Child Stunting on the Global Stage

The first global commitment related to child malnutrition was the 1989 Convention on the Rights of the Child. Article 24 of this convention committed country governments to “combat disease and malnutrition” in children.

At the time, stunting was not explicitly mentioned in the global convention; instead, underweight (low weight for age) was the indicator of choice. It was, nonetheless, a watershed moment for efforts to eliminate stunting. Governments had previously not been held accountable for tracking stunting or reducing its prevalence. The convention pushed governments to collect data on the number of children affected and report on their efforts to eliminate malnutrition.

These efforts gained greater urgency when the Millennium Development Goals included a commitment to reduce the percentage of underweight children by 2015. The Sustainable Development Goals (SDGs) further elevated the issue by explicitly including a target on stunting. Sustainable Development Goal 2 committed countries to eliminate hunger. Target 2.2 commits countries to “end all forms of malnutrition,” with child stunting as an explicit target.

By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under 5 years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women and older persons.

- SDG Goal 2.2

The targets referenced in the SDGs refer to WHO’s 2012 resolution to reduce the number of stunted children by 40 percent by 2025. Achieving this goal would bring the total number of stunted children down from 171 million in 2010 to 100 million in 2025.1

Of note, the SDGs also emphasize the importance of reducing inequalities. SDG 17.18 supports strengthening capacity to collect “data disaggregated by income, gender, age, race, ethnicity, migratory status, disability, geographic location and other characteristics relevant in national contexts” to track progress on outcomes for children of marginalized or otherwise disadvantaged backgrounds.2

Global efforts to reduce stunting

Mobilizing Global Efforts

Nutrition rose to the top of the global health agenda in the late 2000s. Building on a solid foundation of scientific research, new nutrition initiatives pushed a globally cohesive approach to addressing stunting and other forms of malnutrition.

The Lancet Nutrition Series

In 2008, the Lancet published a landmark series of papers on maternal and child undernutrition. The series made it clear that the first 1,000 days of life (from pregnancy through two years of age) are the most critical time to intervene and drew attention to the scale of the problem. According to the series, over a third of child deaths and 11 percent of total disease burden worldwide is due to maternal and child undernutrition.3

Despite this, Richard Horton, editor in chief of the Lancet, said that nutrition was “a desperately neglected aspect of maternal, newborn, and child health.”4 The Lancet series spurred a host of global initiatives that followed shortly after its publication.

In 2013, the Lancet published an update to its 2008 series, this time reevaluating issues around undernutrition while also examining growing problems in overnutrition. The research found that malnutrition was responsible for even more child deaths than previously conceived—nearly half of all child mortality each year. The series also modeled a series of ten direct nutrition interventions that could address up to 20 percent of stunting if coverage for all of them were to reach 90 percent.5

In 2021, the series was updated again, with three main messages: (1) the world still needs to make up the long-standing funding gap; (2) although evidence-based nutrition interventions exist, delivering them on a larger scale has not been straightforward, which policy makers and practitioners need to address; and (3) focusing on the health of women before pregnancy is critical. Specifically, the field needs to gain more insight into adolescent nutrition.

Stunting interventions in undernutrition

Stunting interventions in undernutrition
Data source: The Lancet

Tools for Advocacy and Action

Inspired in part by the Lancet Nutrition series, the Scaling Up Nutrition (SUN) Movement was initiated in 2010 through the combined efforts of several stakeholders. With the goal of facilitating a global push for action and investment to improve maternal and child nutrition, SUN aimed to end malnutrition in all forms by 2030.

The SUN Movement established its model early on—led by governments of participating countries, it unites people from across civil society, the United Nations, donors, researchers, and the private sector in a cohesive effort to eliminate malnutrition. Each participating government nominates a SUN Government Focal Point, who is responsible for driving the movement at the national level. Globally, SUN operates by convening stakeholders to address malnutrition, fostering commitments to behavior change, and mobilizing resources to scale up coverage of both direct and indirect nutrition interventions.

