It has been public opinion that the stunting rate of children under the age of five years below is at the increase in the country but this is no longer the case.

This has been proved in a study conducted by Scientists at Makerere School of Public Health and partners across the country in a bid to collect data about the current child stunting rates in the country.

The indicators are that since 2016 the stunting rate has decreased drastically with intervention of Malaria prevention using Mosquito nets emerging as prominent factor.

Malaria as key factor in fighting stunting in children under five years

Dr Richard Kajjura from Makerere School of Public Health one of the lead of research team while explaining the research results on March 31^st, 2021 in Kampala noted that his team examined the national, community, household and individual level factors that have driven stunting reduction in Uganda from 2000 to 2016 using mixed methods while carrying out the study.

“The National stunting prevalence decreased by 16% points and mean height for age between at  birth and 5 years score improved by 0.55 standard deviations between 2000 and 2016. However, improvements were not consistent across Uganda’s regions, with the Northern and region experiencing the slowest gains. Furthermore, child stunting prevalence was consistently lower among the richest, most educated, and urban households.  The most important drivers of stunting decline among children under-five were increased coverage of insecticide-treated bed nets, improved maternal nutrition and improved maternal education,”

According to him since most people are now sleeping under treated mosquito nets especially the mothers and their babies, this has reduced malaria prevalence which otherwise may affect the health system of the babies leading to stunting.

“Effects on stunting may have also been achieved through reduced malaria prevalence among children.  Continued strengthening of Uganda’s health system through outreach by Village Health Teams (VHTs), community level behavior, change in communication strategies and increased number of health facilities have been improved  with access to quality health services and increased coverage of direct and indirect nutrition interventions.,” Dr Kajura noted.

Background of the study

Dr Kajura explained that his team designed the study for exemplars in Stunting Reduction to investigate the trends, determinants and success factors among countries that had achieved a rapid rate of childhood stunting reduction relative to their economic growth.

Phase I of the project comprised 5 countries that decreased stunting by almost 50% over a 15-20 years period are Peru, Kyrgyzstan in Central Asia, Nepal, Senegal and Ethiopia with the reduction rate of 70%

Results from Phase I suggested that stunting declines were driven by advances from both within and outside the health sector, including higher maternal education, improved household wealth, access to improved sanitation and the scale up of certain health and nutrition interventions.

Building on these findings, the second phase of the project aimed to explore two additional exemplar countries, which have had an outsized reduction in stunting, along with three counterfactual countries, which have not managed to reduce national level of stunting despite economic growth and improvements in other sectors.

Uganda was chosen as a phase II exemplar country because of its considerable reduction in childhood stunting over the past 30 years by 18%

The figures indicate that stunting declined from 48% in 1988 to 29% in 2016, while GDP per capita increased from $377 to $957 over the same period.

Moreover since the early 2000s, Uganda has experienced considerable poverty reduction, decreased maternal, newborn and child mortality increased adult and youth literacy and female empowerment, increased livestock and cereal production, improved access to maternal care, and widespread malaria-reduction strategies all of which link to a multifactorial stunting reduction success story.

A systematic review, descriptive and advanced quantitative analyses, qualitative research, a policy program review and a nutrition of financing analysis were undertaken and data was triangulated to inform the study objectives.

Process of the Study

Dr. Peter Waiswa who was part of the research team from the same Institute explained that his team picked two districts to examine the stunting rate which include Serere in Eastern Uganda and Kasese in Western Uganda.

The indicators are that Serere has the least stunting rates of babies under the age of 5 in the entire country rated at 15% while Kasese has the highest rate and this is comprising the entire Toro region with the rate being 45%

In the Toro region and the entire Western region the figure indicates that out of every 2 children born 1 will be stunted. This is because the families consume mono type of food, meaning if families prepared posho with cassava leave as the vegetable, it is consumed both for KLunch and Supper.

This is not the case in Eastern and Northern regions, because in one dish, there is cross cutting food nutrients

A case in point is if families prepare beans as sauce, it is mixed with vegetables and peanut butter is added. This will be consumed for Lunch and in the evening another different version of food is prepared for supper.

Key findings of the study are summarized in this brief.

According to the team one of the key findings they identified from interviewed mothers is that they now have knowledge on which nutritious food and porridge to give their children.

