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Chapter 2: Regional Trends in Nutrition


Sub-Saharan Africa
Near East and North Africa
South Asia
South East Asia
China
Middle America and Caribbean
South America


Sub-Saharan Africa

(Panel 1)

Sub-Saharan Africa’s nutrition situation is fundamentally different from other regions of the developing world: the underlying trend is deteriorating in many countries. The basic reason is the failure to develop. This is clearly true economically (see Panel ID), but also applies in contrast to most other regions in terms of health infrastructure and education. These have shown some progress over the last 15 years - for example, they help explain the decrease in infant mortality rates - but the trend is discouraging. Compounding the difficulties, population is growing faster than anywhere else in the world, at nearly 4% per year in a number of countries - double the rate in Asia, for example. Coupled with slow development, this means that per caput indicators of production are declining significantly.

On these underlying problems are superimposed persistent or repeated crises: drought, civil wars, and economic recession and adjustment. These periodically lead to famines that still affect millions. This too is now unique to Africa, as famine has been virtually eradicated elsewhere in the world.

The long-run failure of development and short-run crises reinforce each other. The results can be seen in most of the indicators discussed here, and (as will be seen in Chapter 6) most projections into the future for Africa envisage a deteriorating or only slightly improving trend. This is in contrast to other regions, and starkly different from the goals put forward at the World Summit for Children, the International Conference on Nutrition, and every other forum that has addressed the issue.

The average prevalence of underweight children in Sub-Saharan Africa has been static at around 30% between 1980 and 1990. The results shown in Figure 2.1 attempt to capture year-to-year fluctuations, since African conditions change fast, giving more detail than Panel 1B. Results from individual countries tend to confirm by direct observation the generally static or deteriorating trend. Details of nutritional trends in four countries, Kenya, Nigeria, Tanzania, and Zimbabwe, are given in Volume II, and these will be referred to in this section. One conclusion is that where there are vigorous community-level programmes, such as in Tanzania and Zimbabwe, malnutrition in children can be contained and indeed improved. Thus, for example, it is estimated that the prevalence of underweight children in Zimbabwe came down from around 23% to around 12% between 1985 and 1990. On the other hand, indications are that the prevalence of underweight children in Nigeria is high, greater than 35%, and may well be increasing.

The overall prevalence of underweight children remaining static implies a substantial increase in the numbers, because of the population expansion. Estimates of the preschool population underweight thus rose from around 18 million in 1975 to 30 million in 1990. These levels are estimated from direct results from 24 countries in the region, and the static or deteriorating trend is generally observed in repeated surveys in six of these (see Table 1.3). For example, national surveys in Togo and Zambia showed increasing prevalence, while this probably stayed much the same in Rwanda. Improving trends were, however, observed in Lesotho and Zimbabwe, and on average in Kenya.

Figure 2.1 Sub-Saharan Africa: Underweight preschool children, 1975-1990 (Below -2 s.d. weight-for-age)

Famine now worsens these problems. The horrors of Somalia vividly demonstrate that the poor and children suffer most during anarchy. Civil wars have devastated large areas in the Horn of Africa, including Ethiopia and Sudan, as well as Somalia, for several years. Nobody knows the extent of malnutrition and death, but it must be enormous. At the same time, population movements lead to heightened malnutrition amongst refugees, notably in northern Kenya from the troubles in the Horn. As if nature were conspiring with man, much of this region has suffered recently from an unusual drought. A somewhat parallel situation exists in southern Africa, particularly in Mozambique. Here, drought has added to the devastation of civil war and led to large numbers of refugees, many malnourished, in Malawi, Zimbabwe, and South Africa. In West Africa, fighting has caused large-scale destruction of resources and population movements, centered on Liberia, again exacerbating malnutrition.

The drought of 1983-84 was one of the worst for many years. That which is now affecting southern Africa and parts of East Africa is even more severe - in southern Africa, probably the worst in living memory. In Zimbabwe and South Africa, for example, the issue is not only in providing food, but in supplying water itself to sustain life and prevent people dying of thirst. Nonetheless, although the import requirements are enormous and logistical problems appear insuperable - for example, the transport capability for grain cannot keep up with need in Zimbabwe - there are some hopes that concerted action may reduce or even prevent the deaths from famine which would otherwise be inevitable.

Infant and child mortality rates have continued to fall during the period, although (in contrast to other regions) not rapidly enough to bring about a decline in the total number of infants and children dying. The IMR is estimated to have fallen from around 135 per 1,000 live births in 1975 to approximately 120 in the early 1980s, and to 105 in 1990. Over this period, numbers of infants dying rose from approximately 1.5 million in 1975 to 2 million in 1990. The fall in IMR may be ascribed to improved outreach of health services and, notably, immunization of mothers against tetanus which WHO reported to have covered 46% of mothers in 1991 compared to 12% in 1983.

The average income as estimated by GNP per capita has also declined since 1981, and is now back to around the levels experienced in the 1970s, of around US$300 per year. The improvement of the late 1970s was sharply reversed around the beginning of the 1980s, primarily due to the twin effects of drought and recession. At the same time, the debt burden rose rapidly - for example, typical debt service was around 5% of export earnings in the 1970s, rising from 20% to 30% in the latter part of the 1980s. The average indebtedness overall is around US$280 per caput, not far different from the average annual GNP per caput. Servicing this debt takes, on average, around 25% of export earnings.

Food production per caput has been declining during the last 20 years, especially in the drought years of 1984 and 1991/92. At the same time, food consumption has increased in the first part of the period, the gap being made up by imports and food aid. With the current drought (1991/92), food production is no doubt showing a continued fall, and, indeed, the calorie supply per caput will be hard pressed to maintain the relatively low level of approximately 2,100 kcals per day. This usual level is, itself, no better than that experienced ten years ago on average (see Panel IF).

The proportion and numbers of people estimated not to be eating adequate food, on average, to maintain productive activity parallel the estimates of calorie availability, since the distribution is not thought to have changed. It is now estimated that around one-third of the population of Sub-Saharan Africa is not consuming adequate calories, so mat the numbers of people underfed rose rapidly in the last 15 years, from around 130 million in 1980 to around 170 million in 1990 (Panel 1G). This proportion of “food insecure” people is now by far the highest in the world, and indeed the rapidly rising trend in numbers so affected is in contrast to other regions.

One factor that importantly protects child nutrition in most of Africa is the almost universal practice of breastfeeding, certainly in rural areas, although this is under threat with urbanization. Moreover, there is some evidence that promotional campaigns may be having an effect. For example, in Kenya, the mean duration of breastfeeding amongst educated women has actually increased over the last 15 years. Similar results have been observed in Ghana. It is obviously of enormous importance to protect the practice of breastfeeding, which is as extensive in African countries, or more so, than anywhere else. At the same time, as will be discussed further in Chapter 4, there is a relatively low incidence of low birth weight in Africa, probably related, in turn, to the fact that African mothers are relatively well-built, compared with women of similar poverty in, for example, Asia.

The economic crisis in many African countries has led to rapid increases in consumer prices. As examples, the consumer price index tripled in Zimbabwe between 1980 and 1987; it rose by nearly ten rimes during a similar period in Tanzania; and around six times in Nigeria. Fortunately, the food price index did not rise any faster than the consumer price index in most countries (Tanzania is an exception), as it is generally observed that the ratio of FPI/CPI is more closely related to underconsumption and malnutrition than the consumer price index itself. In other words, at least food did not preferentially become more expensive.

Panel 1 SUB-SAHARAN AFRICA

POPULATION

A. Million, log scale

CHILD GROWTH AND SURVIVAL

B. Underweight preschool children

C. Infant mortality rate

ECONOMICS

D. GNP per capita

E. Debt service ratio

FOOD

F. Dietary energy supply

G. Underfed population

HEALTH

H. Immunization coverage

I. Access to health services and potable water

J. Low birth weight

WOMEN’S STATUS AND CARING CAPACITY

K. School-age females in secondary school

L. Maternal mortality rate

M. Total fertility rate

The economic crisis in most countries led to programmes of structural adjustment, with significant cutbacks in public expenditure in the social sectors, such as health and education. Indicators such as enrollment in secondary school, which, on average, declined slightly during the latter part of the 1980s, reflect this. Individual country data (see Volume II) will show that expenditures on health and education tended to decline from the mid-1980s, both as a percentage of the government budget and in absolute terms - this was certainly the case in Nigeria and Tanzania, and for health in Kenya; Zimbabwe managed to protect its expenditures, as did Kenya, on education, up to 1988.

