The general picture for Sub Saharan Africa (see Panel 1B3) averages out differing national patterns to show a static trend in underweight prevalence, but this is associated with quite rapidly rising numbers of malnourished children when population growth is taken into account. Results from countries that had repeated nutrition surveys are given in Table 3 (at the end of the paper) and certain results are plotted in Figures 2 and 3. In Kenya and Zimbabwe (Figure 2) improvement in the mid-80's, with relatively favorable economic conditions, and expansion of public services, was followed by drought and recession in the early 90's, reflected in the pattern of prevalence trends. Madagascar suffered hurricane damage and drought in 1992, recovering later. Elsewhere, Zambia probably had deterioration in the late 80's, with political and economic problems, then stabilized (Figure 3). Ethiopia reached the highest underweight prevalences in Africa (47% in 1992) after many years of internal conflict, exacerbated by drought. Eritrea, Mozambique, and Somalia with prevalence estimated at around 40% in 1993, were the next highest, for similar reasons.
Recent estimates of poverty trends in Africa show an increase from 1987-90 (38.5% to 39.3%), with an essentially static situation 1990 to 1993 (39.1%).4 This is consistent with the regional average prevalence trends.
The GNP per capita5 for the region has fallen throughout the last 10 years (see Panel ID), from around US$350 per head in the 1970s to about $300 in the 1990s. While unfavorable weather and drought have contributed, worldwide recession and falling commodity prices have had a major effect; structural adjustment programmes have been undertaken in most countries in the region, having at least short term effects on nutrition for much of the population. The debt service ratio is about 20% for the region, which while less than in the 1980s, still leads to much reduced inflows of badly needed external resources, and squeezes national expenditures for social support.
Figure 2. Trends in prevalence of underweight children from repeated national survey results, 1985-1995
Figure 3. Trends in prevalence of underweight children from repeated national survey results, 1985-1995
A considerable number of countries in the region have experienced civil wars and political unrest that have severely disrupted economies and led to the destitution and displacement of millions of people. Large scale conflicts continue to afflict masses of people in Liberia, Rwanda/Burundi, Somalia, Southern Sudan, and parts of Zaire, while resettlement and recovery proceed but still cause distress in Angola, Ethiopia, and Mozambique.
Estimates of dietary energy supply, as kcals/head/day shown in Panel 1E indicate a fall in food availability around 1990. The peak of underweight prevalence at this time is no doubt in part related to this. Despite the very severe drought in the Horn and Southern Africa in 1991-92 it seems that imports and food aid prevented the average food availability from dropping still further.
The regional IMR in Sub-Saharan Africa remains the highest in the world (see Panel 1C) falling only slowly. The fact that IMR is highest here, although underweight prevalences are lower than in Asia, stresses the point that some causes and consequences of growth failure in children differ by region, for complex reasons; trends across regions, and levels within regions, should be directly comparable.
PANEL 1. SUB-SAHARAN AFRICA
A. Million, log scale
CHILD GROWTH AND SURVIVAL
B. Underweight preschool children (Percent below -2 s.d. weight for age)
C. Infant Mortality Rate (Per 1,000 live births)
ECONOMICS AND FOOD
D. GNP per capita (Atlas US dollars)
E. Dietary energy supply (Kcals per caput per day)
F. Immunization coverage (Percent)
G. Access to health services and potable water (Percent)
WOMEN'S STATUS AND CARING CAPACITY
H. School-age females in secondary school (Percent)
I. Total fertility rate (Births per woman)
Indicators of preventive health measures and health services (Panel 1F & 1G) show a lack of further improvement in the 1990's, in fact a slight deterioration according to the four available indicators. With the lowest coverage of any region, inadequate access to health contributes to poor nutritional performance.
Finally (Panel 1H) female secondary education remains extremely low in Sub-Saharan Africa, with less than 20% secondary school enrollment for girls. Total fertility rate (at nearly six) is the highest of any region and is falling only slowly.
Overall, it is easy to understand in general terms why nutrition has not improved in Sub-Saharan Africa. Knowing how this could be turned around, which is increasingly urgent, is considerably more difficult.