Introduction
Uganda has a vision for the year 2025 as stated in the government’s recent Strategic Framework for National Development. The human and economic aspirations of this vision include, among other things:
Tripling of real per capita gross domestic product from $300 to $900, reducing mass poverty to a fifth of its current level from 26% to 5%, and increasing life expectancy from 43 to 70 years.
These goals are realistic but require development of a healthy, educated and productive work force over the next 25 years, which in turn requires that the children conceived and born today are well nourished and well cared for. Sadly though, too many Ugandan children born today will miss this opportunity because of malnutrition. Current data indicate that the main nutrition problems affecting Uganda are: inadequate intakes of foods containing energy and protein, iodine deficiency, iron deficiency anemia and vitamin A deficiency.
This presentation will show how timely investments in nutrition interventions are needed if we want to realise our aspirations for the year 2025 and avoid the serious but invisible consequences of malnutrition. Let’s look at some of these consequences.
Consequences of Malnutrition
Vitamin A deficiency and Protein Energy Malnutrition reduce survival, PEM also reduces productivity, while iron deficiency anaemia affects both physical capacity and intelligence. Iodine deficiency in pregnant women results in intellectual impairments of the foetus, with implications for future school performance and thus for future productivity.
We are now able to quantify these effects and to demonstrate the enormous impact of malnutrition on human and economic development. To do this, we have used a computer programme called PROFILES.
PROFILES uses current nutrition, demographic and scientific data to relate malnutrition to functional consequences such as child survival, illness, impaired intelligence and reduced productivity.
The consequences of malnutrition are calculated over a 6-year period from 2000 to 2005, which is the first stage of the revised national poverty eradication action plan.
The data used in this analysis are based on demographic data estimates from the 1991 Uganda Census and the 1999 projections from the Uganda Bureau of Statistics. The nutrition data is based on the Uganda Demographic and Health Survey of 1995, local surveys and international literature. 3 The targets used to estimate benefits are based on targets of the current National Health Plan.
Let us now describe the consequences of malnutrition on: child health and survival, education and economic development, beginning with child health and survival.
Consequences of Malnutrition on Child Health and Survival
It should be noted that Protein-energy malnutrition, vitamin A deficiency and sub-optimal breastfeeding, significantly lower the resistance of children to infections and increase dramatically their risk of illness and death.
Our most recent national survey found that 26% of children below 5 years of age in Uganda are underweight. Since malnutrition reduces a child’s resistance to infection, underweight children are more likely to become sick and die. It is further estimated that in Uganda 43% of child mortality is caused by protein-energy-malnutrition and its interaction with infection. This makes protein energy malnutrition the single greatest cause of child mortality.
In-fact, using PROFILES we have estimated that if there is no improvement in the prevalence of PEM over the next 6 years, 271,000 children will die due to PEM. If we are able to achieve the National Goal, to reduce PEM from the current 26% to 16% over the next 6 years, 53,000 lives can be saved over the same period.
Vitamin A also has an immense impact on the levels of child morbidity and mortality. In Uganda, Vitamin A deficiency affects an estimated 54% of children under 6 years of age, resulting in increased levels of illness and deaths.
Using PROFILES, we estimate that over the next 6 years, 184,000 child deaths will be attributed to Vitamin A deficiency. On the other hand, if Vitamin A deficiency is reduced from the current level of 54% to 11%, that is by a factor of 80%, over the next 6 years, then 65,000 child lives will be saved.
There would also be significant financial savings to both government and individual families from the treatment and care of children experiencing vitamin A related morbidity.
One other factor that influences child morbidity and mortality is poor breastfeeding practices. Breastfeeding protects infants against infections and death. The National Food and Nutrition Policy (1996) recommends that babies be exclusively breastfed for their first 6 months of life with no other foods or liquids, not even water. However, by 4-5 months, 64% of infants receive some form of supplement, unecessarily exposing them to possible infection and reducing the protective advantages of breastfeeding.
We have estimated that as a result, if breastfeeding practices remain unchanged, there will be 4,400 infant deaths each year caused by diarrhea and respiratory tract infections that are due to sub-optimal breastfeeding.
We all know that exclusive breastfeeding also contributes to child spacing and therefore improves the health of mothers and infants.
We have estimated that if all our children were not breastfed, the current total fertility rate in Uganda of 6.9 would increase to 10.7. The monetary value of this contraceptive effect of breastfeeding in our country is 12 million dollars per year and could be even more if the rates of Exclusive Breastfeeding were improved.
Consequences of Malnutrition on Education
Good nutrition is essential for optimal mental development, learning potential and school performance in children. Malnutrition wastes educational resources.
Protein Energy Malnutrition and Education
For example, stunted children, who are too short for their age, have been shown to have 3lower Intelligence Quotients and 3lower specific factual knowledge than comparable non-stunted children. In addition, children stunted at 2 years have delayed enrollment in school, high absenteeism, 3higher rates of class repetition and 3low concentration. The degree of cognitive impairment is related to the severity of stunting.