On the positive side, improvements in infant and child mortality rates (if not numbers) are linked to effective campaigns for immunization, notably for neonatal tetanus and measles, and some improvements in access to health services and sanitation overall. For example, it is now estimated that nearly 60% of the population have some access to local health care (defined as access to treatment within one hour’s walk or travel), and that 30% to 40% of the population have access to sanitation and/or clean water, up by around 10 percentage points between 1984 and 1990 (Panel II).

Indicators of the situation of women are scarce, but not encouraging. For example, the enrollment of girls in secondary school increased significantly between around 1975 and 1985, but appears to have declined since then, from 20% in 1985 to 16% in 1990 (Panel 1K). While this may reflect the rapidly increasing population of this age, it also shows that the facilities have not kept up. Maternal mortality remains among the highest in the world - and the latest statistics from WHO show evidence of deterioration (Panel 1C). Between 1983 and 1988, maternal mortality rates per 100,000 live births increased to 680 from 660 in East African countries, to 710 from 690 in Middle African countries, and to 760 from 710 in West Africa. The incidence of low birth weight is difficult to estimate because of low coverage of attended births, but such evidence as there is tends to demonstrate virtually no improvement in the last decade.

The nutrition situation in Africa is expected to become increasingly serious as the end of the century approaches. Projections to the year 2000 suggest that filling the projected gap in basic staples in the region would require more than twice the 1.7% annual growth in production which occurred from the 1960s to 1980s. Among the sub-regions, the major concern in this respect is West Africa, where growth in food output is still very slow and the population is expected to increase by more than 3% annually in the 1990s. Africa’s agricultural production potentials are far from being fully utilized. Roots and tubers, for example, have yet to benefit from technological breakthroughs. The concern of governments for food self-sufficiency, however, should not deviate attention from the primary objective of household food security, which is mainly a question of household income.

Unless a great deal of change occurs and soon, the people of the continent could suffer even more chronic and acute hunger. It is important to distinguish the situation in war areas, from those where there is a chance of stability. It is absolutely essential that the civil wars, such as in the Horn of Africa, cease, as is vividly demonstrated by the situation in Somalia. All that follows depends on peace.

Refugees and displaced people, when they reach an area where relief can be provided, must have their needs for food and health, at a minimum, met - and usually this will require external assistance. Nutritional needs must be better borne in mind in the future, not the least ensuring adequate quality of diet, preventing epidemics of micronutrient deficiency diseases.

But the underlying situation throughout most of the continent has to be of grave concern. If economies continue to decline, population continues to increase, and the health situation (including AIDS) deteriorates further, much of Africa could become a disaster area. On the other hand, with stability established, there are real prospects for technological change in rural and urban areas beginning to turn the situation around. Pressure on cultivatable land is high, but still less than many other parts of the world, and if “green revolution” technologies can be developed and adapted, these could begin to transform rural areas and help economic growth. Equally, the tradition of community organization could be built on, and the successes already seen in community-level programmes could become more widespread. Sub-Saharan Africa has a long way to go in developing health and education infrastructure, but the positive side of this is that there is clear potential for widespread improvement. There are basic resources of land and people, but time is running out to reverse deteriorating trends.

Near East and North Africa

(Panel 2)

The region has three different groups of countries: the high-income oil-exporting countries of Kuwait, Saudi Arabia, United Arab Emirates, and Libya; the middle-income group of Iraq, Cyprus, and Algeria; and the low-income countries with per capita GNP below US$2,000, including Egypt, Jordan, Morocco, Syria, Tunisia, Turkey, and Yemen.

In the last five years, nutrition in the region as a whole improved. Prevalence of underweight preschool children was estimated at around 15% in 1985, declining to around 13% in 1990 (Panel 2B). The numbers of underweight children also fell marginally over the period - from 5 million to around 4.8 million. Direct assessments from surveys in Egypt and Tunisia showed improving trends (see Table 1.3). Data for the period since the Gulf War (early 1991) are scarce. However, it is likely that receipts from workers’ remittances have been affected (e.g., for Egypt, Syria, and Turkey) hence possibly consumption. From Iraq, there have been several reports indicating deteriorating health, food availability, and nutrition.

The incidence of low birth weight, anyway reasonably low in the region, is estimated by WHO/UNICEF to have fallen slightly on average during the 1980s, from around 12% to around 11% (Panel 2J). Specific country results are, for example, 7% in 1985 in Saudi Arabia, and about 12% in Algeria, with most countries falling in between these values. Contributing to the relatively adequate birth weight is the high percentage of women receiving antenatal care. Nearly universal coverage has been achieved in, for example, Cyprus and Kuwait; it is estimated to be above 75% for Jordan, Libya, and Saudi Arabia, although lower in countries such as Egypt and Morocco.

Breastfeeding, fortunately, remains the almost universal practice in most countries. The percentage ever breastfed is 90-95%, for example, in Egypt, Morocco, and Tunisia, slightly higher in rural than urban areas. This proportion has held fairly steady over the last ten years. According to World Fertility Survey (1970s) and Demographic and Health Survey (1980s) results in Egypt and Morocco, breastfeeding initiation is now higher in educated women than earlier, and the median duration of breastfeeding slightly longer. This encouraging finding indicates that promotional programmes may succeed; moreover, as the proportion educated increases anyway, breastfeeding may be further supported.

The trends in the price of oil dictated, to a large degree, the movement in the economies of the region, including those countries which were not net exporters of petroleum products such as Egypt, which, nonetheless, benefitted from workers’ remittances from the oil exporting countries. The regional GNP per caput rose from around US$1,100 in 1975 at the start of the first oil crisis to around US$2,600 in 1982, but falling sharply thereafter with the decline in the price of oil. The 1990 regional weighted GNP per capita figure is estimated at US$1,900, back to where it was in 1980 (see Panel 2E). However, other indicators show some improvement through the 1980s, and since so much of GNP is from oil here, the indicator may not well reflect changes in actual income for much of the population. Egypt, the most populous country, had rising per caput GNP in the 1980s (see Volume II).

With very little arable land and largely dependent on rainfed agriculture, nearly half the food supply in the 1980s came from imports, as well as from food aid for the less well-off countries. In Egypt, Morocco, Tunisia, and Algeria in 1990, for example, out of the 39 million metric tons of cereal supply, 18 million metric tons were from external sources (15.8 million from commercial imports and 2.2 million from food aid receipts). At the same time, food consumption patterns are changing, particularly in the middle income class. Meat consumption per capita has increased, resulting in increased demand for grains for livestock. In 1981, 17% of the total cereal supply was used for animal feed, increasing to 34% in 1990, which accounted for much of the increase in total cereal supply.

Consumer food subsidies are very important in several countries. Egypt has one of the largest food subsidy schemes in the world, covering 93% of the population; per capita food availability is above 3,000 kcal - similar to developed countries. Overall, the trends of per capita calorie availability in the region have been upward, from around 2,650 in the mid-1970s to 3,100 in 1990 (Panel 2F). Marked increases occurred in Algeria, Saudi Arabia, and Tunisia, but at a lesser rate in Cyprus, Yemen, Turkey, and Jordan. Egypt, while not the richest country in the region, achieved the highest level of calorie availability per capita of 3,336 by deliberate policy, although at a high foreign exchange cost. Imports of cereals in Egypt for the 1990-91 crop year reached 6.7 million metric tons while 1.7 million tons of food aid (mainly wheat from the United States) were received. Such policies of subsidies and imports did lead to fiscal problems, for instance, in Egypt and Morocco.

FAO data show that the proportion of the population considered to be “underfed” fell from 8% in 1980 to 5% in 1990. In absolute numbers, this implies 15 million people in 1980 compared to 12 million in 1990 (Panel 2G).