Today, the SUN Movement encompasses 63 countries and four Indian states. The most recent SUN strategy (2021–2025) details four priorities:

• Implementing country action plans with clear targets for investment • Creating enabling environments to elevate nutrition as a key sustainable development issue • Establishing knowledge management and technical assistance support for the development, financing, implementation, and tracking of country action plans • Strengthening governance of SUN to promote inclusivity and accountability

On June 8, 2013, 90 stakeholders met at a summit in London to sign the Nutrition for Growth Compact. Nutrition for Growth included individual commitments by various organizations, including a total of US$4.15 billion pledged for nutrition-specific projects and US$19 billion for indirect nutrition projects.6

Since then, Nutrition for Growth has continued to serve as a platform for governments, investors, and civil society to collaborate on investments in ending malnutrition. It continues to provide political momentum behind nutrition efforts.

Nutrition for Growth (N4G)

In 2013, 90 stakeholders representing governments, development partners, private sector actors, civil society groups, and scientists met at a summit in London to sign the Nutrition for Growth Compact. Nutrition for Growth generated a total of $4.15 billion pledged for nutrition-specific projects and $19 billion for nutrition-sensitive projects.7

Since then, Nutrition for Growth has continued to serve as a platform for governments, investors, and civil society to collaborate. An upcoming Nutrition for Growth summit in Tokyo, in 2021, promises to build on past successes.

Tracking our progress

Tracking progress consistently is vital for evaluating the success or failure of global nutrition efforts and holding stakeholders accountable for progress. Over the years, various mechanisms have been developed to estimate the global burden of stunting and other forms of malnutrition.

UNICEF State of the World’s Children

The State of the World’s Children, first published in 1980, is UNICEF’s flagship annual publication. Its 1982–1983 edition ignited the child survival revolution.7 The 1998 edition focused on nutrition and examined three factors that affect children’s ability to develop fully: access to food, basic health services, and caring practices.7

Today, The State of the World’s Children provides an annual, country-by-country update of stunting, wasting, severe wasting, and overweight prevalence, using data from the Joint Malnutrition Estimates. It also includes coverage of interventions aimed at improving infant and young child feeding (i.e., early initiation of breastfeeding; exclusive breastfeeding; introduction to solid, semi-solid, or soft foods at 6 to 8 months of age; minimal acceptable diet from 6 to 23 months of age) and micronutrient supplementation and fortification (i.e., vitamin A supplementation and consumption of salt with iodine).8

Joint Malnutrition Estimates

An interagency team made up of representatives from UNICEF, WHO, and the World Bank collates data on child stunting, overweight, wasting, and severe wasting prevalence and develops estimates of child malnutrition (global, regional, and by income group). The data are taken from Demographic and Health Surveys, Multiple Indicator Cluster Surveys, national nutrition surveys, and other high-quality national surveys.9

These data and estimates, collected and modeled annually, provide a snapshot of global and regional malnutrition burden, and are considered the authoritative source for malnutrition epidemiology.

Global Nutrition Report

The Global Nutrition Report was created in the wake of the first Nutrition for Growth Summit in 2013. First published in 2014, it has since become the world’s authoritative report on the state of nutrition. The report typically covers the following areas:

  • Global, regional, and country-level burden of various forms of malnutrition
  • Trends, especially relevant to SDG targets
  • Funding by governments and donors relative to commitments
  • Highlighted areas of progress and remaining challenges
  • Recommendations for the global community
  • The Global Nutrition Report is produced independently by (1) a stakeholder group including high-level representatives of governments, donors, civil society, multilaterals, and private-sector entities, which guides the development of the report; (2) an independent expert group, responsible for the quality of the report’s data, analysis, and conclusions; and (3) a report secretariat, which supports creation (through research, analysis, and coordination) and dissemination of the report. 10

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    Progress and Pitfalls to Date

    The world has made significant progress on reducing stunting. Since 1990, when consistent data collection began, the number of stunted children under age five has declined from over 250 million globally (40 percent prevalence) to 144 million (22 percent) in 2019.11, 12

    This is remarkable progress, but it is not enough to reach the WHO and SDG goals. Before COVID-19, trends expected stunting to affect 127 million children by 2025, more than 25 percent higher than the WHO goal. While it is unclear how long the pandemic will last, the expectation is that its repercussions will only increase the number of children facing stunting.13

    Progress has been made, but has been highly uneven.

