Context Specific Opportunities for Progress

Within this framework, it is possible to determine the sub-set of activities most likely to reduce stunting. We have compiled a 10-part list, enumerated below with specific examples, of highly effective approaches to fighting stunting. The list is based on a review of current knowledge in relevant fields cross-referenced with findings from our Exemplar case studies and selected studies of other countries that have reduced stunting (including Brazil, Cambodia, Mexico, Thailand, Vietnam, and Zambia).

1. Secure high-level political and financial support:

Because addressing stunting successfully requires multisectoral effort, countries where leaders and civil society make nutrition a clear priority and where government facilitates coordination across sectors are more likely to succeed.

Leadership

• Peru ’s and Senegal’s  presidents made stunting a specific priority, issuing landmark nutrition policies and personally holding their governments accountable for results.

Institution-building

• In Senegal, the president created the Cellule de Lutte Contre la Malnutrition (Coordination Unit for the Fight Against Malnutrition; CLM), which brings together relevant ministries to design and implement nutrition policies and programs.

Civil society movements

• In Peru, NGO leaders created the Initiative against Chronic Infant Malnutrition (IDI), which eventually comprised 17 organizations and led successful nutrition advocacy efforts in the country.

• Globally, in 2010, the multilateral Scaling Up Nutrition (SUN) movement was launched. SUN, which included a “framework for action” and a “roadmap,” has been joined by businesses, civil society groups, donors, and 61 governments, including all our Exemplar countries: Ethiopia (2012), Kyrgyzstan (2011), Nepal (2011), Peru (2010), and Senegal (2011), who were relatively early adopters.

Donor coordination

• Ethiopia, the Kyrgyz Republic , Nepal , and Senegal  attracted substantial donor assistance in key areas to complement increased domestic resources for nutrition programming.

• The Kyrgyz Republic employed a sector wide approach (SWAp) in which more than a dozen donors engaged in a single planning process with the Kyrgyz government and then aligned their funding, thereby eliminating gaps and redundancies.

• Ethiopia, whose government uses the slogan of “One Plan, One Budget, One Report” to emphasize the need for donor coordination, has built enough trust with donors to launch a $1 billion donor-funded block grant to local governments that spend the money without specific donor restrictions.

2. Invest in granular data for decision making:

The best policies and programs, including those that sensitively target specific populations and improve equity, require high-fidelity, high-resolution data; although many low- and middle-income countries lack robust data institutions, many Exemplars launched pilot data initiatives that paid dividends.

Data collection

• Ethiopia created new institutions to generate data for evidence-based decision-making on population health, nutrition, and disease, including the Ethiopian Public Health Institute (1995) to conduct research and the Central Statistical Agency (2005) to collect, analyze, and disseminate data.

• Peru incentivized mothers to take part in a growth monitoring program known as CRED, generating more granular, reliable data about child growth.

• Peru and Senegal improved their Demographic and Health Survey, with both countries now focusing more on subnational data and running the survey continuously and Peru continually increasing sample sizes to produce more actionable results.

Data-driven targeting

• To target the Productive Safety Net Program (PSNP) to people who needed it most, Ethiopia selected eligible districts and villages (woredas and kebelas) based on data about where emergency food aid had gone, then selected eligible households in a community-led process.¹

• The Kyrgyz Republic used a means test based on cash and imputed farm income to determine who was eligible for its Universal Monthly Benefit (UMB).

• Nepal invested heavily in its Health Management Information System (HMIS) to facilitate optimal coverage across a remote country with difficult terrain.

• Peru used data to target social protection programs to the people who needed them the most; for instance, the country selected eligible districts based on a poverty index, then selected eligible households based on a proxy means test whose findings were validated by the community validation.

• Peru also used a sophisticated means test to determine eligibility for a national health insurance program, Seguro Integral de Salud (SIS).

Data-driven community mobilization

• Thailand introduced the basic minimum needs approach (BMN), which deployed comprehensive local surveys to generate detailed data that not only strengthened monitoring and evaluation but also helped communities set their own priorities.^{2 3}  

Results-based budgeting

• Peru launched results-based budgeting programs for nutrition and maternal and neonatal health that were based on district (department) level survey data and facility-by-facility administrative data; these programs ensured that adequate funding was available to provide key services everywhere and incentivized local health officials to deliver those services.

3. Increase access to family planning and reducing high-risk pregnancies:

In Exemplars where women are empowered to plan their families, where they are educated about the health benefits of planning for themselves and their babies, and where they have access to contraceptives and reproductive health care, delay of first pregnancy and the safe spacing of births improved both the mother’s and her children’s nutritional status.

Education, particularly for girls

• Countries invested in education infrastructure and prioritized the enrollment of girls kept girls in school longer, therefore delaying marriage and pregnancy and increasing the likelihood that they would be aware of and able to use contraceptives.

