By Richmond Aryeetey, Olutayo Adeyemi, Mara Van Den Bold, Elodie Becquey. Nick Nisbett, Zusia Turowska
The ‘stories of change in nutrition’ initiative is a series of studies designed to systematically assess and analyse drivers of change in countries that have had success in accelerating improvements in nutrition. The multi-methods approach, which combines data and policy analysis with data from interviews with stakeholders at national, sub-national (e.g. state), and in some cases community level, has become an important part of the work by partners in Transform Nutrition West Africa. The studies help focus on lessons and challenges in three of our four focus countries: Nigeria, Burkina Faso and Ghana (the fourth focus country, Senegal, was already the subject of our earlier round of studies under the Transform Nutrition Research Consortium). Researchers from the University of Ghana, the Institut Superieur Des Sciences de La Population, Burkina Faso, Ibadan University, Nigeria, as well as IFPRI and IDS have been working alongside consultant researchers (Olutayo Adeyemi, Zuzanna Turowska, Emilie Buttarelli) to study the stories of change in prevalence of stunting in all three countries as well as Anaemia in Ghana.
As we near the end of our second full year of Transform Nutrition West Africa, two of the studies, in Ghana and Burkina Faso, are nearing completion and so, as we bring together our final synthesis of those studies, we reflect on their findings here.
Burkina Faso and Ghana have both experienced impressive change in stunting: in Burkina Faso, under-five stunting declined from 45% to 25% during 1998/99 to 2018, while in Ghana, under-five stunting declined from 28% in 2008 to 19% in 2017. Nevertheless, in Ghana during the same period, the rate of anaemia in children remained intractably high (78% in 2008), only declining by a small margin (67% in 2014).
Data analysis in Ghana (via a technique known as decomposition analysis) reveals that improvements in short-term interventions like household wealth, infectious disease control, and reproductive health services, alongside the longer-term well-being of mothers (represented by mothers’ height and education) is likely to explain about half of the anaemia and stunting reduction that has occurred among young children. Stakeholder interviews and policy analysis point to multiple policies and programs that were initiated to address stunting across sectors. For example, a flagship National Nutrition Policy (NNP) was developed and published in 2016. The NNP positioned stunting reduction as a key human development outcome. Key intervention programs initiated/implemented during the period included mass food fortification, micronutrient supplementation, infant and young child feeding, infection control, social protection, and water and sanitation. These policies and programs were stimulated by multiple situations including:
1) the role of the Ghana Health Service in leading on policy and implementation, supported by local and international development partners,
2) Ghana signing up as a member of the SUN movement in 2011,
3) evidence demonstrating the high cost of undernutrition among children in Ghana, and
4) the resulting prioritization of nutrition as a key health outcome in the health sector.
More broadly, several important structural developments are driving this change: Ghana has experienced significant socio-economic growth in the past decade (2009-2018). Indicators of this growth include expansion in the economy (becoming a Lower Middle-Income country), and expansion in social, technological, and health infrastructure and services. Alongside reductions in undernutrition, there have been associated changes in poverty, morbidity and mortality among women and children.
In Burkina Faso, data analysis reveals improved rates of immunization have been the largest driver of change regarding improvements in stunting outcomes for children between 1993 to 2010. Like Ghana, stakeholder interviews and policy analysis point to the Ministry of Health (MoH) and its technical and financial partners as having had the most visible commitment to and action in nutrition in Burkina Faso, despite the Ministry of Agriculture being described as the most influential ministry working in the domain of food and nutrition security. The MoH and its Directorate of Nutrition have passed numerous nutrition laws, increased hiring of health agents and nutritionists, and is executing preventive health programs (including immunization) and a policy of free healthcare for pregnant women and children under 5 that have together driven improvements in nutrition.
Community level work in Burkina Faso shows the benefits of delving deeper into community members’ perceptions of local drivers of change. Community members cited improvements in access to healthcare systems and diversified food. Communities also described agents from different ministries (health and agriculture) engaging the population through women, youth, and civil society organizations. However, systemic poverty hinders communities’ abilities to cover basic needs and stymies improvements in nutrition. Community respondents reported that they are not able to purchase food, pay school fees, buy agricultural inputs, or pay the cost of prescriptions. More attention in advancing literacy, financing education, creating access to credit, and providing social services would possibly alleviate some of these issues.
More widely, analysis in Burkina Faso highlights the need to consider whether further advances could be made on other known drivers of stunting, particularly, e.g. open defecation or prevalence of malaria, while in Ghana, emerging findings point to the need of future programs to advocate for increased funding from government, scale up geographic coverage of effective interventions, enhance quality of children’s diets, build capacity for nutrition service delivery, and improve coordination of efforts across stakeholders. In both countries, future problems are also likely to revolve around the growth in relatively new forms of malnutrition – i.e. the prevalence of overweight and obesity. At the community level in Burkina Faso, women described cakes and candies as new phenomena in the market place, and raised concerns about the nutritious value of these foods. Although the central government does not appear to be systemically addressing issues surrounding over-consumption of high-fat, high-sugar foods, these women’s concerns are a possible signal of what challenges are to come in the future. Lessons of what to avoid may be taken from Ghana, where obesity amongst women has already reached 16.6 % and the prevalence of women overweight stands at 41% (levels amongst men are still significantly lower at 4.5 % and 22.1%).
Challenges such as these have influenced a new set of studies around the world that will be looking at different countries’ ‘stories of challenge in nutrition’, particularly concerned with obesity, overweight and the ‘double burden’ (of multiple forms of malnutrition coinciding together), including a study that will focus on community perceptions of the drivers of female . overweight and obesity in Ghana. Together, these should provide an impressive set of resources from those wanting to transform nutrition in West Africa.
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