Good nutrition provides a foundation for child growth and development that is paramount to meeting the child’s full potential. When nutrition status among under-five improves, their cognitive abilities will develop more fully, allowing them to learn more both within and outside of school. This turns in children who are more likely to be more productive later in life get better jobs and suffer fewer illnesses as adults – ageing healthily and living longer. The 2015 Global Nutrition Report indicates that every 1 US$ of investment in nutrition yields 16 US$ in benefits(1), while the cost of inaction, expressed as GDP losses in several African countries, was estimated to range from 2 % to 16·5 %(2).
Malnutrition remains a problem of staggering size in sub-Saharan Africa, particularly in West and Central Africa Region. In May 2012, the World Health Assembly adopted a resolution that included six global targets to improve maternal, infant and young child nutrition(3). The first target addresses the scourge of stunting and aims to reduce by 40 % the number of stunted children under 5 years of age in 2025. According to recent estimates, from 2000 to 2019, Sub-Saharan Africa remains with slow progress, with West and Central Africa Region having registered some reduction in stunting rates of only one-fifth (from 40·4 % to 32·7 %), but an important increase in the number of stunted children during the same period, from 22·4 to 29 million(4). At this pace, only a few countries in the region are likely to reach the 2025 World Health Assembly target for stunting, and subsequently the 2030 Sustainable Development Goals(5).
Thus, the legitimate question coming to anyone’s mind is why Sub Saharan Africa is lagging behind, compared with other regions in the world. The situation is particularly concerning in West and central Africa with a backward trend in the number of stunted children, along with a precarious situation of other forms of malnutrition, showing an increase of overweight and obesity in children(4).
Yet, effective interventions exist and are well known as reported by the 2013 Lancet Series(Reference Bhutta, Das and Arjumand6). Unfortunately, there is a perception that many professionals and development partners, including nutritionist and programme managers, failed to understand that these effective interventions cannot be considered as the solutions.
The papers by Debpuur et al.
(Reference Cornelius, Nonterah and Chatio7–Reference Watson, Kehoe and Erzse10) bring some light to the challenges to nutrition that communities in the Sub-Saharan African region are facing as an attempt to contribute to a better understanding of the causes and solutions. Using qualitative methods to assess the perceptions of the causes and perspectives from communities, the authors made a significant contribution to our knowledge.
These papers especially fill a gap because most of the causal analysis generally come from institutions and little from the populations on the ground. The papers cover different perspectives, including two dimensions, that is, urban v. rural as well as gender, with a focus on the low socio-economic groups.
To our opinions, the solutions are in the HOW effective interventions are wisely combined to converge and address the determinants in a specific area and then implemented at scale. In turn, this means the need to understand the specific causes and the specific bottlenecks to effective implementation one need to lift.
Looking at the findings reported in these papers, issues around gender inequality, poverty, agriculture and regulations, both food and market came out strongly as fundamental factors, along with food insecurity and control within the family, nutrition education, as well as domestic food supplies for which expectation was clearly to receive support from the Government.
It is important that the papers pointed out the epidemiological transition, the nutritional transition, as well as the link to diseases because they must be factored in when engaging to bring solutions. Concretely, this is a call for multisectoral, multi-system approach to nutrition, coming from the ground. However, we must recognise that the concept of multisectoral approach is not at all new. It is a ‘renewed call’ coming 30 years after the first International Conference on Nutrition in the 1990s, but this time from those the most concerned. Furthermore, the 2013 Lancet series has explicitly recommended thirteen high-impact interventions(Reference Bhutta, Das and Arjumand6), the Scaling Up Nutrition Movement launched the ambition to improve the coordination and leadership. Additional initiatives all aimed at improving nutrition were taken, including high-level leadership at global and national level, worldwide commitments under the framework of Millennium Development Goals, then Sustainable development Goals and the unprecedented financial commitment through Nutrition for Growth. However, the question that has never been seriously addressed with all these initiatives is the HOW to design and implement a strong multisectoral approach?