Vitamin A and Education
Children with vitamin A deficiency can suffer from night blindness or even total blindness. This increases the cost of training in special schools of the blind and prevents enrollment of some of those affected. We have already described the effects of vitamin A deficiency on the immune system. The resulting illnesses 3increase absenteeism and 3reduce concentration at school, further wasting educational resources.
Iodine and Education
Iodine is necessary for the normal development of the baby’s brain during pregnancy and pregnant women living in Iodine deficient regions are more likely to give birth to mentally retarded children. Due to its permanent effects on mental development, iodine deficiency during pregnancy considerably reduces children’s learning ability, school performance and retention rates. It also causes 3speech and hearing defects.
The total goiter rate amongst school children in six selected districts in Uganda is 60% while visible goiter affects 30% with wide variations noted. Presence of visible goiter has traumatic effects on the affected children causing absenteeism, inferiority complex and pain, amongst others.
If every household in our country consumes salt fortified with iodine, this simple, low-cost intervention would have an enormous impact on our children’s ability to learn.
Iron and Education
Iron deficiency anemia also reduces the learning ability of children.
Iron deficiency anemia in young children is associated with reduced physical capacity to do work, mental capacity to think and learn, school retention, 3school attendance and enrollment.
If anemia among school children, is not urgently addressed, it will reduce the expected benefits of the investments in universal primary education and the contribution our children can make to the future economy.
Consequences of malnutrition on education have physical and social economic losses in terms of time, money, energy, scholastic materials, 3human resource and physical infrastructure. In addition, reduction in intellectual development occurs due to low intelligence and manipulative skills. All these factors compromise educational achievement, waste investments in Universal Primary Education, and threaten future prosperity, yet Uganda is for our children!
Consequences of Malnutrition on Economic Productivity
In Uganda’s Vision 2025, rapid modernization of agriculture was identified as a primary strategy.
This and other aspirations for increased economic productivity are threatened by three major malnutrition problems, namely:
¨ Stunting, due to protein-energy malnutrition
¨ Mental impairment, due to iodine deficiency, and
¨ Anemia due to iron deficiency,
All of which have adverse effects on economic development.
The Effect Of Stunting
At age 2, 45% of Ugandan children are stunted. The damage caused by stunting by this age is permanent so stunted children become stunted adults who never attain their full productive potential.
Using PROFILES, we estimate that if no intervention to reduce stunting over the next 6 years is adopted, the present value of future productivity lost due to stunting will be 201million US dollars. Yet the country would be able to gain 26 million dollars in productivity over the same period with interventions costing only 12 million dollars, yielding a benefit: cost ratio greater than 2 to 1.
Goitre
Let’s look next at the effect of iodine deficiency on economic productivity.
We have already seen that iodine deficiency causes mental impairment 3in newborn babies, which is irreversible and that goiter prevalence among Ugandan children of school going age currently stands at 60%.
Using profiles, we estimate that if iodine deficiency remains unchanged over the next 6 years, Uganda will lose 744 million dollars in productivity. Yet with interventions costing only 5 million dollars the country would be able to 3reduce these losses by 380 million dollars over the same period, with a benefit: cost ratio of 73 to 1. Over 2 million newborn babies would be spared from mental impairment over this period.
Anemia
Turning now to anemia, scientific research shows that there is a 1% drop in productivity for every 1% drop in iron status.
Anemia results in:
¨ Poor reproductive health leading to greater risk of death of mother and infant; and
¨ Reduced productivity in manual work.
¨ Current estimates put anemia prevalence in Uganda at 50% in pregnant women and 35% in non-pregnant women.
¨ Using profiles, we estimate that if no intervention to reduce iron deficiency over the next 6 years is adopted, Uganda will lose 120 million dollars in productivity just in the female agricultural work force. Yet with interventions costing only 10 million dollars, the country would be able to gain 21 million dollars in productivity benefits over the same period, with a benefit: cost ratio greater than 2 to 1.
In SUMMARY, Ladies and gentlemen the overall cost benefit analysis of what we are advocating for can be summarized as follows:
If nutritional deficiencies remain unchanged, the net present value of productivity loss for the 6-year period from 2000 to 2005 would be:
¨ 201 million dollars for Stunting
¨ 744 million dollars for IDD, and
¨ 120 million dollars for Anemia
This is a total loss of over 1 billion dollars. This compares with projected gain of 427 million dollars from interventions costing only 27 million dollars, üyielding a benefit: cost ratio of 16 to 1. For every dollar invested, Uganda will reap 16 dollars in return.
Breast- feeding and Economic Development
Poor breast feeding practices have also been already identified as a key underlying cause of malnutrition. Exclusive breast-feeding for about six months has economic benefits from improved nutrition, savings on health care costs and accompanying savings on breast milk substitutes.
Just counting the savings on breast milk substitutes, we estimate that the economic value of breast milk currently consumed by infants in Uganda is 325 million dollars per year.
This analysis, ladies and gentlemen, also acknowledges the huge economic contribution of the breastfeeding mother.
Solutions
These gains cannot be realized without our commitment and effort.
