Egypt’s Stunted Children: A Silent Cry of Social Injustice

Improving Health Outcomes of the Poor – A Social Justice Agenda for Egypt (2)

While Egypt has made impressive progress on each of the MDGs especially MDG 4 and 5, it continues to face challenges with MDG 1 relating to the eradication of extreme poverty and hunger. Moreover, regional disparities and gender inequalities continue to persist across governorates.

Malnutrition in Egypt is increasing.  In 2008, the prevalence of malnutrition increased than those figures reported in both 2000 and 2005.  Nationwide, 29% of children under the age of five are stunted, 6% are underweight, and 7% are wasted. The situation is likely to have further deteriorated since the continuing political instability following Egypt’s revolution at the start of 2011 as recently announced by CAPMAS indicating an increase in unemployment rates to 11.9% in September 2011 and poverty to 25% in 2012. National averages, however, obscure vast regional differences in undernutrition prevalence.

Nutrition is central to human and economic development.  Malnutrition frequently escapes full attention, and as a result is referred to as “the silent disaster.”  It rarely attracts the attention of policy and decision makers and never was on their agenda.  The most affected people are the poor, who lack a political voice preventing them from adequately demanding interventions to combat malnutrition, even if they realize that the problem exists.   Malnutrition is a barrier for development, and a determinant for economic development and poverty reduction, health status, and educational attainment, and its reduction is central to achieving these broader development goals.

The Window of Opportunity must be sized to avoid irreversible damage. Children who are undernourished between conception and age two are at high risk for impaired irreversible cognitive development and stunting, which adversely affects the country’s productivity and growth. Interventions outside this window of opportunity would only provide relief measures but will not be able to reverse the damage that happened.

The Cost of malnutrition is high for Egypt. Over one-third of child deaths are due to undernutrition, mostly from increased severity of disease. The economic costs of undernutrition and overweight include direct costs such as the increased burden on the health care system, and indirect costs of lost productivity. Childhood anemia alone is associated with a 2.5% drop in adult wages. The current economic crisis and its potential impact on the poor make investing in child nutrition more urgent than ever to protect and strengthen human capital in the most vulnerable groups in Egypt.

What is Stunting? Stunting implies long-term undernutrition and poor health among young children, measured as height-for-age. It is a striking form of social injustice. It means that stunted children were not allowed to attain their potential height and will be shorter than their peers.  Their IQ could probably be lower than their peers and will be less able to learn and accordingly will be less able to compete for jobs.

Three in ten Egyptian children under the age of five are stunted. Of these three, at least one is severely stunted. Lower Egypt Governorates have the highest rates of stunting, where one third of children U5 living in rural areas are stunted, and four in ten children U5 in urban areas are stunted. 

Surprisingly, neither the mother’s education nor the wealth quintiles, the usual suspects of bad indicators, affected the prevalence of stunting amongst children U5. The question remains: “why almost one third of Egypt’s children are stunted and on the increase, when all other health indicators are improving?” Maybe because it is not a health problem.  Unicef concludes that socioeconomic factors do not seem to have effect on the chronic malnutrition levels observed amongst Egyptian children and may suggest that there are a number of complex factors interfering with the proper nutrition of children. 

This means that more food or cash is probably not the solution, and it might be behavior related.  An intervention is needed that combines (i) behavior change including promotion of breastfeeding, appropriate complementary feeding practices (but excluding provision of food), and proper hygiene, specifically handwashing; and (ii) complementary and therapeutic feeding for the prevention and treatment of moderate malnutrition among children 6–23 months of age, and management of severe acute malnutrition among children under five years of age.

The key demand side package of service for such a problem is the promotion of optimal Infant and Young Child Feeding (IYCF) practices and adequate nutrition during pregnancy.  It proved to be of a high potential to reduce malnutrition at relatively low cost and most effective if applied during the first 1000 days of life, from conception to 24 months as the effects of malnutrition are still reversible. However, these programs are difficult to implement without an adequate incentive for behavior change and usually better implemented by NGOs at community level. 

Beneficiaries would use existing health services provided by the MOHP for supply side services for treatment of moderate and severe malnutrition, for which the poorest districts with good functioning primary health care services would be selected.