    A global decline in prevalence of stunted growth

        

    East Asia, Latin America, and the Middle East have achieved impressive gains—average stunting prevalence in those regions now falls at or below 15 percent.1 Meanwhile, the prevalence of stunting in sub-Saharan Africa has declined only slightly since 1990 and remains at close to 35 percent. In fact, the total number of stunted children in sub-Saharan Africa has increased since 2000, from 50 million to 57.5 million in 2019 because of population growth. While South Asia has seen more relative progress over time, its prevalence is still similarly high at 33 percent. Overall, the burden of stunting is disproportionately higher in the poorest countries, with three-quarters of the global burden in sub-Saharan Africa and South Asia; 91 percent of global stunting is clustered in low- and lower-middle-income countries.11, 14

    Large disparities in stunting prevalence also exist within regions. For example, Laos has a child stunting rate of 33 percent, which is three times than its neighbor, Thailand, whose rate is 11 percent.10 These disparities offer opportunities for policy makers to examine their neighbors’ progress when looking for appropriate models to adapt.

    Finally, while child stunting prevalence has declined in most low- and middle-income countries, equity gaps have persisted within countries. Gaps between population subgroups, particularly between the richest and poorest wealth quintiles, actually increased in many low-income countries between 1993 and 2014.15

    What’s next?

    Meeting the WHO and SDG stunting targets would cost approximately US$8.50 per child per year (approximately US$50 billion total between 2015 and 2025), according to projections by the World Bank, in partnership with the Bill & Melinda Gates Foundation and Children’s Investment Fund Foundation.14 Global spending currently totals less than half of this: about US$3 per child per year.

    “The reality is that the sum total of country actions and financial commitments thus far don’t add up to the size and scale we need to address the stunting crisis.”

    -

    Jim Yong Kim, former World Bank Group President16

    The economic case for additional spending on evidence-based interventions proven to reduce stunting is strong. According to recent estimates, US$1 invested in child stunting reduction generates at least US$3 in economic returns (often much more) by also reducing child mortality and improving the quality of the workforce as children who reach their full growth potential enter adulthood.17

    Reducing child stunting is one of the best investments a country can make; however, just US$2.9 billion per year—less than a third of the funding need—is currently being spent on stunting-specific interventions in high-burden countries.14 Donors and governments must invest more in proven interventions or risk perpetuating the cycle of stunting.

    Estimated spending for scaling up stunting reduction interventions and business as usual scenario financial projections

    Money alone will not get us across the finish line. Top-performing countries have combined financing with political commitment, which has translated into effective policies and programs. To help other countries replicate these successes, the World Bank created the Human Capital Project, which promotes improvement through three primary means:

    1. Creation of a Human Capital Index, of which stunting is a key component
    2. Improvement of outcomes measurement and scaling of monitoring and evaluation initiatives
    3. Provision of direct technical assistance and strategic support for governments

    Ultimately, achieving the WHO and SDG goal of a 40 percent reduction in stunting will require significant long-term investments, political commitment, improved understanding of the pathways leading to stunting reduction , and a focus on population subgroups that are disproportionately affected.

    Despite ongoing debate among experts on what works, countries continue to make progress in identifying interventions most appropriate for their own contexts and implementing complex programs that require broad collaboration across government ministries, economic sectors, and civil society. Adapting these lessons globally will accelerate progress in reducing stunting worldwide.