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Mainstreaming interventions in the health sector to address maternal and child undernutrition.

Malnutrition is a contradiction of sorts – a multisectoral problem that needs to be addressed sector by sector. The health, education, water and sanitation, agriculture, trade and several other sectors have a role to play in addressing malnutrition. Cognizant of this need for ‘thinking multi-sectorally and acting sectorally’ (World Bank 2006), the World Bank awarded a grant under its Development Grant Facility to the International Center for Diarrheal Disease Research, Bangladesh to host a partnership to mainstream nutrition through the health sector. The plan is to learn from this experience and to follow this up with an expanded partnership that would bring under its umbrella similar efforts through other critical sectors. One of the key objectives of the Development Grant Facility grant is to support the documentation of the evidence, lessons and experiences from strengthening the nutrition component in Maternal and Child Health (MCH) initiatives. This global review of nutrition interventions, coordinated by the Mainstreaming Nutrition Initiative in collaboration with the Aga Khan University, is a part of this larger attempt. Undernutrition represents the non-income face of poverty and is embodied within Target 2 of Millenium Development Goal 1 (MDG 1). Addressing maternal and child undernutrition is, therefore, in itself a major MDG target and also a critical input factor for achieving MDG 4 and 5. As highlighted by the World Bank (2006), while most of the world is on track vis-à-vis the income poverty goal of MDG 1, only 24% of the countries are on-track vis-à-vis non-income poverty, 18% are improving but do not show sufficient progress, another 18% show a deterioration in progress, and, for a large number of countries (40%) there are no trend data available to monitor progress. Although there is some indication of improvement in global trends for stunting (de Onis 2000), the effect is not uniform. An estimation of these trends indicated that the prevalence of stunting fell in developing countries from 47% in 1980 to 33% in 2000 (i.e. by 40 million). Although this analysis indicated that stunting had reduced in South-Eastern Asia, a subsequent analysis of the data indicates that the trends were largely driven by China and that stunting rates in south Asia have largely remained static (Svedberg 2006). The same is the case for trends in underweight (World Bank 2006). It has been shown that undernutrition in childhood has a multiplicative effect on mortality and that even mild to moderate malnutrition was associated with increased risk of death (Pelletier et al. 1994).A recent analysis of changes in general malnutrition and mortality trends in 59 developing countries between 1966 and 1996, as measured by child weight-for-age (WA) and, on changes in child survival, indicates a significant relationship between improvements in WA and changes in child mortality, independent of socioeconomic and policy changes represented by the secular trend (Pelletier & Frongillo 2003). This evidence of the impact of undernutrition on morbidity and mortality is also accompanied by emerging evidence of the link of maternal and child undernutrition with impaired cognitive development, reproduction, physical work capacity and risks for several adult-onset chronic diseases. The World Bank (2006) has underscored the critical link of improving nutrition at population level as a fundamental pre-requisite for health, human development, human capital formation and economic growth. While poverty alleviation strategies are important for improving nutrition outcomes, income growth alone is insufficient to promote a rapid rate of decline in undernutrition, and the shorter route to improving nutrition is through integrated evidence-based interventions. The recent reviews of interventions that can affect newborn and child mortality (Jones et al. 2003; Darmstadt et al. 2005) suggest that almost one-third of child deaths are potentially avertable through nutrition interventions. However, many of these interventions are not available to the very populations in need and inequitable distribution of key interventions, especially multiple related interventions, is a major challenge in health systems (Bryce et al. 2006). Editorial