Egypt, starting with Lower Egypt, will need an intervention that address both the demand and supply side of the problem at the same time with strong referral system between them through public private partnerships established between those implementing demand side services and those implementing supply side services.    

Until we meet again...

Improving Health Outcomes of the Poor – A Social Justice Agenda for Egypt

Health outcomes are usually measured in terms of the ability of health systems to introduce improvements in three areas: (i) health status; (ii) financial protection; and (iii) client satisfaction and dignity.  The challenges related to these health outcomes reflect an attention and priority to be provided to the poor and those potentially who could fall in poverty, an opportunity for adoption of a social justice agenda.

These challenges, which mainly indicate unfairness to the least advantaged group of the society, could be shortly summarized as follows:

In terms of health status, inequity that could be observed in disparities in achieving MDG 4 (child mortality) and MDG 5 (maternal health) across geographic regions and income quintiles.  Inequity is demonstrated by the persistent prevalence of high level of stunting, strongly linked to poverty. With the expected increase of non-communicable diseases and the high prevalence of hepatitis C, the burden of disease is expected to increase on Egyptians, especially the poor and probably would drive more people into poverty.

In terms of financial protection, the inability to protect the Egyptians from the impoverishing effects of health expenditures especially against catastrophic illness is significant.  This is presented by coverage of about half of the population with Social Health Insurance (SHI), inequity to access to Program for the Treatment on Expense of State (PTES), and that three fourths of total health expenditure is out of pocket.

In terms of client Satisfaction and system responsiveness, a nationwide dissatisfaction with the health care system presented by the high utilization rates and number of visits at private sector providers and the very low utilization rates at public health facilities. Further, utilization rates of the poor are the lowest among different income quintiles for all types of health services, although the poor are more likely to utilize public health facilities than the better off groups emphasizing the phenomenon of inequity.

There are other cross cutting developmental challenges that would affect the outcomes of the health sector that are important to consider such as stagnated fertility rates, high level of illiteracy, poor outcomes of the education system, high unemployment rates especially among the youth and in particularly among women, low rates and inequitable sanitation coverage, the rise and potential endemicity of avian flu, lack of proper social safety net to the poor, strong social and cultural factors expected to increase that would affect women empowerment. These would emphasize that parallel attention should be provided equally to the least advantaged in other sectors.

Positioning social justice at the center of the health sector agenda, taking in consideration the slogans that were raised by the January 25^th revolution and its context, would present a non-controversial theme to set related goals for the next five-year strategy as part of Egypt’s transition in the health sector.  This theme would be presented as Improving Health Outcomes of the Poor, as the least advantaged group of people in the society.  

A social justice agenda would naturally focus on the poor based on principles of distributive justice, a key principle would be the Difference Principle.  This principle stipulates that social and economic inequalities would be allowed in a community as long as they work to satisfy two conditions: (a) a fair equality of opportunity for all to compete for positions and offices; and (b) they are to be to the greatest benefit of the least advantaged members of society.  Its main moral motivation is to provide equal respect for persons whatever their social or natural status.  In order for that to happen, the least advantaged members of the society will be prioritized by redistributing resources to benefit them from the better off to raise their health status to a level equal to those in higher quintiles of income of the population, and that as a result this would allow them to have equal opportunity to compete for jobs and earn income. As well as it presents a favorable redistribution to those most affected group of the population in terms of poor health outcomes.

Improving the health outcomes of the poor would significantly contribute to improve Egypt's health goals and indicators in total, as the concentration of poor performance of the health system resides in poor areas.  

Setting goals under this theme would then focus on three elements that could be quantified:

(i)     improving the health status of the poor in specific regions (Regions such as Upper Egypt, Lower Egypt, Frontier governorates; or governorates such as Sohag, Assiut, Sharkia; or districts such as urban slums)

(ii)     protecting the population and especially the poor from the impoverishing effects of health expenditure and the near poor from getting poor

(iii)     seeking the poor’s satisfaction of service provision and treating them in a manner that preserves their dignity

If we pursue that route, we should be looking for improvements to be achieved at the health systems level to achieve the theme of improving health outcomes of the poor that would represent a possible continuation to the earlier efforts of reform of the health sector that started in 1996/1997 and hopefully coincides with it but with a more sharpened focus on the poor. This will be the subject of future posts

Until we meet again....