The causes and solutions suggested by the communities sound to me critical. They indicate the right directions to us beyond the formal science. This is so because, first of all, these solutions are coming from those who are day in day out dealing with the issues. These are mostly women, farmers, poor, regardless of being rural or urban. It is amazing to realise that their suggested solutions cover a variety of sectors, ranging from direct to roots causes of malnutrition as presented in the UNICEF conceptual framework(11). Some are specific, contextual and intuitively responding to their needs while some require global actions. Women are the majority of farmers in sub-Saharan Africa. They play a critical role within the family, in agricultural production, and especially in subsistence agriculture, as well as in livestock raising and food processing(12,13) . In addition and unlike men, they have the major responsibility of providing the care to children, including health, hygiene, adequate feeding, etc.; however, they are those the less educated, among the poorest, exposed to early marriage and adolescent pregnancies. Evidence on the association of early pregnancy with poor health and nutrition of both the teenage mothers and their offspring has been demonstrated in extended research(Reference Sagalova, Le Dain and Bärnighausen14). While in a number of countries, modest progress was made in recent years with respect to reducing teenage pregnancies, multiple countries in the region exhibit decreasing median ages at marriage and first childbirth but much more is needed(Reference Suzanne, Mara and Fenn15). Greater attention and interest must be directed to women. This has not been the case so far. Consideration of policies and programmes contributing to realising girls’ and women’s right and reducing gender discrimination and improving financial control in the household are part of the solutions, as powerful enablers.
Second, we note that some of the solutions must and can be addressed locally while others need action from the central level. For example, food regulations, while important and useful, can hardly be addressed locally; unlike, day to day bottleneck can be addressed at decentralised level, including district and community. The latter can deal with challenges faced on the ground to access health services, reduce the workload of women to allow for more care to children or better local market for mothers.
Third, the above calls for a nutrition governance beyond the central level, where line Ministries have proven difficult to lead and coordinate among others the nutrition portfolio. It is important to establish a decentralised level governance, embedded into the district and community level, where nutrition and related issues must become part of the local development plan, and owned locally. Such governance that is close to the populations and to the actions would open doors for local solutions to local bottlenecks. In Yorosso in Mali, a project led to remarkable impact on the burden of chronic malnutrition in a short time span (from 27·8 % in 2014 to 15·4 % in 2016), showing the impact of multisectoral nutrition platforms established at district and commune levels, strengthened planning and coordination of interventions, empowerment of local authorities and the leadership of local administrative authorities(16).
The main message not addressed by the authors but transpired from these papers is that fundamental changes in working modalities are required to achieve better nutrition results. Innovative and breakthrough strategies to accelerate and get the region on track, especially considering the current context of COVID-19 pandemic posing grave risks to the maternal and child nutrition are required(17). Implementation science must become central and bring beyond nutritionists other relevant capacities.
In that sense, our reflections are aligned to the Lancet‘s new Series papers in 2021 on maternal and child undernutrition progress that high-quality ‘how to’ research must become a priority and be built into the design of large-scale nutrition programmes(Reference Victora, Parul and Vidaletti18). Bringing the education system, health system and social protection system together around the same leadership is more likely to happen at decentralised level. The start probably needs to be there. Nutrition progress with communities at decentralised level, generalised in many districts, will likely call for greater success at national level, supported by longer term programmatic convergence across the line ministries.
However, one cannot deny that resources, both financial and human, have limited the progress of nutrition in Sub-Saharan Africa. National capacity development is highly required at all levels. To address the high level of dependency of the nutrition sector to external funding in Sub Saharan Africa, effort to secure strong commitment from policy makers for increasing domestic budget for maternal and child nutrition is required.
All these actions call for a better use of data. As the 2014 Global Nutrition Report highlighted, nutrition needs a data revolution(19). Data are central to our planning. Many programmes, policies/strategies in the region are poorly designed, not evidence based and without a theory of change. Regular surveys and better routine data will allow effective monitoring progress, bottleneck identification and corrective actions to improve programme performance.
Transformative solutions that go beyond effective interventions and service delivery science are key to secure nutrition progress for women and children.