Many countries in the region adopted stabilization and adjustment programmes designed to correct their external imbalances and credit worthiness. Morocco, Algeria, and Tunisia, in particular, pursued aggressive reforms aimed at strengthening the balance of payments and promoting economic efficiency. Egypt’s total debt increased nearly tenfold over a 15-year period - from US$4.7 billion in 1975 to US$40 billion in 1990, implying a per capita debt of about US$800 in 1990. Rapid increases in debt were also experienced by Turkey, Morocco, and Algeria. The debt service ratio in the region hit a maximum of around 35% in 1986 to 1989. In 1992, substantial debt relief was provided to Egypt following the Gulf War of 1991.

Future food security is closely tied to the ability to import cereals. Domestic production capability is limited by the scarcity of arable land and irrigation. Agricultural production, mainly rainfed, has been unstable due to erratic rainfall patterns. Egypt’s irrigation capability has been threatened recently by the unstable supply of upstream water from the Nile - including drought in Ethiopia, reducing water in the Aswan Dam.

On the positive side, reforms in agriculture in Egypt, Morocco, and Tunisia in the second half of the 1980s helped to increase overall agricultural output to record levels in 1990-91. Agricultural policies in Egypt have aimed to increase production of cotton to generate foreign exchange and thus help to pay for food imports.

The improvements in nutrition in the region are also tied to developments in the health situation. In most countries, local health care coverage has been very high compared to other regions of the developing world. The proportion of the population with access to health care (defined as being within one hour’s travel) increased from 83% in 1983-85 to 89% in 1988-91 (Panel 21). Access to clean water supply increased from 75% to 86% over the same period, although the proportions of those with sanitary facilities remained at around 75%. Immunization coverage against measles has increased, doubling between 1983 and 1991, to around 80% (Panel 2H). The proportion of pregnant women immunized against tetanus increased from only 5% in 1983 to 56% in 1991. Programmes such as diarrhoea control were successfully implemented - and in Egypt, in particular, where access to ORT reached 83% of the population in 1989. These developments in health care coverage no doubt contributed to the decline in IMR.

Female literacy is on the rise, although the levels in various countries vary widely. Cyprus, Lebanon, Libya, and Kuwait, for instance, report over two-thirds of school-aged females are enrolled in schools, and with a rising trend. Saudi Arabia, Morocco, Yemen, and Tunisia, on the other hand, have female literacy rates below 40%, which are half the rates of males in the same countries. For the region as a whole, female enrollment in the secondary level increased from 32% to 52% between 1975 and 1990. Recent surveys in Egypt and Morocco have re-emphasized the relevance to nutrition: they found that women with at least primary schooling are only half as likely to have underweight children as those women without schooling at all.

Maternal mortality rates overall are estimated by WHO to have dropped to 360 per 100,000 live births in 1991 from a high of 500 per 1,000 in 1983. Improvements were observed particularly in Egypt and Morocco. No trends in coverage in antenatal care and delivery by trained personnel are available. However, the levels reported in 1988 of proportions of deliveries by trained personnel were relatively high - for example 75% in Jordan and 83% in Turkey.

The child underweight prevalence is expected to drop further from 13% in 1990 to less than 10% by 2000. The rate of improvement will, however, be somewhat dampened by the increasing food import bill. This will be felt more seriously by the non-oil producing countries in the region. As population increases, total demand for food will rise. The increasing fiscal cost of food subsidies (particularly for the non-oil producing countries in the region) will put a strain on the government budget. Reliance on domestic sources for food is limited by the lack of arable lands, and the fragile situation of irrigation in Egypt. The impact of re-targeting subsidies to the poorest would be cost-effective, but involves political risks. Rising incomes and changing food habits in the region have tended to shift the focus of the debate to diet-related chronic diseases. In Egypt, several regional studies indicate a rising trend in obesity among school children - 11% were above 120% of weight-forage in 1962, and around 23% in 1987.

The prospects are for continued improvement of nutrition, particularly if economic recovery continues, and per caput incomes increase again. A number of trends are in the right direction. Fertility rates are falling, and access to health and potable water are improving, to the point where they will soon be universal. Immunization is equally going to reach complete coverage before long. The trend in malnutrition is downwards, although indicators such as IMR still have a considerable distance to go. Food availability is relatively high, and provided imports can be maintained, is likely to remain so.

Threats to the continuation of these encouraging prospects include rising population density and urbanization, linked to increased strain on productive and social resources. Nonetheless, as discussed further in Chapter 6, with accelerated programmatic efforts, there are prospects that nutrition in the Near East and North Africa will continue to improve, and could even begin to meet internationally agreed goals.

Panel 2 NEAR EAST AND NORTH AFRICA

POPULATION

A. Million, log scale

CHILD GROWTH AND SURVIVAL

B. Underweight preschool children

C. Infant mortality rate

ECONOMICS

D. GNP per capita

E. Debt service ratio

FOOD

F. Dietary energy supply

G. Underfed population

HEALTH

H. Immunization coverage

I. Access to health services and potable water

J. Low birth weight

WOMEN’S STATUS AND CARING CAPACITY

K. School-age females in secondary school

L. Maternal mortality rate

M. Total fertility rate

South Asia

(Panel 3)

In South Asia, the proportion of underweight children is nearly double that of elsewhere in the world. This is in line with some related indicators, such as low birth weight; however, others, such as infant mortality rate, on the one hand, or income, on the other, are similar to Africa where the underweight prevalence is substantially lower. That healthy well-fed children from South Asia grow at the same rate as children everywhere else is well established; the growth failure is undoubtedly environmental and preventable.

Although it is uncertain how far the causes and consequences are directly comparable with other populations, the high underweight prevalence levels undoubtedly indicate an extensive problem, and the huge numbers so affected constitute probably the biggest nutritional problem in the world. The trends over time can be interpreted more straightforwardly and compared with those in other regions.

Direct estimates of levels and trends in the prevalences of underweight preschool children are available from India (eight states), Pakistan, Sri Lanka, and Bangladesh. Regional averages are obviously dependent largely on India, because of its population size. During the 1980s, the prevalence fell overall for the region, from an estimated 64% to 59% (Panel 3B). This change, only recently established notably from results in India, is of great importance in assessing world nutrition. The rate of improvement in India, of around one-half percentage point per year, probably occurred also in Pakistan and Bangladesh.

The rates of improvement were, however, lower than the population growth rate and consequently the total number of underweight preschool children increased, from 90 to 101 million children in the last ten years. South Asia has the highest prevalence of underweight young children in the world, while the absolute number accounts for over half of the entire world total.

Substantial differences exist in prevalences between countries, although all are high. In the 1980s, India, Bangladesh, and Nepal had underweight prevalences above 60%, with Pakistan and Sri Lanka around 40%. Within India, there is only limited variation on average between states, aside from Kerala. Using the National Institution of Nutrition’s indicator (75% of NCHS standards) for 1988-90, Kerala had 35% underweight one to five-year-olds; Tamil Nadu was next lowest at 50%, Gujarat being the highest at 59%. Improvements varied by state - for example, in Kerala and Maharasthra, the underweight prevalence dropped significantly more than in Madhya Pradesh and Gujarat.

In Pakistan, the national survey by DHS in 1990/91 confirmed that the rates declined from the previous decade. As discussed in the Vol. II, the correction of early survey data for age-misreporting was necessary for this conclusion. In Bangladesh, the proportion of underweight children was reduced to 65% in 1990 from a level of 70% in 1985 and 84% in 1975 - but Bangladesh continues to have the highest rate in the world.

The infant mortality rate, estimated as 112 per 1,000 live births for the region in 1983, fell to 91 in 1990. These improvements are estimated to have taken place in all countries in the region, except Afghanistan, where the IMR is not thought to have changed from the extremely high value of 182 per 1,000 live births in 1983, up to the present.

The incidence of low birth weight is extremely high in the region, averaging around 30% of live births (Panel 3J). There is some evidence that this has fallen slightly, on average, according to available information. In general, during the last five years, the rates were around 33% in India, and 25% in Pakistan and Sri Lanka.

GNP per caput for the region grew at a moderate pace of 3.2% on average in the 1980s, faster than the 1.7% in the previous decade. Economic growth was more pronounced in the first half of the 1980s, slowing somewhat in the second half. South Asia was less affected by economic recession and structural adjustment than other regions. Poverty estimates point to some continuing improvements. In India, the proportion below the poverty line was estimated at 48% in 1977-78, falling to 37% in 1983-84, and further to 29% in 1987-89. National household surveys in Pakistan in 1979 and 1984-85 showed mat the proportion in poverty had declined from 34 to 28%.