Secondly they praised Ministry of health for bringing VAT’s closer to communities because once they detect that their babies are sick, they will quickly rush to a nearby health centre to seek for medical attention.

Other important factors included maternal and newborn care, paternal education, access to piped water, increased household wealth, reduced open defecation, women’s empowerment and reductions in diarrhea, improved inter-pregnancy interval and declines in adolescent births.

Insecticide-treated bed net coverage, along with preventive and curative approaches in pregnancy, worked to reduce maternal malaria burden and subsequently improve health hazard effects at birth.

Investments in expanded access to primary and secondary education, especially for girls and improved school attendance over the last two decades.

This had downstream, positive effects on women’s empowerment, employment opportunities, adolescent births and the intergenerational transfer of malnutrition.

The agricultural sector has been a major driver of poverty reduction through employment opportunities and many Ugandans rely on subsistence farming for household consumption.

Growing of crops with rich food nutrients such as range fleshed sweet potato, millet, sorghum, ground nuts, simsim, the East African Highland banana and cassava among others which contain vitamin A, Zinc, Iron, carbohydrates and protein among others.

However national investments in new technologies to improve productivity have been low, so the sector is stalling as land is used up and processes remain inefficient.

Coupled with this, Uganda is prone to climate shocks such as droughts and floods which contribute to poor agricultural productivity and food insecurity.

The 2011 Uganda Nutrition Action Plan was a critical multi-sectoral strategy that shifted nutrition out of health and mainstreamed it across related sectors.

However, stakeholders have noted that federal oversight and coordination could help to translate policy into action.

Policies

Dr Waiswa explained that his team while collecting this data considered some of the existing policies are a major actor for stunting rates to drop.

Some of them are the Food and drug policy, Child survival policy, Nutrition of HIV / Aids and Tuberculosis Policy and baby meal hospital initiative policy of 1996.

Others are Uganda nutrition action plan policy of 2016, World Food Safety Action and the National agriculture plan of 2013.

Financing for Nutrition

The team said in the last two decades the expenditure used to reduce stunting focused on Water, Sanitation and Hygiene (WASH) mainly funded under the UNAP programme through ministry of health.

The enhanced food diversity programme which was implemented from 2008-2015 costed $1.2 billion. It covered promotion of nutrition for babies in VHT’s with foods rich in Vitamin A, Iron and Zinc plus good breast feeding practices.

At the same time the ministry of agriculture implemented good agricultural practices amongst farming communities which costed $1.6 billion in the same period.

In the period 2007-2015 the education sector spent $7.3 billion with some parents going to school with their children to learn good ways of feeding while the Nutritional financing for the period 2012-2020 increased from $500 billion to $730 billion with 90% accounting for water implementation projects and other sectors shared the 10%.

Challenges

The team observed there is no specific budget line set out by the government for nutrition, there is lack of mechanism for development partners to direct funding and how much can be spent in a specific period is also lacking.

Recommendations for Further Accelerating Stunting Reduction

Dr Kajura noted that the team observed and came up with the following recommendations as stated below.

Strengthen strategies that deliberately target the poor, least educated and rural populations along with high-burden northern and western districts.

Invest in new technologies and nutrition sensitive innovations in the agriculture sector to improve productivity such as scaling-up biofortification of orange fleshed sweet potato to reach subsistence farmers and potentially improve vitamin A status among women and children.

The average cost of this program would be $8.70 per child/woman and $4- 7 per daily averted, underscoring a very cost-effective intervention according to the World Health Organisation (WHO) standards.

Develop expanded social protection schemes for vulnerable populations to manage the increasing impact of climate shocks and other humanitarian crises which can contribute to food insecurity.

Continue to prioritize malaria reduction strategies, including bed net distribution campaigns and prevention or treatment approaches for mothers and children.

Ensure that adolescent friendly health services are available and keep girls in school to further reduce adolescent pregnancies. 

Promote antenatal and postnatal care for mothers, including education around breastfeeding and complementary feeding practices.

The unit cost of a community and facility delivered breastfeeding and complementary feeding promotion program in Uganda is estimated to be $6.901 per person and would avert 102,998 cases of childhood stunting annually.

Create a federal level coordination body for nutrition that could improve the multi sectoral planning, implementation and monitoring and evaluation of nutrition actions in the country.