Access to contraceptives and family planning information

• Beginning in the mid-1970s, Bangladesh used its large frontline health workforce to educate women about the benefits of delaying their first pregnancy and spacing their pregnancies in a healthy way—and to provide family planning supplies; these efforts led to a decline in fertility from more than 6 children per woman to approximately 3 children per woman today.^{4  5  6}  

• Following Bangladesh’s lead, Ethiopia’s Health Extension Workers (HEW), Nepal’s Female Community Health Volunteers (FCHV), and Senegal’s matrones and bajenu gox provide awareness-building and education about family planning and contraceptives.

• Peru’s flagship maternal and newborn health program, Programa Presupuestal Salud Materno Neonatal (PSMN), set aside funds to support family planning services provided in local communities.

4. Improve maternal nutrition and access to high-quality maternal and newborn health care:

All Exemplars dramatically improved access to maternal, newborn, and child health care through multiple means. In several cases, investment in community-based health systems scaled up services very quickly, although the quality of care provided by these systems may be uneven.

Supply-side interventions

• The governments of Ethiopia, Nepal, Peru, and Senegal  put considerable resources into building health posts, health huts, and health clinics and training doctors, midwives, and nurses.

• The community-based health programs in Ethiopia, Nepal, and Senegal  and the results-based financing programs in Peru (PSMN and PAN) incentivized and prepared health systems and health workers to prioritize providing maternal and newborn health and nutrition services.

• Through the Manas program, the Kyrgyz Republic restructured its expensive hospital system and created equitably distributed Family Medicine Group Practices and Family Medicine Centers to be the new “front door” to the health system.

• In Zambia, where more than 90 percent of the population is at risk of malaria infection, the government pursued an aggressive malaria control strategy focused on the distribution of insecticide-treated bed nets; research has found that the decline in stunting since 2002 has been driven by bed-net ownership⁷ , although in general there is surprisingly little research on the link between malaria and child growth.

Demand-side interventions

• Nepal’s Aama program provides cash incentives to mothers to deliver their babies in facilities instead of at home.

• Community health worker programs in Ethiopia, Nepal, and Senegal  reached the vast majority of mothers, even in remote areas, with messages about the importance of antenatal care, including good nutrition during pregnancy, and helped change norms about giving birth at home; as a result, the number of women who visited the facility at least four times while pregnant and gave birth in facilities increased dramatically in all three countries.

• Conditional cash transfer programs in Brazil (Bolsa Familia) ^{8  2} , Mexico (Oportunidades⁹ / PROSPERA¹⁰ ), and Peru (Juntos) incentivized pregnant women to seek antenatal health care—and to seek newborn care for their children.

5. Promote early, exclusive, and continuous breastfeeding:

A combination of legal regulations, community mobilization strategies, and communications and marketing campaigns improved both the quality and quantity of breastfeeding in the Exemplar countries, which helped prevent growth faltering in babies’ first six months.

Laws and policies

• Brazil enacted laws in 1988 that led to the enforcement of the International Code of Marketing of Breast-milk Substitutes; maternity leave was extended from two months to four months in 1998 and eventually to six months in 2006, enabling working mothers to choose breastfeeding.^{8 11}

• The Kyrgyz Republic issued a national breastfeeding law in 1996, including new guidelines intended to increase the quantity and quality of breastfeeding; in 2000, it joined WHO and UNICEF’s Baby Friendly Hospital Initiative (BFHI), which outlines key clinical and management procedures and certifies hospitals that comply; in 2008, the government passed a law regulating the marketing of infant formula to help encourage breastfeeding.

Community-Based Healthcare

• Breastfeeding education was among the key responsibilities assigned to frontline health workers in Ethiopia, Nepal, and Senegal.

• The Krygyz Republic, whose health system does not rely on frontline health workers, nevertheless created Village Health Committees  responsible for health awareness and promotion, and they focused on proper breastfeeding practices.

• In Thailand, communities selected health and nutrition volunteer mobilizers who were assigned to cover 10-20 households and were trained to provide education on breastfeeding and other nutrition best practices. ²

Integrated campaigns

• In 1981, Brazil established the National Program for the Promotion of Breastfeeding^{11  8} , remarkable for its broad scope, including activities aimed at protecting (employment legislation, control of marketing of substitutes for mother's milk), promoting (use of the media, professional training), and supporting breastfeeding (mothers' groups, information material, and direct counseling).

