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Nutrition And Malaria Control For Child Survival Project
         


Program Background


Situation

  • Ghana has had a sustained economic growth in recent years.  However, this favorable situation has not been equally translated into every aspect of the human development, leaving the health and nutrition status of children lagging behind.  Improvement in macroeconomic management and strong export growth has expanded.  The annual real gross domestic product (GDP) growth rate has been maintained at almost 6 percent in 2004 and 2005 and the fiscal deficit has continued to decrease to 2.4 percent of GDP by the end of 2006.  Poverty and food insecurity have also decreased.  The poverty headcount has declined by 7 percentage points since 1997, reaching 35 percent in 2003.  At the same time, the proportion of people with insufficient food has declined from 37 percent in 1991 to 18 percent in 1996 and further to 11 percent in 2003.  Health outcomes such as infant and under five mortality rates, on the other hand, have stagnated since the late 1990s, even though health service delivery such as immunization has continuously expanded (Figure 1).

Figure 1. Prevalence of undernutrition and infant and under five mortality rates

Source: Demographic and Health Survey (DHS) 1998-2003;
Preliminary Multiple Indicator Cluster Survey (MICS) 2006
* Prevalence of undernutrition in 1993 is among children under three

 

  • Most of childhood deaths are caused by preventable or treatable health conditions:  the main causes of childhood deaths are malaria (26%), pneumonia (18%), diarrhea (18%), and neonatal factors (38%).  Recent analyses based on state-of-the-art epidemiological evidence show that in Ghana, 40% of all deaths that occur before the age of five are due directly and indirectly to undernutrition, making it the single most important cause of child mortality.  A recent study suggested that the high prevalence of undernutrition coupled with inadequate maternal and child care behavior (e.g. low rate of iron supplementation among pregnant women, early or late initiation of complementary feeding among children), might be reasons for the stagnated child mortality levels in Ghana.  While there was a steady improvement of the nutritional situation in recent years, the prevalence of undernutrition is still unacceptably high.  The prevalence of stunting among children under the age of five declined from 29.4 percent to 22.4 percent, and that of underweight declined from 21.8 percent to 17.8 percent between 2003 and 2006.  The prevalence of low birth weight among infants with known birth weight also declined from 7% in 2004 to 6% in 2006.  Protein and energy undernutrition is the major problem, and the micronutrient deficiencies are of public health significance.  A national survey in 2003 show that 77 percent of children aged 6-59 months and 47 percent of women aged 15-49 are anemic.  According to a study in the early 90s, one third of districts in Ghana are reported to have severe iodine deficiency disorder problems.
  • The prevalence of stunting in Ghana varies widely by residential and socio-economic factors. Disaggregation of the national average shows that the prevalence of stunting is significantly higher among children from rural areas, from poorer households, and whose mothers were less educated.  Regional variation was also considerable with children from the Northern Region being almost three times more likely to be stunted than those from the Greater Accra region.  As expected, older children were substantially more likely to be stunted, given the historicity of the problem. 

 

