Child stunting in Brazil

Summary of published research¹

A study to assess trends in the prevalence and social distribution of child stunting in Brazil and to evaluate the effect of relatively recent income and basic service redistribution policies has just been completed.

The Brazilian government has prioritised the elimination of hunger and poverty since 2003. Recent reports suggest that redistributive policies have successfully redressed one of the most skewed income distributions in the world. The prevalence of stunting (height-for-age z score below -2²) among children aged less than 5 years was estimated from data collected during national household surveys in 1974-5 (n=34,409), 1989 (n= 7,374), 1996 (n=4149) and 2006-07 (n=4,414). Absolute and relative socio-economic inequality in stunting was measured by means of the slope index and the concentration index of inequality, respectively.

The study found that over a 33 year period, there was a steady decline in the national prevalence of stunting from 37.1% to 7.1%. Prevalence dropped from 59% to 11.2% in the poorest quintile and from 12.1% to 3.3% among the wealthiest quintile. The decline was particularly steep in the last 10 years of the period (1996 to 2007). During this time the gaps between poor and wealthy families with children under 5 were also reduced in terms of purchasing power, access to education, health care and water and sanitation services and reproductive health indicators. The analysis shows that two-thirds of the decline could be attributed to improvements in four factors, maternal schooling, family purchasing power, maternal and child health care and coverage of water supply and sanitation services.

Estimates from national annual socioeconomic surveys indicate that family income remained relatively stable from 1996-2002. Beginning in 2003, however, an increase in average income, combined with better income distribution, led to strong declines in the proportion of people living below the poverty line. There appear to be three main explanations for these trends. First, the reactivation of economic growth and the consequent reduction in unemployment rates. Secondly, systematic annual increases in the official minimum wage received by unskilled workers and thirdly, a major expansion of cash transfer programmes for poor families. One fifth of the recent improvement in income distribution in Brazil has been attributed to cash transfer programmes. There has also been progress in primary school enrolment and completion in the 1990s. A minimum proportion of the country's budget was earmarked for public primary education and for reducing disparities between poor and rich municipalities.

In 1994, the Family Health Strategy was set up for the specific purpose of promoting equity in access to primary health care. The strategy has succeeded not only in targeting the poorest rural municipalities and peri-urban slums but also in contributing to reduced child mortality. By 2006, over 26,000 Family Health teams were present in over 90% of municipalities and covered 86 million individuals, mostly from low-income families. In addition, expansion of sanitation services in the last decade have benefited the poor more than the more affluent, while severe food insecurity at the family level was reduced by 27% between 2004 and 2006-7.

Other determinants of reduced stunting appear to be improvements in maternal education that have led to reduced parity (i.e. fewer children ranking 5th or higher in birth order), a widening of birth intervals and nearly universal access to modern contraceptives with greatest improvements seen amongst the poor. In addition, preliminary assessment of recent breastfeeding trends in Brazil indicates that median duration increased from seven to 14 months between 1996 and 2006-7. Exclusive breastfeeding, however, remained very brief, duration having increased from 1.1 to 1.4 months only, in the same period.

Given these trends, it is not surprising that child morbidity and mortality have declined in Brazil. Diarrhoea was responsible for 17.3% of all registered infant deaths in 1985-07, but by 2003-05 accounted for only 4.2% of all deaths. Brazil is now among the few low and middle income countries that are on track to reach the Millenium Development Goal (MDG) of reducing mortality in children under 5 years of age.

The authors conclude that in Brazil, socioeconomic development coupled with equity-oriented public policies have been accompanied by marked improvements in living conditions and a substantial decline in child under-nutrition. They have also seen a reduction of the gap in nutritional status between children in the highest and lowest socio-economic quintiles. Future studies will show whether these gains will be maintained under the current global economic crisis. However, these policies should be at the top of the agenda of governments truly committed to reducing under-nutrition and improving the quality of life of future generations.

¹Monteiro. C et al (2010). Narrowing socioeconomic inequality in child stunting: the Brazilian experience, 1974-2007. Bulletin of the World Health Organisation, vol 88, pp 305-311

²WHO 2006 Growth Standards