Major gains in food production were achieved over the last two decades, although these were offset by high population growth rates. The trend in the per capita food production was nonetheless upwards, particularly between 1987 and 1989, following the drought in western India. In Bangladesh, the food production hit a low in 1988, but recovered in 1989-90 to the levels of the early 1980s. Agricultural production was accelerated by technological change, through the “green revolution” package of high yielding wheat and rice varieties. National cereal self-sufficiency was achieved in India, Pakistan, and Bangladesh as a result of such policies, although the gains differed regionally.

Thus, despite intermittent natural disasters such as drought in India in 1987, and intermittent flooding and cyclones that devastated many parts of Bangladesh in the late 1980s, the long-term trend in per capita calorie availability in the region was slightly upwards - from about 2,070 kcals per caput per day in 1975 to nearly 2,250 in 1990 (Panel 3F). FAO calculated that for the region as a whole, the proportion of underfed in the population declined from 30% in 1980 to 24% in 1990 (Panel 3G).

Panel 3 SOUTH ASIA

POPULATION

A. Million, log scale

CHILD GROWTH AND SURVIVAL

B. Underweight preschool children

C. Infant mortality rate

ECONOMICS

D. GNP per capita

E. Debt service ratio

FOOD

F. Dietary energy supply

G. Underfed population

HEALTH

H. Immunization coverage

I. Access to health services and potable water

J. Low birth weight

WOMEN’S STATUS AND CARING CAPACITY

K. School-age females in secondary school

L. Maternal mortality rate

M. Total fertility rate

Famine was largely prevented throughout the region, partly through better food stock management. For example, Pakistan’s food security management mechanism, using a demand/supply forecasting capability, enabled crises to be mitigated through timely actions in farm procurements, interannual price stabilization, and import and distribution in the case of deficits. In India, the Public Food Distribution System - involving the distribution of subsidized food grains via a network of fair-price food shops to the eligible poor holding ration cards - while varying by state in terms of coverage, has played a vital role in tackling food crises. Income support was provided through poverty alleviation schemes (India), and food for work and public works programmes in Bangladesh, among others. Together with price stabilization, such measures contributed to improving household food security among the poor in the region.

Fiscal pressures have led to cuts in direct public food distribution systems. Sri Lanka cut back its food stamp programme by default, by fixing the value of the food stamps while prices increased. In 1987, Pakistan eliminated the food radon shop system (principally of wheat flour) which had been in place for the past 40 years. In early 1992, Bangladesh virtually dismantled its rural food rationing system, largely as a result of the confirmation by studies of large leakages. In some cases, e.g., Pakistan, general consumer welfare may have benefitted from such policy changes. However, in Sri Lanka, the food consumption of the poor probably suffered.

Consumption surveys in India, Pakistan, and Bangladesh showed that over the last two decades, food consumption on average changed very little. Indeed, the National Nutrition Monitoring Bureau of India considered that average consumption of calories may have fallen slightly in eight states between 1975-79 and 1988-90. Per capita calorie consumption in Pakistan is also not thought to have changed much between the 1977 and 1988 survey periods. These results from direct food consumption surveys are only slightly different from conclusions from food balance sheet data and it probably is indeed the case that average consumption has largely been unchanged. However, there is evidence that the food consumption of the poor, for example, the landless, may have increased - results from India show this. This would be consistent with the steady, if slow, reduction in underweight in preschool children, of around half a percentage point per year.

Health conditions in much of the region remain severe, for example, the incidence of diarrhoea is particularly high, and there is little evidence for much change over the last two decades. Government expenditures on health care as a percentage of the national budget in Pakistan and India remain very low - 1.0% and 2.1% in 1986, respectively, compared to the average of 5.3% for the developing world. The lower health budgets in the two countries is evident even after accounting for the state and provincial health budgets in the calculations. There is, however, evidence of improvement in efficiency in health delivery systems, in terms of increased coverage of local health services in India and Pakistan, although not in Bangladesh and Nepal. In Sri Lanka, the proportion of the population having access to health care within one hour’s travel remains high at 90%. Access to health services, and to safe water, are estimated by WHO to have improved during the 1980s, as shown in Panel 31.

Utilization of health services is a separate issue which needs to be addressed in the provision of health care. In Pakistan, a study in rural communities observed that while 90% of households reported access to government clinics, only 25% chose to use them, due to the irregular supply of medicines. The public health systems in these countries are also disproportionately urban - whereas the majority of people live in the rural areas. In Pakistan, for instance, almost 90% of all doctors serve the 30% of the population living in urban areas.

Large-scale direct actions in primary health care (including immunization (Panel 3H)) have been emphasized in most countries, along with nutrition and health interventions such as the Integrated Child Development Services (ICDS) and the Tamil Nadu Integrated Nutrition Project (TINP) in India, and the Triposha and school meal programmes in Sri Lanka, etc.

Sanitation is still a major problem in South Asia, with only 28% households in 1988-91 having access to adequate sanitation facilities. On the other hand, WHO reported that 70% households had access to a clean water supply in 1988-91, up significantly from 52% in 1983-85 (Panel 31).

Long-term nutrition improvements in the region are strongly associated with female educational levels. Research in Pakistan has shown that the likelihood of having an underweight child in the household where the mother has no education is three times that of the household where the mother has primary education; and this remains the case when me effect of income is removed analytically. However, only 11% of adult females in Pakistan are literate, compared with 37% for males (in 1988), which no doubt contributes to growth failure in children. The trend in the female enrollment ratio at secondary level for the whole region is upwards (24% in 1975 to 35% in 1990) but the improvement is slow.

Recent statistics from WHO indicate that maternal mortality rates in the region have fallen from 650 per 100,000 live births in 1983 to 570 in 1988. Increasing coverage of antenatal care as well as delivery by trained health personnel is likely to account for some of these improvements. Antenatal care by trained health personnel increased from 45% in 1983 to 70% in 1991 in India, 26% to 70% in Pakistan, but was still low in Nepal at 17%. The success in training traditional birth attendants has improved the proportion of deliveries by trained health workers from 60% to 70% in Pakistan, and from 32% to 60% in India. But only 7% of births in Bangladesh were delivered by trained health personnel in 1991.

The prospects for future nutrition in South Asia are mixed. On the one hand, food availability remains relatively low and has not shown much improvement in the last several years. Moreover, there are no really clear prospects for increasing food availability comparable to the green revolution - yield limits are beginning to be reached, as is me availability of land suitable for irrigation. The proportion of landless people is high and increasing. It is likely that the important prospects for future improvement lie with industrialization. Underlying this is a continuing race between population growth and economic growth. Fertility is decreasing, but not yet nearly enough to reduce population growth as much as is needed,

Thus a key question, outside the scope of this report, remains how economic development can be accelerated. Nonetheless, there are a number of programmes in place mat protect nutrition mat seem well-founded. These include poverty alleviation and public works programmes, as well as food supply and price stabilization measures. Direct nutrition and health programmes, such as the Integrated Child Development Services in India, are most probably benefitting large numbers of women and children. More effective targeting of such programmes is important, and potentially could be achieved. One particular constraint which could be more energetically addressed concerns discrimination against women, common particularly in the northern part of the subcontinent.

Given the very high numbers of underweight children, and widespread inadequate consumption among a huge population, what happens to nutrition in Asia profoundly affects the overall world nutrition situation. Although the trend is in the right direction, it is far too slow to see a resolution of the problem in the foreseeable future. Both intensification of existing programmes, and new investments and ideas, are needed to accelerate improvement.

South East Asia

(Panel 4)

Among the regions of the world, South East Asia achieved the fastest rate of economic expansion in the last two decades, with annual growth rates in GDP per caput averaging 6 to 8%. GNP per capita for the nine countries included in this region more than doubled from around US$350 in 1975 to US$800 in 1990. The growth rates in farm and industrial production outstripped population expansion in the region as a whole, and this translated into improvements in real incomes and reduction in poverty in most of the countries.

Overall nutrition in the region improved at a rapid pace. The prevalence of underweight children fell rather steadily, at close to one percentage point per year, from 1975 to 1990 (Panel 4B) (Table 1.2). This rate of decrease was sufficient to bring numbers of underweight down, from 24 million in 1975, to 22 million in 1985, and to 20 million in 1990.