  • Heterogeneity in the rate of change of stunting prevalence between 2003 and 2006 by selected background characteristics is also of concern.  The percentage reduction in stunting prevalence from 2003 to 2006 was substantially lower among the disadvantaged:  children in rural areas (18%),  whose mother has no formal education (21%), girls (18%), compared to those in urban areas (34%), whose mother has at least secondary education (30%), and boys (29%).  The fact that such regions as Upper West and Northern Regions managed to considerably reduce the proportion of stunted children during the same period, even thought the prevalence is still extremely high, is encouraging (Figure 2).
  • Undernutrition has enormous consequence for morbidity, mortality, and development of children.  It retards their physical growth and increases their susceptibility to and severity of disease, which in turn increases the risk of further undernutrition, thereby putting the child in the midst of a vicious circle of infection and undernutrition.  Particularly, the interplay between undernutrition, anemia, and malaria is deleterious.  Malaria is more frequent and severe among children with protein-energy undernutrition and/or micronutrient deficiencies, leading to higher morbidity and mortality due to impaired host immunity.  A recent study in northern Ghana reported that underweight children are significantly more likely to have clinical malaria and anemia (odds ratio=1.67 and 1.68 respectively).  At the same time, the incidence of malaria has a significant effect on the prevalence of anemia, underweight and stunting, especially among children under two.  A meta analysis of community based studies of insecticide-treated bed nets (ITN), anti-malarial chemoprophylaxis and insecticide residual spraying shows that malaria control interventions increased hemoglobin among children by, on average, 0.76 g/dl, and thereby substantially reducing both mild and severe anemia (relative risk= 0.73 for hemoglobin <11g/dl; 0.4 for hemoglobin <8 g/dl).  Therefore, malaria control programs alone may not have the desired impact on childhood morbidity on a large scale without concomitant nutrition programs and vice versa. 

Figure 2. Health outcomes among children by selected background characteristics


Source: DHS 2003; MICS 2006

  • Undernutrition in children also affects cognitive and motor development, limits educational attainment and productivity, and ultimately perpetuates poverty (through direct losses in productivity from poor physical status, indirect losses from poor cognitive function and deficits in schooling, and losses from direct health care costs).  Undernutrition at any age of childhood affects schooling by reducing capacity to learn and the number of total years of schooling and thus lifetime earnings potential as much as 7 -12 percent.  Research has shown that productivity of physical labor declines by 1.4 percent for every 1 percent reduction in adult height.  Data from 10 developing countries show that the median loss in reduced work capacity associated with anemia during adulthood is equivalent to 0.6 percent of GDP, while an additional 3.4 percent of GDP is lost due to the effects on cognitive development attributable to anemia during childhood.  The impact of iodine deficiency disorders on cognitive development alone has been associated with productivity losses of about 10 percent of GDP. At the current rates of malnutrition, Ghana could lose up to US$41.0 billion life time earning potentials as a consequence of productivity loss caused by stunting, low birth weight, and anemia as well as mental impairment caused by iodine deficiency.  In addition, economic burden of malaria in Ghana which is estimated to be more than US$60.0 million per year is likely to continue.

 


Policy and Program Environment

  • Recognizing the significance of high prevalence of undernutrition and its effects on other human development outcomes including the Millennium Development Goals (MDGs) and economic growth, the government, especially the Ministry of Health (MOH) and the Ghana Health Service (GHS) spearheaded the launch of ‘Imagine Ghana Free of Malnutrition’, a multi-sectoral strategy that addresses malnutrition as a developmental problem in the context of the Ghana Poverty Reduction Strategy and the second Five Year Program of Work (5YPOW) of the MOH (Table 1).  The government adopted a new National Health Policy in 2006, which emphasizes child as well as adult nutrition.  The importance of nutrition, including regenerative health, is underscored even more in the 2007 Program of Work (POW) and the draft 5YPOW III (2007-2011). 

Table 1.  How investing in nutrition is critical to achieving the MDGs


Goal

Nutrition effect

Goal 1: Eradicate extreme poverty and hunger.

Malnutrition erodes human capital through irreversible and intergenerational effects on cognitive and physical development.

Goal 2: Achieve universal primary education.

Malnutrition affects the chances that a child will go to school, stay in school, and perform well.

Goal 3: Promote gender equality and empower women.

Anti-female biases in access to food, health, and care resources may result in malnutrition, possibly reducing women’s access to assets. Addressing malnutrition empowers women more than men.

Goal 4: Reduce child mortality.

Malnutrition is directly or indirectly associated with most child deaths, and it is the main contributor to the burden of disease in the developing world.

Goal 5: Improve maternal health.

Maternal health is compromised by malnutrition which is associated with most major risk factors for maternal mortality. Maternal stunting and iron and iodine deficiencies particularly pose serious problems for mothers and children.

