South Asia and child wasting – unravelling the conundrum
This is a summary of a Field Exchange field article that was included in issue 63 – a special edition on child wasting in South Asia. The original article was authored by Harriet Torlesse and Minh Tram Le.
Harriet Torlesse is Regional Advisor Nutrition at UNICEF Regional Office for South Asia (ROSA), Kathmandu, Nepal.
Minh Tram Le is Nutrition Specialist at UNICEF ROSA, Kathmandu, Nepal.
Background
South Asia is the epicentre of the global wasting crisis. Prevalence rates of child wasting (14.8%) and severe wasting (4.5%) are double those of the next highest region of sub-Saharan Africa. However, responses by national governments and the development and humanitarian community have failed to achieve the necessary quality and scale; currently less than 5% of severely wasted children in South Asia access treatment. High child wasting rates and poor access to treatment have far-reaching consequences for child survival, growth and development. They also likely contribute to the higher stunting prevalence (33.2%) observed in South Asia than in any other region.
In 2020, the COVID-19 pandemic posed a further threat to child nutrition in South Asia. Thus, there is a critical need to reframe the response to wasting in the region with a focus on context-specific drivers, barriers and bottlenecks to progress and to better the mobilisation of resources.
Child wasting in South Asia
Almost all wasted children in the region live in five countries: India, Pakistan, Bangladesh, Afghanistan and Nepal. The national wasting prevalence hovers just below 10% in Afghanistan, Bangladesh and the Maldives, exceeds 10% in Nepal and exceeds 15% in Pakistan, Sri Lanka and India. No country is on track to achieve the World Health Assembly target to maintain wasting below 5% by 2025 or below 3% by 2030.
Child wasting in South Asia has several unique characteristics including high levels of wasting in early life, prolonged periods of wasting in the first two years of life, high prevalence of concurrent stunting and wasting and relatively low post-neonatal mortality rates. High prevalence of low birth weight (LBW 27%) and wasting at birth, as well as high rates of thinness (body mass index <18.5 kg/m2) and short stature (height <145 cm) in women, suggest a strong link between maternal and early-life malnutrition in South Asia. The highest incidence of wasting in South Asia occurs in the first three months of life and children who experience wasting in their first six months are more likely to suffer wasting and stunting later on. These findings call for greater attention to wasting prevention at birth and during the first six months of life.
Data shows that a high proportion (7%) of children in South Asia experience persistent wasting in the first two years of life and concurrent wasting and stunting; experiencing wasting and stunting concurrently increases the risk of mortality to a similar level of severe wasting. Wasting and stunting are closely related and share common causes which highlights the need for this integrated programming to address both across the lifecycle.
Post-neonatal mortality rates are relatively low in South Asia which may imply a lower risk of mortality in severely wasted children compared to other regions. Studies also show that severely wasted children in South Asia are slower to respond to treatment compared to children in Africa. Potential regional differences in wasting aetiology require more investigation.
Policy and programme response to child wasting in South Asia
Nutrition is high on the political agenda in South Asia and most countries are implementing multi-sector national nutrition plans to meet global nutrition targets. However, wasting has received limited attention in these plans. This may be due to a focus on stunting reduction in countries belonging to the Scaling Up Nutrition (SUN) movement (Afghanistan, Bangladesh, Nepal, Pakistan, Sri Lanka and selected states in India) and the separation of efforts to address stunting and wasting. South Asia also attracts comparatively lower levels of donor support and non-governmental organisational (NGO) presence to address wasting than sub-Saharan Africa and the Middle East.
Three South Asian countries (Afghanistan, Nepal and Pakistan) have national policies and guidelines for the treatment of medically uncomplicated severe wasting at community-level. These programmes began as humanitarian responses and are at various stages of integration into routine health services. In most cases, countries have relied on humanitarian funding for the procurement of ready-to-use therapeutic food (RUTF) for treatment of severe wasting in the community with limited support from government. This means that needs exceed financial resources and coverage remains low (<5% in Pakistan and Nepal). Neither Bangladesh nor India have fully adopted World Health Organization (WHO) recommendations on community-based management of uncomplicated cases of severe wasting. However, some states in India are implementing community-based management of severe wasting using nutrition products financed by the government and, in some cases, philanthropic foundations.
A number of concerns have been raised by public officials and academics in Bangladesh and India around the suitability and cost of RUTF. This, and differences in the presence of strong health service platforms for the delivery of wasting treatment in many South Asia countries and differences in the epidemiology of wasting, make it a unique setting. Evidence is needed to objectively inform policies and programmes for severe wasting in this region and to inform global normative guidance which is largely based on evidence from sub-Saharan Africa.
Continuity of care between pregnancy and childhood, as well as between early detection of wasting and treatment, must be examined to reduce the numbers of wasted children and to prevent relapse. Opportunities to identify wasted children are currently being missed due to a reliance on weight-for-height for screening as opposed to mid-upper arm circumference (MUAC). More integrated approaches for community-based treatment of wasting are also needed.