Rates of improvement were not the same in all countries, but direct estimates from national surveys confirmed improvements in Thailand, Myanmar, Malaysia, Vietnam, and Indonesia (Table 1.3). The largest improvements in the 1985-90 period were noted in Thailand (20% to 13%), which benefitted from a surging economic growth (above 10% annually) in the second half of the 1980s, coupled with a highly successful direct nutrition and health programme begun at the start of the decade. Consistent improvements were also seen in Indonesia, the largest country in the region, but in the Philippines, the proportion of underweight children stood at around 33% in 1990, slightly lower than 1986 at the height of the economic and political crisis. Surveys in Myanmar showed that for the under-three-year-old children, prevalence declined from 38% in 1987 to 32% in 1990.

Available data (Panel 4J) point to a marked drop in the percentage of low birth weight babies in the region as a whole, from 18% in 1983-85 to 15% in 1988-91. Marked declines were reported by WHO/UNICEF in Laos, Vietnam, Indonesia, and Thailand.

Nutritional improvements were no doubt influenced by the overall strong performance of the economies in the region. Oil exporting countries such as Indonesia and Malaysia enjoyed rapid growth rates in the 1970s followed by weaker but still high growth rates in the 1980s when the price of oil began to fall. Growth performance in the oil importing countries - such as Thailand and Vietnam - was generally robust particularly in the second half of the 1980s, but faced the adverse effects of the Gulf crisis which increased the import bill for oil. Countries with large numbers of migrant workers abroad, such as the Philippines, suffered from large declines in remittances - a significant portion of the dollar earnings. Added to these were pressures of debt servicing which were rapidly increasing in the mid-1980s, up to more than 40% average for the region by 1986 (see Panel 4E) but men falling towards the end of the decade. In 1986, debt service ratios in Myanmar reached 80%, 39% in Indonesia, 35% in the Philippines, and 30% in Thailand.

Structural adjustments were necessary in Indonesia (1983), the Philippines (1987), Malaysia (1986), and Thailand (1986). Most countries responded quite well to the shocks, although at varying degrees. Growth in the economies resumed and debt service payments were reduced in 1990 to 17% in Thailand, 21% in the Philippines, and 30% in Indonesia.

Many of the countries in the region made substantial progress in reducing poverty - in Indonesia, for example, the estimated level of absolute poverty declined from 33% in 1978 to around 17% by 1987. The far reaching economic and institutional reforms in Vietnam beginning in late 1987, where the economic system was completely restructured, provided impetus to the strong agricultural performance - increasing agricultural GDP at a rate of 4.5% in 1989. In Malaysia, poverty declined from 27% in 1980 to 15% in 1987; in the Philippines, a recovery from deteriorating poverty conditions was seen from studies comparing conditions between 1985 and 1988.

Food production gained momentum in the last five years of the 1980s, growing at an annual pace of 4.5% in 1988-89 and 3.1% in 1989-90 crop years as regional averages; generally continuing from the “green revolution” which started in the 1970s with the wide dissemination of IRRI high yielding rice varieties. Most countries achieved food self-sufficiency in the 1980s. Indonesia, one of the largest importers of rice in the post-war period, achieved self-sufficiency in 1984. Thailand, Vietnam, Myanmar, and Indonesia accounted for 43% of the global exports of rice in 1991. Thailand exported 4 million metric tons of milled rice (out of the world total exports of 12.2 million metric tons). Vietnam’s liberalization in agriculture in late 1987 resulted in record harvests in 1988-90, making the country the third largest exporter of rice in the world - a big achievement for the once net importer, just a decade earlier.

Food production in the region is still vulnerable - from population growth, natural calamities such as tropical storms which are common in the region, as well as drought. Yields in rice have remained largely unchanged in the latter 1980s following the prior growth rate gains fueled by the high yielding varieties; and the expansion in cultivated land has now about covered most of the more fertile areas.

The availability of calories for the region has increased steadily, generally in line with food production (see Panel 4F). The per capita calorie supply increased from 2,400 to 2,500 from 1985 to 1990. In 1975, this figure was 2,150 per capita. These trends reflect not only growth in supply, but in demand, mainly through increasing incomes and stable prices. As a result, FAO calculated that the number of people considered underfed, or not eating adequate food to maintain light activity, fell from 101 million in 1970 to 74 million in 1990 (Panel 4G).

Improvements in overall nutrition could be traced partly to deliberate actions in health and nutrition programmes in the 1980s. Primary health care was emphasized in virtually all countries. The success of me nationwide nutrition and health programmes were seen clearly in Thailand and Indonesia. Here, awareness and public opinion moved policy towards nutrition goals, making these explicit in national development plans; and community intervention programmes had a big impact on malnutrition.

The proportion of the population having treatment for common diseases available within one hour’s travel (according to WHO, see Panel 4I) increased from 57% to 84% between 1983 and 1991 for the region as a whole. Over mat period, the population covered by safe water supply rose from 44% to 53%. The coverage in Malaysia, the Philippines, and Thailand was over 70%. The proportion of households in the region with adequate sanitary facilities is estimated to have increased from 41% to 51% between 1983 and 1991.

Infant mortality rates declined by nearly half - from 92 to 55 per 1,000 live births from the mid-1970s to 1990 (Panel 4C). Some of me countries have achieved remarkable improvements - Malaysia and South Korea, for example, had IMRs in the low 20s per 1,000 at the end of the 1990s (equivalent to the levels in the United States and France in 1965). This meant that in the 15-year period, the absolute number of children dying annually before their first birthday declined in the region from about 946,000 to 635,000. Many factors account for such improvements, one of which is the likely synergy of health status with the positive nutritional trend. A good part is attributed to the increase in direct actions by governments in local health services.

Compared to other developing regions of the world, South East Asian women enjoy a better overall position, in general. Female literacy has been rising - females enrolled at the secondary level rose from 29% to 46% in 1990 (71% in the Philippines, equal to the levels for males). In general, women are finding fewer barriers to their participation in the labour force, in education, and in public life.

Panel 4 SOUTHEAST ASIA

POPULATION

A. Million, log scale

CHILD GROWTH AND SURVIVAL

B. Underweight preschool children

C. Infant mortality rate

ECONOMICS

D. GNP per capita

E. Debt service ratio

FOOD

F. Dietary energy supply

G. Underfed population

HEALTH

H. Immunization coverage

I. Access to health services and potable water

J. Low birth weight

WOMEN’S STATUS AND CARING CAPACITY

K. School-age females in secondary school

L. Maternal mortality rate

M. Total fertility rate

Maternal mortality rates have been estimated at 420 per 100,000 live births in 1983, and WHO estimated that this declined to 340 in 1988 for the region as a whole (Panel 4L). Direct estimates show improvements in maternal mortality in the Philippines and Malaysia, and declining but still at a high level in Indonesia and Laos. Both the proportions of women receiving antenatal care (e.g., from 66% in 1985 to 84% in 1991 in Malaysia, 26% to 47% in Indonesia) improved, as did the proportion who delivered babies attended by trained personnel (e.g., from 33% to 71% in Thailand in the same period).

The prospects for nutrition for the rest of the decade for the region as a whole are clearly positive. The transition into market economies in Vietnam, Laos, and Kampuchea which started in late 1980s is gaining momentum. Reforms in the agriculture sector in these countries are now reflected in increasing agriculture outputs. The Philippines and Indonesia are gearing up to become export-led economies following the success of Thailand and Malaysia in the 1980s. Increasing pressures of population and rising incomes will generally fuel increasing demand for food. If the trends in the last decade continue, the proportion of underweight (currently at 31%) and underfed populations in the region is likely to continue to decline to the year 2000.

Rapid economic growth together with vigorous community-level health and nutrition programmes have brought malnutrition down rapidly in countries such as Thailand and Indonesia. Where there is less growth, there has been less resources and organization for programmes, and less progress, such as in the Philippines. If such programmes can be intensified, the rate of improvement may speed up. In favour of this is the health service infrastructure and high levels of education in most countries in the region. Whether improvement can be accelerated even further, for example as needed to meet the goals of the World Summit for Children, is not clear - but sustaining and intensifying existing programmes would clearly play a role. Threats to the generally positive prospects would include, obviously, economic slowdown, possibly related to hitting up against the technological limits of agricultural production, and increasing pressure from population growth. But in general, if growth and stability can be maintained, future prospects for nutrition in the region are good.