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Good nutrition provides a foundation for child growth and development that is paramount to meeting the child’s full potential. When nutrition status among under-five improves, their cognitive abilities will develop more fully, allowing them to learn more both within and outside of school. This turns in children who are more likely to be more productive later in life get better jobs and suffer fewer illnesses as adults – ageing healthily and living longer. The 2015 Global Nutrition Report indicates that every 1 US$ of investment in nutrition yields 16 US$ in benefits(1), while the cost of inaction, expressed as GDP losses in several African countries, was estimated to range from 2 % to 16·5 %(2).
Malnutrition remains a problem of staggering size in sub-Saharan Africa, particularly in West and Central Africa Region. In May 2012, the World Health Assembly adopted a resolution that included six global targets to improve maternal, infant and young child nutrition(3). The first target addresses the scourge of stunting and aims to reduce by 40 % the number of stunted children under 5 years of age in 2025. According to recent estimates, from 2000 to 2019, Sub-Saharan Africa remains with slow progress, with West and Central Africa Region having registered some reduction in stunting rates of only one-fifth (from 40·4 % to 32·7 %), but an important increase in the number of stunted children during the same period, from 22·4 to 29 million(4). At this pace, only a few countries in the region are likely to reach the 2025 World Health Assembly target for stunting, and subsequently the 2030 Sustainable Development Goals(5).
Thus, the legitimate question coming to anyone’s mind is why Sub Saharan Africa is lagging behind, compared with other regions in the world. The situation is particularly concerning in West and central Africa with a backward trend in the number of stunted children, along with a precarious situation of other forms of malnutrition, showing an increase of overweight and obesity in children(4).
Yet, effective interventions exist and are well known as reported by the 2013 Lancet Series(Reference Bhutta, Das and Arjumand6). Unfortunately, there is a perception that many professionals and development partners, including nutritionist and programme managers, failed to understand that these effective interventions cannot be considered as the solutions.
The papers by Debpuur et al. (Reference Cornelius, Nonterah and Chatio7–Reference Watson, Kehoe and Erzse10) bring some light to the challenges to nutrition that communities in the Sub-Saharan African region are facing as an attempt to contribute to a better understanding of the causes and solutions. Using qualitative methods to assess the perceptions of the causes and perspectives from communities, the authors made a significant contribution to our knowledge.
These papers especially fill a gap because most of the causal analysis generally come from institutions and little from the populations on the ground. The papers cover different perspectives, including two dimensions, that is, urban v. rural as well as gender, with a focus on the low socio-economic groups.
To our opinions, the solutions are in the HOW effective interventions are wisely combined to converge and address the determinants in a specific area and then implemented at scale. In turn, this means the need to understand the specific causes and the specific bottlenecks to effective implementation one need to lift.
Looking at the findings reported in these papers, issues around gender inequality, poverty, agriculture and regulations, both food and market came out strongly as fundamental factors, along with food insecurity and control within the family, nutrition education, as well as domestic food supplies for which expectation was clearly to receive support from the Government.
It is important that the papers pointed out the epidemiological transition, the nutritional transition, as well as the link to diseases because they must be factored in when engaging to bring solutions. Concretely, this is a call for multisectoral, multi-system approach to nutrition, coming from the ground. However, we must recognise that the concept of multisectoral approach is not at all new. It is a ‘renewed call’ coming 30 years after the first International Conference on Nutrition in the 1990s, but this time from those the most concerned. Furthermore, the 2013 Lancet series has explicitly recommended thirteen high-impact interventions(Reference Bhutta, Das and Arjumand6), the Scaling Up Nutrition Movement launched the ambition to improve the coordination and leadership. Additional initiatives all aimed at improving nutrition were taken, including high-level leadership at global and national level, worldwide commitments under the framework of Millennium Development Goals, then Sustainable development Goals and the unprecedented financial commitment through Nutrition for Growth. However, the question that has never been seriously addressed with all these initiatives is the HOW to design and implement a strong multisectoral approach?