For infants less than six months of age, countries across the region have integrated the care of low birth weight (LBW) infants into neonatal services at health facilities. However, continuity of care for the early identification of nutritional vulnerability once infants are discharged into the community is lacking. While guidelines for inpatient care of wasted infants under six months of age exist, no country has national programmes to manage nutritionally at-risk infants and their mothers at community level although options are being explored in India, Afghanistan and Bangladesh.
Many of these issues were raised during the regional conference convened by the South Asia Association for Regional Cooperation (SAARC) and UNICEF on “Stop Stunting – No Time to Waste” in 2017. The conference concluded with a Call to Action to guide policy and programming action to reduce child wasting which was endorsed by the SAARC Ministers of Health later that year. This Call to Action remains relevant and will likely be reflected as countries move forward under the Framework for Action of the United Nations Global Action Plan on Wasting (“GAP Framework”).
Child wasting and COVID-19
Since early 2020, the COVID-19 pandemic has upended lives across South Asia. Losses of income, combined with disruptions in the production, transportation and sale of affordable foods, have severely impacted the ability of vulnerable households to feed their families. Social protection systems are unable to meet the growing needs which are likely to persist long after the removal of lockdown measures. Global estimates released in July 2020 suggest that, in the absence of timely action, an additional 6.7 million children will become wasted with South Asia being most affected.
Overwhelmed health systems have struggled to continue providing essential services to prevent and treat wasting and to reassure families about their use. By June 2020, most countries were reversing the initial downward trend in admissions for severe wasting. However, nutrition services are still not back to prior capacity. Thousands of children have become wasted due to the indirect impacts of the pandemic and have missed out on treatment when needed. As countries continue to grapple with the pandemic, and the threats of further lockdown measures and economic hardship continue, it is essential that governments and their partners take action.
In July 2020, UNICEF, the Food and Agriculture Organization (FAO), the World Food Programme (WFP) and WHO issued a global Call to Action to protect children’s right to nutrition in the face of COVID-19. Putting this Call to Action into place will require substantial investment from governments, donors, the private sector and the United Nations at a time of economic downturn. The focusing of resources on actions most likely to mitigate the impact of the pandemic on children’s nutrition are needed at country-level.
Reimagining care for wasted children in South Asia
The response to wasting in South Asia is misaligned with the magnitude of the problem. In particular, national programmes for the community management of severe wasting are lacking including in Bangladesh, India and Sri Lanka. In countries such as Afghanistan, Nepal and Pakistan where programmes do exist, limited financial resources are a key barrier to scale. While a greater emphasis is being placed on wasting prevention, the incidence and prevalence of wasting remains high in early life due to poor maternal nutrition and insufficient care for nutritionally vulnerable infants. At the same time, South Asia offers capacity and opportunities to drive innovative approaches to wasting prevention and treatment which would help to inform policy and programming in this and other regions.
Government leadership and ownership of the prevention and treatment of child wasting is critical to progress. However, given that most wasted children live in a development context, the development community should also pay proportionate attention to South Asia, supporting governments through technical assistance and funding.
Preventive actions should be at the centre of national efforts to reduce the number of wasted children. In South Asia, this would involve prioritising the nutritional and health care of women before and during pregnancy, strengthening care for LBW infants and their mothers at facility and community levels, improving breastfeeding and complementary feeding practices in the first two years of life and identifying and referring children who become wasted. This requires coordination between health and other sectors and improved understanding of how to delivery wasting prevention programmes.
The integration of wasting treatment into a continuum of care that includes prevention and treatment of moderate and severe wasting is needed. For some countries, this should begin with consensus on evidence-based approaches to treat wasting at community level. In all contexts, interventions to prevent and treat wasting should be considered a part of the essential healthcare package and be appropriately reflected in policies, plans, budgets, health workers’ pre-service training, supply chain management and health management information systems.
Finally, efforts must be made to build the evidence base for the epidemiology of child wasting in South Asia and effective models of care. In particular, research on the implementation of alternative models and innovative approaches to the care of wasted children is needed. In order to address some of the research gaps, the UNICEF Regional Office for South Asia (ROSA) has formed a Technical Advisory Group (TAG) of regional and global experts to examine existing evidence from South Asia. Evidence generated should be discussed in open forums to drive policy and programme decisions.
As countries continue to grapple with the COVID-19 pandemic and its effects, business cannot continue as usual for South Asia’s wasted children. This crisis may be the catalyst that forces national governments and development partners to rethink wasting prevention and treatment in South Asia. Identification of the most impactful actions to reach the region’s most vulnerable children will be central to securing both domestic and external financial resources. In addition, greater visibility of child wasting in South Asia will help national and international actors to resolve the challenges that currently limit progress.