Goal 6: Combat HIV/AIDS, malaria, and other diseases.

Malnutrition may increase risk of HIV transmission, compromise antiretroviral therapy, and hasten the onset of full-blown AIDS and premature death. It increases the chances of tuberculosis infection resulting in disease, and it also reduces malarial survival rates.

Source: Adapted from Gillespie and Haddad (2003).

  • Since 2000, the country follows the “Roll Back Malaria” strategy.  Interventions include provision of impregnated bed nets (ITN), intermittent preventive treatment during pregnancy (IPT), case management with artemisinin combination treatment and information, education and communication (IEC) activities.  These control activities were only implemented nation-wide since 2005.  Wide availability and utilization of long-lasting insecticide treated nets (LLINs) is key to prevent malaria morbidity and mortality particularly in children under five.  Substantive ITN distribution commenced only in 2003, gradually increasing from about 150,000 nets annually to half a million in 2005.  Importantly in late 2006, assisted by DFID and UNICEF, the first large scale distribution of LLINs took place: over 2.1 million LLINs were distributed free of charge as part of the measles vaccination campaign.  ITN coverage and usage is still limited and uneven across the country, but recent progress is encouraging.  The reported number of children under five sleeping under a bed net has increased from 3.8% in 2003 to 32% in 2006.  The target, based on international operational experience, is a minimum of two nets per household for 80 percent of households.  Funding for the purchase and mass distribution of additional ITNs to reach the minimum coverage is a major concern.  The ITN program relies exclusively on external financing, the major sources of funding being the Global Fund (Round Two: US $7.2 million disbursed out of $8.8 million; Round Four, US $ 18.6 million disbursed out of US $35.9 million), UNICEF, United States Agency for International Development, and the Government of Japan.

 

  • Ghana has a good track record in implementing its programs and strategies, including nutrition interventions.  The government, in close partnership with development partners (DPs), has implemented a number of priority interventions.  Under the overall child survival framework of High Impact Rapid Delivery (HIRD) approach, the growing commitment for nutrition by the MOH enabled the GHS to increase the annual coverage of two doses of vitamin A supplements to more than 80 percent.  The Community-based Nutrition and Food Security Component (CBNFSC, US$1.8 million) of the recently closed Community-based Poverty Reduction Project (CPRP; US$5.0 million), supported by the International Development Association (IDA), produced good outcomes with an integrated community-based approach for basic health and nutrition service delivery (e.g. higher rate of exclusive breastfeeding and iodized salt consumption, lower prevalence of underweight among children under five).  This project tested various innovative ways to improve the nutritional status of children in the beneficiary communities including; (i) use of volunteers as community growth promoters to undertake growth monitoring and counseling sessions reaching all families with small children in the community; (ii) involvement of community leaders and creation of Community Implementation Committees (CIC) to increase ownership and ensure support at the community level; (iii) fighting malnutrition using preventive measures including BCC and household food production through establishment of backyard gardens.  This project reached approximately 10,000 children in 40 communities.  All 40 communities continue the child growth monitoring and promotion activities despite the lack of support beyond infrequent supervision by the Community Health Nurses (CHN) and/or Community Health Officers (CHO).  The current policy and program/project environment is favorable for prioritizing, strengthening, and coordinating nutrition and child survival programs at all levels.

