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.
Until we meet again...