• Between 2000 and 2010, exclusive breastfeeding rates in Cambodia rose from 11 percent to 74 percent¹² , as a result of an integrated breastfeeding campaign that included mass communication and advocacy about the benefits of breastfeeding, regulations of the marketing of infant formula, incorporating breastfeeding promotion into all infant and young child programs, and implementing a baby-friendly child initiative that combined BFHI for facility births and mothers support groups to reinforce key messages in communities.¹³

6. Improve complementary feeding, including dietary diversification, and micronutrient supplementation / fortification:

Research shows that high-quality complementary feeding is critical for addressing stunting, but it is challenging to implement—and it is also challenging to measure, since the quality of diet is data tends to be low. Community-based approaches to educating parents about proper feeding practices can work in food-secure areas, as can fortification and supplementation programs, but making diverse diets widely available may require wholesale food-system transformation.

Laws and Policies

• In 2014, Nepal enacted a Strategy for Infant and Young Child Feeding, which promotes appropriate breastfeeding, complementary feeding, and consumption of micronutrients.

• Based on WHO and UNICEF recommendation, Senegal adopted a National Policy on Infant and Young Child Feeding in 2006 to promote appropriate nutrition for all children from birth to 5 years.

Community-Based Healthcare

• The community health workers in Ethiopia, Nepal, Senegal provide training on complementary feeding best practices.

• In Peru, the main nutrition program, Programa Articulado Nutricionall (PAN) explored innovations such as community kitchens and cooking lessons for mothers about using locally available ingredients to provide a healthy diet for their children.

Food diversity, quality, and access to micronutrients

• In Ethiopia, big increases in agricultural productivity helped rural families consume a more diverse diet; in some cases, they were able to grow more diverse foods for their own consumption, whereas in other cases they were able to use their rising incomes to purchase fruits, vegetables, and other non-staples.

• In Nepal, FCHVs administer a semi-annual vitamin A campaign that has achieved high levels of coverage and has, according to research, reduced the odds of death among 12- to 60-month-olds by slightly more than half.

• With donors’ support, the Kyrgyz Republic engaged in a number of fortification and supplementation programs; although some were effective in the short-term (e.g., Vitamin A supplementation), in general the government did not prioritize them once donor funding expired./ Vietnam’s National Plan of Action for Nutrition, initiated 25 years ago, targets deficiencies in iron, vitamin A, and iodine through supplementation, diet diversification, and food fortification; as a result, maternal and child anemia declined, overall nutrition improved, and the stunting rate fell. ¹⁴

7. Address food insecurity and marginalized populations:

All the Exemplars engaged in pro-poor policymaking, and several made noteworthy investments in food security and safety nets that helped the poorest and most vulnerable improve their nutritional status.

Food insecurity

Agricultural development

• Ethiopia invested in rural infrastructure and a large network of agricultural extension workers to disseminate best practices and technologies like fertilizer and improved seeds to smallholder farmers.

• The Kyrgyz Republic enacted radical land reform, breaking up Soviet-era collective farms and giving all Kyrgyz citizens equal access to farmland on which to grow food crops for subsistence.

• In the wake of severe climate shocks, Senegal launched several policies  and programs that bolstered early warning and agricultural information systems to prevent food crises and ensure food security.

Marginalized populations

Pro-poor policy agendas

• Newly established governments in Ethiopia (1991), the Kyrgyz Republic (1991) , and Nepal (1990)  pursued policies of equitable development.

• Peru’s post-civil war National Agreement (2002) identified equity and unity as guiding principles while also listing 29 specific pro-poor policy objectives.

Targeting of inequalities

• As part of its Guaranteed State Benefits Package, the Kyrgyz Republic made specialist and inpatient care available on a sliding scale based on ability to pay and other factors.

• Nepal’s free health care policy makes selected services available free of charge to specified groups, including the poor, marginalized castes and ethnic groups, the disabled, and the elderly.

• Peru’s Seguro Integral de Salud (SIS) uses a proxy means test to determine eligibility and its nutrition strategy, CRECER, prioritized 880 disadvantaged regions for additional funding and services.

Social protection programs

• Mexico’s PROSPERA¹⁰   program (formerly Progresa and Oportunidades ⁹ ), among the first conditional cash transfer programs in the world, provides a cash benefit, a basic nutrition package for children and pregnant and lactating women, and scholarships for students from primary school to university. Studies have linked enrollment in PROSPERA with improved child growth.

• Brazil’s Bolsa Família ² program is the largest conditional cash transfer program in the world, reaching 25 percent of the country’s population; it merged four different programs into one umbrella program with payments conditioned on a wide range of health- and education-seeking behaviors. Studies show that Bolsa Familia has contributed to a drop in poverty, a rise in income equality, and improved nutrition outcomes.

• Ethiopia’s PSNP provides 10 percent of the population with cash payments; recipients who are able are required to work on agriculture-related public works projects.