China

(Panel 5)

Survey data of anthropometry in young children, covering much of the country, were collected in 1987, giving a first assessment reasonably comparable to other countries. The results gave an estimate of around 21% of children under six as underweight. As previous anthropometric surveys were not national in scope, it is not possible to compare this result directly with earlier surveys. However, results from surveys over many years in Beijing (as given in the SCN’s Update Report) showed rapid improvement in the 1970s, leveling off during the 1980s. Estimates have been made of likely trends from 1975, as shown in Panel 5B, using methods similar to those for other countries based on data such as calorie availability, education, etc. From these, the proportion of underweight children is estimated to have fallen from around 26% in 1975 to the present level of 21%; the calculations indicate a more rapid fall in 1975-85, and, in fact, a slight increase in the prevalence in the late 1980s. These results imply that total numbers underweight were roughly stable at 21 million between 1975 and 1985, increasing slightly to around 24 million by 1990.

The prevalence of underweight children varied greatly by location - for example, in data from 1987, between 6% and 27% in urban areas, and 12% to 47% in rural areas. The provinces of Zheijang and Shandong seemed to have the lowest prevalence rates, while Guandong Province had the highest. In general, the problems are greater in the northern and inland provinces. The southern and coastal provinces, particularly in the Shanghai and Shandong areas, have lower prevalence rates, associated with higher income levels.

Nonetheless, the overall levels of underweight are remarkably low, considering that China remains one of the poorest countries. The per caput GNP is fairly similar to South Asia (compare Panels 3F and 5F), but China has about one-third of South Asia’s prevalence of underweight children.

The National Survey on Child Growth indicated that China’s percentage of low birth weight babies, which was 9% in 1987, is also among the lowest in the developing world.

Infant mortality rates are low in China, in line with nutritional indicators. Moreover, they have continued to fall in recent years, from around 40 per 1,000 live births in 1980 to 30 in 1989. These values are indicative of the successful deliberate actions in the social sector in China, and no doubt benefit from the adequacy of birth weights. Countries of similar GNP per capita as China in 1990 (around US$370), such as Pakistan, Kenya, Haiti, Ghana, and India, have infant mortality rates ranging from 67 to 103 per 1,000 live births. China’s IMR is equivalent to that found in Argentina and Venezuela - countries that have incomes which are six times that of China. A reasonable comparison may be with the state of Kerala in India, which has similar low income but excellent IMR figures, and a much lower child underweight prevalence than other Indian states.

Panel 5 CHINA

POPULATION

A. Million, log scale

CHILD GROWTH AND SURVIVAL

B. Underweight preschool children

C. Infant mortality rate

ECONOMICS

D. GNP per capita

E. Debt service ratio

FOOD

F. Dietary energy supply

G. Underfed population

HEALTH

H. Immunization coverage

I. Access to health services and potable water

J. Low birth weight

WOMEN’S STATUS AND CARING CAPACITY

K. School-age females in secondary school

L. Maternal mortality rate

M. Total fertility rate

The overall trend in nutrition in China in the last two decades is linked positively to overall improvements in the economy, which grew by 5.3% in real per capita terms between 1975-77, and with accelerated growth between 1978-84. Administrative and fiscal decentralization, as well as external trade and exchange rate reforms, had a positive impact on economic growth. After such dramatic growth, the economy slowed down considerably, growing 2.47% annually between 1985-89. The industrial sector’s output growth rate fell to 8.3% in 1989 as compared to 20.8% in 1988.

The slowing of economic growth, especially in 1988-89, resulted from a conscious attempt by the government to remove excess liquidity in the economy and thus lower the inflation rate, which was averaging 20% in 1988 - at one point reaching 30% in urban areas. A combination of restrictive monetary policies, increased interest rates to encourage savings as well as reduced public sector investments, were successful in reducing urban inflation to 3.3% in 1990.

With the significant economic expansion, per capita household income rose considerably during the 1980s. The average Chinese household saw an increase in its nominal income of 240% during the 1978-88 period; in real terms, rural incomes increased by 116%, and urban incomes by 87%. Poverty studies also indicate that the proportion of the population considered to be below the poverty line declined to 13% in rural households in 1988 compared to 17% in 1981.

Food production in the last half of the 1980s increased, but not as fast as during the 1978-84 boom period. In the late 1970s, the government initiated a series of reforms, including increasing fertilizer accessibility, and raising the quota price (at which farmers sold output to the government) by 20%. Households rather than communes once again became the central unit of production and, under a new system of contract responsibility, households had to meet certain production quotas before being able to sell any surplus in local markets under market-determined prices. These agricultural reforms were highly successful and the gross value of agricultural output increased as much in 1978-84, as in the 21 years prior to this. Increase in production in the 1980s was built on earlier investment in irrigation, soil quality maintenance through fertilizer application, and the use of high-yielding varieties of wheat, rice and maize.

Overall per capita calorie availability is estimated by FAO at 2,700 in 1990, up from 2,600 in 1985, and 2,100 in 1975 (see Panel 5F). The proportion of the population estimated to be consuming inadequate energy associated with these kcal availabilities roughly halved between 1975 and 1990, from about 40% to 20% (Panel 5G).

The government spends a considerable amount of money on food subsidies for the urban population through a rationing system which has been in operation since 1953. Under this system, most households receive ration coupons for grain and certain other basic foodstuffs, which are heavily subsidized. In rural areas, there is no formal ration system, but the government does intervene in transferring grain from surplus to deficit areas.

China has given high priority to programmes in health and sanitation. Compared to other countries with similar levels of income, China has implemented far more direct actions to provide social services to its population. Access rates were achieved of 71% for safe water supply and 96% for sanitary facilities in the home or immediate vicinity in 1991. Likewise, immunization campaigns have been very successfully implemented. Reports by WHO indicate that the proportion of infants immunized against measles increased from 75% in 1985 to above 90% in 1991, while one-third of pregnant women in 1985 were immunized against tetanus. In 1991, 74% of infants received BCG shots, 98% were immunized against polio, and 97% with DPT.

Priority for health care in China has strong historical roots. In the Mao period, China implemented a massive health care delivery system linked to the brigades in the rural areas. The ratio of Western-style doctors per 100,000 population is two-and-a-half times that in India, while the number of village-level health workers is 4.5 times. Financing for health care comes from three main sources: private outlays (32%), labour insurance (31%), and state budget expenditures (30%). In 1981, about 70% of the population had complete health insurance. There are, however, significant urban/rural differences: urban expenditures on health are about US$16 per person, about three times the amount spent for the rural areas. State subsidies for health in urban areas are almost ten times those of the rural areas - about US$13 per capita annually compared to US$1.50 per capita.

Indicators of women’s situation in China show a moderately visible role in the economic life of the country. Female labour force participation has been very high (42% of all women in 1975) and has remained at that level for most of me 1980s. This high rate of economic participation of women has put a stress on child care, and this has become a major issue, especially in the urban areas where women have generally worked in factories. Female enrollment in primary education has been increasing. Largely as a result of the effects of increasing labour participation and of the family planning programme which aimed at one child per family, the country has reduced its population growth to an average of 1.5% from the early 1970s to 1990, and total fertility to just over two births per woman on average, see Panel 5M.

Diet-related chronic diseases, dietary patterns, and life styles, especially for more affluent segments of the society, are an emerging concern. Coronary heart diseases, stroke, and cancer are rising as causes of mortality, proportions becoming similar to those of the United States. In 1986, reported deaths from cerebrovascular diseases were four times what they were in 1957, and from heart disease, three times.

China has thus been through a major transition, from large-scale food insecurity, including periods of famine, to widespread dietary adequacy, with even the risk of overconsumption among some people. This was achieved largely as a result of the government’s high - priority to ensuring adequate caloric intakes through rapid production increases of staple crops. The overall trend in food supply, coupled with the high priority the government attaches to direct social actions in sanitation, immunization, and health care, have contributed a good deal to the achievements in nutrition.