Challenges

  • Annual reviews of the sector have identified challenges that need to be tackled to bring down the high prevalence of undernutrition and consequently child mortality.  These include:

  • Inadequate cross-sector coordination and collaboration:nutrition is the outcome of many factors and is affected by policies/strategies and activities of numerous sectors including health, water and sanitation, education, agriculture, and finance.  Therefore, improving nutrition requires a comprehensive and integrated approach.  However, the coordination and collaboration of these actors have been sub-optimal as there is no formal institutional arrangement to discuss and commit to achieve good nutrition;    

  • Low coverage of comprehensive health and nutrition services: the MOH and GHS, with the support of DPs, have expanded over the last several years core health and nutrition services (i.e. immunization, vitamin A supplementation, de-worming) that affect nutritional and health status of children, mainly through the rapid delivery approach.  However, other essential health services including intensive health and nutrition education with necessary inputs (e.g. LLINs) have not been delivered at a scale large enough to bring desirable outcomes at the regional or national level.  A preliminary assessment shows that many programs/project supported by DPs cover just a few communities in each district, if any.  In addition, these services focus more on interventions that require one or few contacts (e.g. vitamin A supplementation) than the more intensive and longer-term interventions (e.g. growth promotion, health education);

  • Insufficient and irregular health budget for effective nutrition and other preventive care programs: while effective and efficient interventions are partly covered by the government, most of them are covered by external funding.  Until recently, the twice-yearly dose of vitamin A supplements has been administered during the annual National Immunization Days (NID) for the eradication of polio, and the yearly Child Health Promotion Weeks (CHPW), the combination of  which produced an annual coverage of 80% or higher.  NIDs are being phased out as eradication of polio is virtually achieved, but the MOH and GHS have not yet put in place an effective post-NID strategy with a reliable financing source identified.  Another example is distribution of LLINs, which have proven to effectively reduce not only malaria attack rate and incidence of clinical malaria, but also the subsequent effects due to malaria, namely the prevalence of anemia as well as stunting and underweight.  Mass distribution of LLINs targeting children under the age of two was carried out recently, but not enough funding has been identified for the next several years to cover all newborn children who are most vulnerable to clinical malaria;

  • Mismatch between causes of undernutrition and nutrition actions: food insecurity is certainly a factor that contributes to a high prevalence of undernutrition.  Many researchers including Ghanaian researchers, have shown that food insecurity is not the most important factor.  Instead, inappropriate feeding and caring practices of children and mothers, poor environment (e.g. poor sanitation and hygiene), and limited utilization of basic health care services are among the most important determining factors.  In Ghana, many nutrition-relevant actions have failed to address these major causes of undernutrition in a comprehensive manner at the household level.  Instead, single component interventions were more common due to limited understanding of the causes of undernutrition, capacity and/or resources;

  • Weak targeting: while it is well known that the window of opportunity to prevent undernutrition is during pregnancy and the first two years of life (Figure 3).  However, many programs in Ghana have targeted a much wider group (e.g. school age children), thereby spreading even thinner the already limited resources that could have been used for effective nutrition programs targeted to those in the window of opportunity;

  

Figure 3.  Prevalence of undernutrition by age


Source:  ORC Macro (2005)

  • Sub-optimal delivery channel:  while the country is scaling up its effort to control ubiquitous micronutrient deficiencies in the country, not all strategies reach the most vulnerable groups.  The two principal causes of anemia in children are poor iron intake and parasitic infections such as helminthes and malaria.  While public health measures are being put in place to tackle the problem of parasitic infections, no strategy exists to correct iron deficiency in children.  Neither the promotion of dietary intake of iron nor prophylactic supplementation is an effective or efficient solution, leaving food fortification as the last and only realistic option.  The government  is about to embark on a large-scale food fortification program of wheat flour, and is in the process of passing a generic legislation enhancing the (mandatory) fortification of other food vehicles as well.  However, the above fortification program will have limited impact on the vitamin and mineral intake of children under two, particularly in rural areas, hence, the need for more efficient and complementary approaches; and
  • Inadequate focus on and human capacity to implement nutrition and other preventive care programs: the focus of the health sector has been curative care, rather than preventive care until recently.  Thus, while the new National Health Policy states the importance of healthy eating, lifestyles and environment, and emphasizes health promotion and good nutrition, health professionals have not been properly trained to provide such services. 


(c) 2014 - Ghana Health Service