The causes and solutions suggested by the communities sound to me critical. They indicate the right directions to us beyond the formal science. This is so because, first of all, these solutions are coming from those who are day in day out dealing with the issues. These are mostly women, farmers, poor, regardless of being rural or urban. It is amazing to realise that their suggested solutions cover a variety of sectors, ranging from direct to roots causes of malnutrition as presented in the UNICEF conceptual framework(11). Some are specific, contextual and intuitively responding to their needs while some require global actions. Women are the majority of farmers in sub-Saharan Africa. They play a critical role within the family, in agricultural production, and especially in subsistence agriculture, as well as in livestock raising and food processing(12,13) . In addition and unlike men, they have the major responsibility of providing the care to children, including health, hygiene, adequate feeding, etc.; however, they are those the less educated, among the poorest, exposed to early marriage and adolescent pregnancies. Evidence on the association of early pregnancy with poor health and nutrition of both the teenage mothers and their offspring has been demonstrated in extended research(Reference Sagalova, Le Dain and Bärnighausen14). While in a number of countries, modest progress was made in recent years with respect to reducing teenage pregnancies, multiple countries in the region exhibit decreasing median ages at marriage and first childbirth but much more is needed(Reference Suzanne, Mara and Fenn15). Greater attention and interest must be directed to women. This has not been the case so far. Consideration of policies and programmes contributing to realising girls’ and women’s right and reducing gender discrimination and improving financial control in the household are part of the solutions, as powerful enablers.
Second, we note that some of the solutions must and can be addressed locally while others need action from the central level. For example, food regulations, while important and useful, can hardly be addressed locally; unlike, day to day bottleneck can be addressed at decentralised level, including district and community. The latter can deal with challenges faced on the ground to access health services, reduce the workload of women to allow for more care to children or better local market for mothers.
Third, the above calls for a nutrition governance beyond the central level, where line Ministries have proven difficult to lead and coordinate among others the nutrition portfolio. It is important to establish a decentralised level governance, embedded into the district and community level, where nutrition and related issues must become part of the local development plan, and owned locally. Such governance that is close to the populations and to the actions would open doors for local solutions to local bottlenecks. In Yorosso in Mali, a project led to remarkable impact on the burden of chronic malnutrition in a short time span (from 27·8 % in 2014 to 15·4 % in 2016), showing the impact of multisectoral nutrition platforms established at district and commune levels, strengthened planning and coordination of interventions, empowerment of local authorities and the leadership of local administrative authorities(16).
The main message not addressed by the authors but transpired from these papers is that fundamental changes in working modalities are required to achieve better nutrition results. Innovative and breakthrough strategies to accelerate and get the region on track, especially considering the current context of COVID-19 pandemic posing grave risks to the maternal and child nutrition are required(17). Implementation science must become central and bring beyond nutritionists other relevant capacities.
In that sense, our reflections are aligned to the Lancet‘s new Series papers in 2021 on maternal and child undernutrition progress that high-quality ‘how to’ research must become a priority and be built into the design of large-scale nutrition programmes(Reference Victora, Parul and Vidaletti18). Bringing the education system, health system and social protection system together around the same leadership is more likely to happen at decentralised level. The start probably needs to be there. Nutrition progress with communities at decentralised level, generalised in many districts, will likely call for greater success at national level, supported by longer term programmatic convergence across the line ministries.
However, one cannot deny that resources, both financial and human, have limited the progress of nutrition in Sub-Saharan Africa. National capacity development is highly required at all levels. To address the high level of dependency of the nutrition sector to external funding in Sub Saharan Africa, effort to secure strong commitment from policy makers for increasing domestic budget for maternal and child nutrition is required.
All these actions call for a better use of data. As the 2014 Global Nutrition Report highlighted, nutrition needs a data revolution(19). Data are central to our planning. Many programmes, policies/strategies in the region are poorly designed, not evidence based and without a theory of change. Regular surveys and better routine data will allow effective monitoring progress, bottleneck identification and corrective actions to improve programme performance.
Transformative solutions that go beyond effective interventions and service delivery science are key to secure nutrition progress for women and children.
Acknowledgements
Acknowledgements: Not applicable. Financial support: No financial support for this paper. Conflict of interest: There are no conflicts of interest. Authorship: N.M.Z. has developed and prepared the manuscript. Ethics of human subject participation: Not applicable.