China has remarkably good nutritional status and related indicators such as infant mortality rate, considering the low GNP per caput. Food availability is relatively better than might be expected from GNP, as are access to health services and literacy, all of which no doubt contribute to the favourable nutritional situation. Improvements in underweight children ceased in the latter 1980s, in line with slowdown in growth of GNP and food consumption, and restoring economic growth would clearly be important for continued improvement in nutrition.

Middle America and Caribbean

(Panel 6)

In the last Five years, nutritional indicators in the region were rather static, after improvements from the mid-1970s to the mid-1980s. In the decade prior to 1985, improvements in prevalences of underweight preschool children from 19% to 15% were enough to negate the growth in zero to four-year-old population; the number of underweight children fell from 3.4 to 2.8 million. Then, between 1985 and 1990, the absolute number of underweight children rose slightly (from 2.8 million to 3.0 million) based on prevalence rates of 15.2% and 15.4% respectively. Direct survey estimates showed improvements in Costa Rica and Jamaica.

Between 1983-85 and 1988-91, the incidence of low birth weight declined from 15% to 12% according to WHO/UNICEF figures, partly as a result of the increasing coverage of antenatal care. As examples, the proportion of pregnant women receiving antenatal care in Costa Rica increased from 1984 to 1989 from 54% to 91%, 26% to 69% in El Salvador, and 66% to 83% in Panama, although, in Haiti, this indicator fell.

The average GNP per capita of the region fell to a 1990 level of US$1,700 per capita from a peak of US$2,300 in 1982. In the earlier decade, dramatic increases in economic output were noted, very strongly in Mexico and many other Central American countries. The sharp swings in income over the 15-year period were brought about by the immediate effects of structural adjustments in Mexico, in particular. Also, generally adverse developments in the world economy in the early 1980s had an impact via reductions in external demand, terms of trade, and the supply of external finance - all crucial elements in the rapid economic growth of the 1970s. Debt in practically all countries in the region rose dramatically - from around US$240 per capita in 1975 to US$1,000 in 1990 - more than one-half of the per capita incomes of the region. Mexico’s total debt rose from US$15 billion in 1975 to USS85 billion in 1990 - one of the largest in the world. The debt service ratios were very high (see Panel 6E), reaching 50% in the late 1970s, and still above 30% by 1990. This curtailed available capital for domestic investments, and stalled economic growth in the last few years.

The impact of the structural adjustments and external debt in the 1983-87 period negatively affected food availability and consumption. Calorie availability per capita, which increased before the adjustment period, from a 2,600 per capita level to around 2,900 in 1982/83, declined to a level of 2,800 by 1987 (Panel 6F). Food consumption declined in the 1984 to 1988 period, but remained unchanged for the rest of the decade. Overall, the proportion of the population with inadequate access to food was estimated by FAO to be unchanged between 1980 to 1990, at around 14-15%. The slide was somewhat stemmed by the end of the decade, particularly in Mexico, which registered a significant rebound in per caput food production in 1990.

Hyperinflation in the mid-to-late 1980s badly hit standards of living - for example, in Mexico, the consumer price index in 1990 was 120 times that of 1980. Food prices were equally affected, but at least not worse than general inflation - the FPI/CPI ratio actually fell during the 1980s in Mexico (see Volume II).

Measures to protect the well-being of the poor (particularly children and pregnant women) from the severe economic shocks differed among countries in the region. In Mexico, general food subsidies were replaced with targeted interventions such as the Tortibonos (tortilla) programme introduced in 1986, which was targeted to low-income households based on minimum wages, and the Liconsa subsidized milk programme in urban neighborhoods. In Jamaica, food stamps were issued to draw cornmeal, rice, and dry milk. Direct maternal and child health and food programmes were also in place in Costa Rica, Honduras, Guatemala, El Salvador, and Panama. However, in Haiti and the Dominican Republic, direct MCH and food programmes were very small in relation to the magnitude of the nutrition problems.

Coverage of such direct programmes was quite high. In Mexico and Jamaica, feeding programmes covered 44% and 57% of all preschoolers, respectively - a far higher proportion than the estimated preschool underweight prevalences of 14% and 13% in 1980, respectively. Coverage in the school-aged population is even higher - averaging 68% in Honduras, 82% in Guatemala, and 96% in Costa Rica in the mid-1980s. Other countries, by contrast, have low levels of direct feeding programme coverage of preschoolers, e.g., 2% in Haiti, 14% in El Salvador, and 10% in the Dominican Republic.

Government expenditures on health fell in absolute terms in the 1980s, generally in line with the total government budget. The most severe decline was in Mexico, where the 1988 total budget for health care institutions was only 47% of the level in 1981. These cutbacks generated a movement towards making health care more cost-effective. WHO estimated that the coverage of people with health care increased from 51% to 91% in Mexico between 1982 and 1987, and 52% to 86% in the region as a whole for the period 1983-85 to 1988-91. Specific programmes such as immunization of infants against measles increased on average from 34% in 1983 to 77% in 1991 (Panel 6C), and had nearly universal coverage in Cuba, the Dominican Republic, Panama, and Costa Rica by 1991. Immunization of pregnant mothers against tetanus covered 38% in 1991, up from only 14% in 1983. These programmes partly explain the general decline in the regional IMR, which is estimated to have fallen to a 1990 level of 47 per 1,000 live births, down from 68 in 1975.

There were other positive developments in the health sector. The high coverage of deliveries by trained personnel in the region contributed to the relatively lower levels of maternal mortality, estimated at around 237 per 100,000 live births in 1983 (220 in Caribbean and 240 in Central America) (Panel 6L). In the latest estimates by WHO, the overall regional maternal mortality fell to around 180 per 1,000 by 1988, with dramatic declines, particularly in Mexico. These are levels which are about one-half those seen in Asia and only one-third of those in Sub-Saharan Africa.

Generally, initiation and duration of breastfeeding probably improved during the 1980s - this was demonstrated in Mexico.

Another factor associated with the relatively better nutrition of children in the region is the high literacy levels of women - above 90% in Costa Rica and Mexico, and about 75% in the Dominican Republic, Guatemala, and El Salvador. The average female enrollment in the secondary schools was 49% in 1990, up from 34% in 1975. The female literacy rates are very high. One striking characteristic of education in the region is that there are virtually no differences between male and female literacy rates in most of the countries.

Recent statistics indicate that the proportion of female-headed households is rising in some parts of the region. In Cuba, statistics available for the mid-1980s indicate that 28% of households are female-headed, 44% in Barbados, 25% in Trinidad and Tobago, 18% in Costa Rica, and 15% in Guatemala. In the Dominican Republic, it was shown from recent studies that children in female-headed households tend to be more at risk of malnutrition compared to male-headed households; but the opposite has been indicated in Jamaica.

Improvements in nutrition slowed down in the latter 1980s, in line with economic problems. Future prospects depend heavily on restarting economic growth. At the same time, the extensive outreach of health care, and relatively good access to food, as well as falling fertility rates, are factors in favour of renewed improvements in nutritional status. On the other hand, levels of malnutrition as measured by underweight children are already relatively low, and bringing these down to the levels of developed countries may require more effective targeting of existing programmes, and special efforts of outreach to the remote and the poor.

Panel 6 MIDDLE AMERICA AND CARIBBEAN

POPULATION

A. Million, log scale

CHILD GROWTH AND SURVIVAL

B. Underweight preschool children

C. Infant mortality rate

ECONOMICS

D. GNP per capita

E. Debt service ratio

FOOD

F. Dietary energy supply

G. Underfed population

HEALTH

H. Immunization coverage

I. Access to health services and potable water

J. Low birth weight

WOMEN’S STATUS AND CARING CAPACITY

K. School-age females in secondary school

L. Maternal mortality rate

M. Total fertility rate

South America

(Panel 7)

The underlying trend in nutrition in South America was for definite improvement in me late 1970s, slowing substantially in the 1980s, or even becoming static in some countries. Direct assessments from national surveys in Brazil, 1975 and 1989, were of considerable importance in identifying long-term improving trends in child growth in the region. The likelihood is that much of the improvement was in the first part of this period, and in fact recent economic problems may threaten to reverse some of the gains (Panel 7B). Falling underweight prevalences were directly observed in Bolivia, Colombia, and Venezuela, and in Chile there was a steady reduction in IMRs; these generally occurred in the face of economic hardship, and are in line with the Brazil results. Thus despite severe economic shocks in the 1980s, the region showed remarkable resilience in terms of nutrition. Part of the reason may be that underlying trends in literacy, in health infrastructure, and in falling fertility rates (Panel 7M) protected nutrition. Certainly, the nutrition results are in line with observations of infant mortality rates (Panel 7C).

