the six countries reviewed, four of which meet on a regular basis. In two cases, these working groups report directly to the office of the prime minister. Regionally, the Assembly of Health Ministers of the Economic Community of West African States (ECOWAS) has recently ratified two relevant resolutions: one on industrial-scale food fortification in 2006 (cooking oil fortified with vitamin A, flour fortified with iron, zinc, folic acid and B vitamins) and the second in 2009 on four nutrition priorities (VAS, IYCN, integrated management of acute malnutrition and capacity building).
Despite these achievements, the situational analyses identified several gaps in critical nutrition-related activities, including: (i) few nutrition programmes reach national coverage; (ii) monitoring and evaluation (M&E) activities lack the depth necessary to identify which programmes are truly effective; (iii) nutrition-related research findings are not effectively disseminated and regularly integrated into programme design and training materials; (iv) the prevention and treatment of zinc deficiency is not yet being addressed beyond the promotion of zinc in the treatment of diarrhoea and voluntary inclusion of zinc in the fortification of wheat flour; (v) programmes have not been effective in reducing iron deficiency and anaemia; (vi) while there has been progress in establishing specialized centres for management of acute malnutrition, screening and treatment are not yet systematically integrated into regular health-centre visits or mainstreamed into community outreach programmes; (vii) maternal screening, anti-retroviral (ARV) therapy and counselling in infant and young child feeding choices to reduce vertical transmission of HIV through breast milk are not yet addressed in all countries1; (viii) nutrition indicators used in many nutrition-related surveys are not harmonized across time and countries, making it difficult to identify critical trends requiring humanitarian and development responses; (ix) access to nutrition-related documents is often difficult to access and documentation of programme activities is often lacking; and (x) although several national nutrition counsels or working groups exist, few have the high-level political support that is necessary to promote multi-sectoral nutrition-related activities.
In addition, during a recent workshop of regional stakeholders, it was concluded that current human and institutional capacities are well below the level required to address the nutritional problems of the region (13). The 2009 ECOWAS Assembly of Health Ministers, mentioned previously, called on the West African Health Organization to initiate efforts to increase nutrition capacity in the region by hosting the secretariat for the West Africa Public Health Nutrition Research and Training Initiative.
The previously mentioned IYCN initiative has been integrated into the global REACH initiative – Ending child hunger and undernutrition. Within this initiative, a regional working group of international agencies in West and Central Africa is collaborating to promote: (i) capacity development; (ii) research and knowledge management; (iii) advocacy and communication; (iv) industrial scale food fortification; and (v) partnership and collaboration in the region. The international agencies involved in these activities include, in alphabetical order: Action Against Hunger, Counterpart International, European Commission for Humanitarian Aid, Food and Agriculture Organization of the United Nations, Helen Keller International, Micronutrient Initiative, University of California – Davis, Save the Children, United Nations Children's Fund, United Nations World Food Programme, the World Bank, and the World Health Organization. The global REACH initiative has also established a regional coordination facilitator in Dakar to assist with the promotion of these activities and the establishment of national REACH facilitators in selected countries in the region (14). Despite the current financial, humanitarian and human investments in nutrition in the region, institutional and human resource capacities, and programme breadth and coverage are not yet sufficient to achieve the desired goal of ensuring optimal nutrition for at least 80% of children in the region, and M&E activities are inadequate for tracking progress.
The way forward
To achieve this target, it will be necessary to:
- • advocate for continued and increased political support at the highest levels to reposition nutrition as a central component of national development activities;
- • establish and/or continue support of effective national and international multi-sector coordination mechanisms for nutrition;
- • integrate health and nutrition-related training modules into the curriculum of pre-service institutions for all health and nutrition-related professionals and their community outreach services;
- • scale up and enhance programmes that have already been shown to be effective, such as promotion of exclusive breastfeeding to 6 months of age, universal VAS for infants as they turn 6 months, semi-annually for children 6–59 months; and for women within 6 weeks post-partum, use of zinc in the treatment of diarrhea, iron–folic acid supplements for pregnant women, universal salt iodization and appropriate hand washing;
- • develop models to make complementary feeding interventions more effective in the Sahel context by: (1) evaluating the quality and affordability of available household complementary foods; (2) assessing whether micronutrient supplements or point-of-use fortification products are necessary to ensure adequate nutritional quality of home-prepared complementary foods; (3) evaluating different delivery mechanisms for these products, including building on the experiences of global food fortification programmes to develop fortified complementary foods that are appropriate for infants and young children; and (4) optimizing the nutritional adequacy of available foods through multi-sector coordination across health, agriculture, food security, livelihoods and social protection;
- • integrate the management of acute malnutrition into general health services, including at the community level: (1) ensure all children attending health clinics are screened for acute malnutrition; (2) establish a more effective link between the health and community systems; and (3) implement systematic screening and referral procedures for acute malnutrition;
- • develop the nutrition evidence base through rigorous monitoring and evaluation of existing and future planned nutrition programmes to determine which programmes are effective and appropriate for large-scale implementation;
- • improve access to relevant IYCN-related documents through a central repository in each country, and advocate for adequate resources to improve documentation of future activities;
- • strengthen integrated multi-sector policies and programmes to increase agricultural and livestock productions, reinforce capacities to respond to food crises, support family livelihoods, and ensure social protection and access to health care;
- • develop human and institutional capacities to carry out the said activities; and
- • conduct a systematic review of research needs in the region to complement the findings of the situational analysis presented in this issue, with emphasis on research to support the implementation of large-scale programmes which can be expanded to achieve national coverage.
The stage is set with high-level support to reduce childhood undernutrition in the Sahel: national legislation is in place, but national and international collaborations, with both technical and financial supports, are now required to implement these plans to ensure children's optimal nutrition. The global community, through the MDGs, has made promises to the future generation for their survival and development. The six countries reviewed here represent nations whose infants and young children are most in need of these activities. National and global commitments will be judged by the delivery of pertinent services in these countries. This analysis provides the road map for concrete actions to address this urgent challenge for development and children's rights.
This analysis was conducted on documentation that mostly predates the new World Health Organization (WHO) recommendations regarding the promotion of ARV therapy for all HIV positive women.