To realize our hopes for the year 2025, Uganda must make conscious efforts to reduce malnutrition, particularly in the most vulnerable groups: infants, children and women of reproductive age. We know that the worst effects of malnutrition occur very early in life, beginning even in the womb. In Uganda most growth faltering occurs during infancy. Whether we look at underweight or stunting, all the damage occurs before age 2, about 40% of infants are affected and there is little or no recovery. We therefore need to act early in this vulnerable period with preventive measures that reach virtually all infants and ensure optimal feeding.
Specifically, we recommend the following nutrition interventions, which experience in Uganda and elsewhere suggests are both feasible and cost-effective.
1. Promote child growth through the provision of:
· better counseling to caregivers on optimal child feeding practices. Counseling should focus on exclusive breastfeeding of infants for the first six months of life, adequate and timely introduction of other foods thereafter while continuing breastfeeding and increased breastfeeding during and after illnesses for full recuperation.
· Counseling should involve all stakeholders at all levels and take advantage of every available opportunity, especially antenatal and postpartum visits, young child clinics including the Integrated Management of Childhood Illness, during home visits and 3through contacts with agricultural extension agents.
· To achieve the above, the knowledge and counseling skills of both health and non-health workers involved in health and nutrition related activities need to be improved.
· To implement these strategies there is a particular need to form and regularly convene the infant & young child nutrition committee as already stipulated in the food & drugs regulations of 1997, which should then oversee a thorough review of policies to enable successful promotion of breastfeeding and child feeding practices.
2. We need to strengthen the micronutrient supplementation programme through:
· The distribution of vitamin A supplements to lactating women within the first 6 weeks after delivery and to children every 6 months. To do this we can use all health contacts and any other means that will increase our coverage for instance, non-governmental health providers, mother support groups and schools.
· The distribution of iron-foliate supplements to pregnant women using midwives, traditional birth attendants and other community-based health providers. To control anemia among pregnant women In endemic areas we also recommend anti malarial, bed nets and deforming.
3. Ensure the consumption of iodated salt through:
· The enforcement of the Food & Drugs (Control of Quality) (Iodated Salt) Regulations of 1997, which require all salt sold in Uganda for human consumption to be iodated; and mandates the formation of a national council for the control of Iodine Deficiency Disorders.
· We also need to educate households on the importance of consumption of iodated salt.
4. Promote sustainable food-based strategies for the alleviation of iron and vitamin A deficiencies. Specifically we need to
· set up a task force on the fortification of foods with vitamin A,
· promote the production and consumption of micronutrient-rich foods (such as yellow-fleshed sweet potatoes and small animals).
· Give more attention to food utilization in the agricultural extension programme.
5. Provide appropriate information, education and communication.
This strategy should focus on developing and harmonizing nutrition messages on:
· Proper feeding practices, such as exclusive breastfeeding, adequate complementary feeding, consumption of vitamin A and iron rich foods and the use of iodated salt.
· Proper hygiene and sanitation practices to prevent and reduce the incidence of diarrhea diseases, malaria and other parasitic infections.
· Communication for behavior change using effective mix of interpersonal communication and social marketing approaches.
6. Use the full potential of the educational system.
· Schools are effective and efficient channels for transfer of nutrition knowledge, for reaching a large population of children and adolescents with direct health and nutrition interventions (such as de worming and micronutrient supplements) and reaching the larger community beyond the school.
· Schools also have the mandate, responsibility and opportunity to enhance child development (including nutrition) but the full potential of this opportunity cannot be realized without adequate policies and resources.
• We therefore need to incorporate mandatory nutrition education into the existing education system, especially at primary and tertiary levels, and
• review education curricula to ensure integration of nutrition education at all levels.
7. Ensure that all Ugandans are adequately fed by:
· ensuring access to adequate nutritious food by all household members; especially pregnant and lactating women, infants and young children and especially during periods of food insecurity.
· Secondly we also need to co-ordinate key sectors in the targeting of populations with food relief.
Conclusion
Ladies and Gentlemen, our presentation shows that an adequate ü investment in nutrition in Uganda would avoid:
· Massive numbers of infant and child deaths;
· A drastic lowering of our children’s school performance, and
· Huge losses in economic productivity.
Three conditions are needed for this poor nutrition situation to change:
· The first is a strong commitment of our political leaders and decision makers at national, district and community levels.
• The second is a clear, focused, comprehensive national nutrition strategy, reflecting consensus among the professional nutrition community and coordinated by a multi sectoral body such as the Food and Nutrition Council which should be transformed into a “National Nutrition Authority” and housed in the in the Prime-Minister’s office.
· The third need should follow from the previous two: an appropriate level of investment in this nutrition strategy with the creation of separate budget line items in the key ministries, and with the full support of all government ministries, donors and multilateral agencies.
Therefore, investment in nutrition in Uganda will reap benefits far outweighing the costs, benefits in terms of child survival, health, education, agricultural productivity and industrial performance, all key determinants of the human and economic development of our country.
With appropriate commitment at the highest levels, Uganda tackled and reversed the deteriorating HIV situation. Though less visible, the nutrition problems that face us are equally serious and equally urgent. Attainment of the human and economic benefits described here is our only hope of making our Vision for the year 2025 a reality.
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