The level of underweight prevalence is the lowest of the developing world, around 8%. Noting that 2.5% prevalence is expected in developed countries and in the standards, there is not far to go in the region, on average, before child growth failure as a widespread problem is a thing of the past. On the other hand, there are large areas and populations, such as North East Brazil, which remain highly vulnerable, and events in the next several years will determine what happens. Absolute numbers of underweight children remained practically the same at around three million during the 1980s.

Overall, regional rates of low birth weight were estimated at 12% in 1983 and declined to 10% in 1990. Estimates by WHO/UNICEF indicate some improvements in Bolivia between 1983-85 to 1988-91, and remain unchanged in Chile, Paraguay, and Venezuela.

Infant mortality rates in the region in 1990 were estimated at 55 per 1,000 live births, compared to 61 in 1983 and 75 in 1975. Although the levels attained in Chile (20 per 1,000 in 1989) parallel those in many developed countries, other countries in the region have very much higher rates. Bolivia, for example, is reported at 110 per 1,000 in 1989, the highest in the South American region. Peru’s IMR is also high at 88 per 1,000.

The economic shocks in the early 1980s, brought about by the debt crisis and international recession, deeply affected the economic well-being of many South American countries. Brazil, Bolivia, Chile, and Colombia faced crises before 1985, followed by Argentina, Ecuador, and Uruguay. Brazil, for example, had a falling real per caput GDP between 1980 and 1984, which recovered to the level of 1980 by 1988; hyperinflation began in 1987, although food prices, if anything, fell as a proportion of the consumer price index. Structural adjustment programmes were introduced in many countries, aimed at reducing imports and government expenditures, in order to stabilize economic conditions and restructure the economies to higher growth paths. Most countries had extremely high debt service ratios - the regional average rising as high as 65% in 1982, and subsequently falling. This peak of 65% debt service ratio was substantially higher than any other region, the nearest being Middle America in the late 1970s, reaching nearly 55%.

With national incomes fluctuating throughout the 1980s, and hardly increasing on average, the population in poverty also varied. Studies by me World Bank indicate that the level of incidence of poverty in Brazil rose from 17% in 1980 to 30% in 1983 at the start of the structural adjustments, then fell later to around 24% in 1987. Other studies (e.g., ECLAC, 1990), using a different cutoff, indicated, however, that there was virtually no change comparing 1979 and 1987 in Brazil, nor in Colombia, but rising poverty in Peru, Venezuela, and Uruguay in the same period. Rural areas appear to have been disproportionately affected by the rise in poverty in the latter countries.

FAO’s recent estimates indicate mat the proportion of underfed populations increased slightly in the 1980s - averaging 12% to 13%. Overall, regional food supply per capita recovered from a severe slump in 1985. The calorie availability estimated by FAO indicates a regional level of calorie per capita of 2,670 in 1990, up slightly from 2,600 calories in 1985. These averages hide considerable variations of consumption patterns among and within countries. While Brazil, Ecuador, and Colombia had higher calorie availability in 1989 compared to 1980, Chile, Paraguay, and Venezuela suffered slight declines. For the first time in 20 years, Bolivia’s calorie availability per capita fell below 2,000 per day in 1989.

The structural adjustments also had the effect of contracting total social spending of the public sector, although most recovered. Central government expenditures on health (as a percentage of total expenditures) were protected in some countries, while in others, the levels were restored following cutbacks in the early years of the crisis. PAHO (1990) reported that public health services were not curtailed during me crisis, and scarce resources did not generally translate into fewer consultations or admissions.

Panel 7 SOUTH AMERICA

POPULATION

A. Million, log scale

CHILD GROWTH AND SURVIVAL

B. Underweight preschool children

C. Infant mortality rate

ECONOMICS

D. GNP per capita

E. Debt service ratio

FOOD

F. Dietary energy supply

G. Underfed population

HEALTH

H. Immunization coverage

I. Access to health services and potable water

J. Low birth weight

WOMEN’S STATUS AND CARING CAPACITY

K. School-age females in secondary school

L. Maternal mortality rate

M. Total fertility rate

For many countries, it was reported that governments faced with serious cutbacks in available resources were able to increase the efficiency of public services, such as those of health and nutrition. In Peru, for example, 84% of preschool children and 77% of primary school children were covered by some form of food aid or supplementary feeding programmes in mid-1980s, while only 13% of preschool children were underweight. Overall regional coverage by supplementary feeding for preschoolers was about 50%, and 64% for primary school children, in the 1980s. This implies a large scope existed for re-targeting in the face of fiscal constraints without necessarily jeopardizing the outreach to the 8% of underweight preschoolers in the region as a whole.

Health care coverage also was reported to have been relatively protected during the economic difficulties of the 1980s. From a survey of several countries in the region, WHO reported that most did not curtail coverage between 1984 and 1990. Levels of coverage remained high, around 95% in Chile, 88% in Colombia, and 80% in Ecuador. Immunization against measles actually increased overall for the region (Panel 7H), from 54% in 1983 to 77% in 1991 - reaching near universal coverage levels for Argentina and Chile and above 80% for Colombia and Uruguay, but lower in Bolivia, Peru, and Ecuador. The number of pregnant women immunized against tetanus increased by nearly threefold between 1983 and 1991. Immunization against polio, BCG, and DPT improved in coverage.

Maternal mortality rates declined from 290 per 100,000 live births in 1983 to 220 in 1988, according to recent data from WHO. This trend can be partly explained by the increase in the proportion of women receiving antenatal care by trained personnel (for example 49% in 1983 compared to 71% in 1991 in Ecuador, 46% to 60% in Peru) and the proportion of women receiving delivery care by trained personnel, which rose from 69% to 82% in Paraguay, and was maintained at 93% level in Chile, and 73% in Brazil, in the same period. Fertility rates continued to fall during the 1980s, from around four births per women to just over three. This had multiple benefits for women themselves, and, as dependency ratios declined, for households, with the possibility of channelling more resources to each child.

Breastfeeding initiation and duration tended to increase between the 1970s and the 1980s (comparing WFS and DHS). Moreover, the positive benefit of education was again seen, the improving trends in breastfeeding being greater in the better educated groups. For example, in Peru, the median duration of breastfeeding remained at around 11 months in urban areas and 19 months in rural areas, but this measure increased from 12 to 16 months in those mothers with four to six years education, and from six to ten months in those with seven plus years. Similar patterns were seen elsewhere.

Female literacy in the region is among the highest in the developing world (above 75%), and the trends appear to be improving, given the increasing percent of female enrollment in the secondary schools, e.g., in Chile 74% in 1990 compared to 55% in 1980, in Uruguay from 60% to 74% in the same period. There is a slight difference in literacy between males and females, but not as high as most other developing regions in the world.

If the trend of improvement in the 1970s were restarted in the 1990s, the problem of underweight children would be solved before the end of the century. Already, countries such as Chile, Venezuela, and Paraguay have virtually contained the problem. The prospects are likely to be determined by the strength of the recovery from the debt crisis. Perhaps, too, the benefit from the decline in fertility has bottomed out already. Adjustments “with a human face” comprise much of the restructuring that continues in the region. The WB and IMF have encouraged governments to put aside a substantial portion of budgets from other sectors (for example, proceeds from the privatization schemes) into “social funds” to be used to protect vulnerable groups. Brazil, Bolivia, and Venezuela are examples of such countries. For the most part, the response of governments in the region to economic crisis were responsible for the protection of nutrition.

This region would then become the first among developing countries to have effectively dealt with its problems of undernutrition. Much depends upon continued stability and economic growth. Underlying conditions are good, in terms of health infrastructure, falling fertility rates, and high immunization rates, as well as a relatively good food availability. On the other hand, many countries in South America were badly affected by economic recession in the 1980s, and it is important that the recovery of the late 1980s continues. Better targeting of available resources will be important. The concern is that there are large areas, such as North East Brazil and the Andean altiplano, that are relatively much poorer and less accessible than the rest of the region. These may lag behind the development elsewhere, with continuing nutritional problems.


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