• The Kyrgyz Republic’s UMB, a modest, means-tested unconditional cash transfer, reaches the neediest 10 percent of the population.

• Peru’s Juntos program, modeled on PROSPERA, provides cash transfers to mothers for seeking prenatal and child health care and keeping children enrolled in school.

8. Invest in education, especially for girls:

All Exemplars took steps to improve education—by building more schools and hiring more teachers, by teaching nutrition-related content, and by incentivizing students, especially girls, to enroll—thereby boosting family’s earning potential, increasing their awareness and knowledge of health and nutrition, and empowering girls to marry later and plan their pregnancies.

Education infrastructure

• As a result of Ethiopia’s Education Sector Development Program, the number of primary schools tripled in under 20 years and tens of thousands of teachers were hired and trained to staff them.

• At the turn of the millennium, the government of Senegal launched two major education initiatives, the Ten Year Education and Training Program and the National Action Plan for Education for All.

• During the first 15 years of Nepal’s Basic Primary Education Program, the number of primary schools increased by approximately 40 percent.

Equitable enrollment incentives

• Conditional cash transfer programs in Brazil (Bolsa Familia), Mexico (PROSPERA), and Peru (Juntos) all include school enrollment for daughters and sons among the conditions required of recipients.

• Bangladesh’s Female Secondary Stipend Program (FSSP)^{5 15} provided a cash transfer to girls in grades 6-10 based on school attendance and achievement.

• UNESCO’s global Education for All movement, launched in 2000, included gender parity and gender equality as explicit goals, helping to push large enrollment gains for girls.

Health and Nutrition Education

• Nepal’s School Health and Nutrition Strategy ensures that students are learning about healthy behavior./ Senegal’s Integrated Education and Nutrition Program targeted both basic education and nutrition among women, children, and vulnerable groups.

9. Address gender disparities and empowering girls and women:

Women’s empowerment was a clear driver in many Exemplar stories, with women citing substantive changes in their ability to obtain an education, earn money, and make decisions about their own health and nutrition and the health and nutrition of their children. Though empowerment in a multifaceted phenomenon, with no easy means of measurement, it was clear through qualitative assessments that success here played a significant role in enabling progress across other sectors.

Decision-making authority

• In the Kyrgyz Republic, Nepal, and Senegal, where large numbers of men migrate for work, women who remained at home gained the power to make spending decisions, especially those related to health and nutrition.

Female health workers

• Frontline health systems in Ethiopia, Nepal, and Senegal employed tens of thousands of local women, providing them with benefits, social status, and (in some cases) income.

Gender Equity in School

• As part of the UNESCO-led Education for All global movement, which emphasized girls’ education, Nepal and Senegal achieved gender parity in primary school enrollment.

• Bangladesh’s Female Secondary Stipend Program (FSSP)^{5 15}  provided a cash transfer to girls in grades 6-10 who attended 75 percent of school days, scored a 45 percent on an annual examination, and remained unmarried; studies show that the program has increased secondary enrollment rates for girls by 20 percent.

10. Improve living conditions, especially WASH:

As families escaped poverty, they were able to invest more in larger and/or sturdier homes and purchase basic conveniences such as access to electricity and clean water, all of which improved the health and well-being—and ultimately the growth—of their children; in the area of sanitation, Community-Led Total Sanitation proved to be a powerful tool to reduce high rates of open defecation, but the direct impact to stunting remains murky, and it remains to be seen if there will be sufficient investment in “safe sanitation” infrastructure to sustain the gains from declining open defecation.

Household improvement

• Ethiopia’s increased agricultural productivity generated more income for rural households, which they were able to spend on upgrades to their homes.

• Kyrgyz Republic, and Nepal are among the top-10 remittance receiving countries in the world by share of GDP ¹⁶, providing families with money to spend on basic conveniences including electricity and clean water.

• Currency reform in Senegal in the mid-1990s boosted exports, leading to GDP growth, large-scale poverty reduction, and therefore improved living conditions.

Community Led Total Sanitation

• In 2000, the Community Led Total Sanitation (CLTS) approach was developed in the Bangladeshi village of Mosmoil; CLTS, a subsidy-free approach, focuses on stimulating demand for safe sanitation through behavior-change communication—and then meeting that demand by training locals in the construction of low-cost toilets. ¹⁷

• Nepal (2003) and Ethiopia (2006) became early adopters of CLTS, adapting the program to local circumstances; more recently, rural regions of Senegal have employed the CLTS approach as well.

Water quality

• With partnership from the World Bank, the government of Senegal leased its water-related assets to a private provider  that charged for connections (and gave subsidies to low-income customers) and improved both the reach and quality of the country’s water system.

• Using a similar strategy, private operators in Senegal were able to provide improved sanitation services in urban and peri-urban areas.