Remarks by Kul Chandra Gautam
At pre-conference workshop on
Interventions to improve maternal and newborn nutrition in Nepal
Eighth Conference of the Perinatal Society of Nepal (PESCON)
Kathmandu, 25 November 2011
I feel greatly honoured to be invited to attend this important workshop on the eve of the Eighth International Conference of the Perinatal Society of Nepal (PESCON).
But as a non-medical person, I also feel awed to address such a distinguished group of medical professionals and specialists from Nepal and elsewhere. I hope you will forgive me for my lack of specialist knowledge and expertise. I am after all, a policy quack in front of real doctors.
Since I worked with UNICEF for over 3 decades, my general interest in maternal and child health and nutrition is long-standing. But my real appreciation of the vital importance of the perinatal period dates from about a decade ago.
Earlier, I had the good fortune to be involved in a major global child survival and development campaign in the 1980s and early 90s that UNICEF spear-headed under the visionary leadership of Jim Grant, the head of UNICEF at the time.
The campaign initially started as GOBI – comprising growth monitoring, oral rehydration therapy, breast feeding and childhood immunizations.
We believed that if coverage of those low-cost, low-tech services could be expanded dramatically, there would be drastic reduction in child mortality and improvement in child health.
Making Child Survival Political Priority
Buoyed by some remarkable early successes, especially to expand childhood immunization and ORT, we managed to convene a World Summit for Children in 1990. That became the largest Summit of top world political leaders in history until that time.
Attended by 71 Heads of State and Government, and many other senior ministers, the Summit came up with an ambitious Declaration and Plan of Action for the Survival and Development of the world’s children, with a set of time-bound and measurable goals and targets to drastically reduce maternal and child mortality, malnutrition, illiteracy, to expand coverage of basic education, water and sanitation and to ensure protection of children from violence, abuse and exploitation.
I was designated as the senior UNICEF official in charge of drafting that Declaration and Plan of Action for the world leaders.
Working closely with senior officials of other UN agencies, including the World Health Organization, we came up with many ambitious goals such as eradication of polio, elimination of tetanus, drastic reduction of measles and malnutrition, a major effort to reduce micronutrient deficiencies, including eventual elimination of iodine deficiency disorders, vitamin A deficiency, iron deficiency anemia, etc.
It is normal for Ministers of Health to deal with such issues, as they do at WHO, but we actually managed to get Presidents and Prime Ministers, Kings and Finance Ministers to pay personal attention to improving the health, nutrition and well-being of children and mothers.
Spurred by the UN Convention on the Rights of the Child, which quickly became the world’s most universally ratified human rights treaty in just a few years, there was vigorous follow-up of the World Summit at the country level.
Progress achieved was impressive. From being just a sectoral issue handled by a usually weak and under-funded ministry of health, maternal and child health became a political priority in many countries.
There was a virtual child survival revolution. Under-5 deaths in the world declined from some 18 million per year in the early 1980s to about 12 million by mid-1990s, and today we are down to less than 8 million.
Childhood immunization rates in developing countries increased from less than 20 percent to over 80 percent. There was massive increase in coverage of ORT, essential drugs, vitamins and minerals.
Stories of progress in child survival received great media coverage. We had famous film stars, sports personalities, religious leaders championing child survival and global health issues. Even Bill Gates joined the bandwagon with his billions of dollars to promote vaccines and immunization.
In other words, we made child survival not just a health priority but a political and development priority.
So when world leaders met again at the historic Millennium Summit at the United Nations in 2000 and adopted the Millennium Development Goals, maternal and child health-related goals became the centre-piece of their commitment.
This was great cause for celebration for all of us who were deeply committed to the health of women and children – which ultimately is the foundation for the health and wealth of all nations, and of humanity at large.
Against this hopeful background, as we used to monitor progress in MDGs and the World Fit for Children goals, in the early 2000s we began to see a worrying trend.
The pace of progress in the reduction of child mortality was beginning to slow down, and maternal mortality rates hardly improved despite significant increase in funding and awareness since the Cairo International Conference on Population and Development.
Centrality of Neo-natal Mortality
As we examined more closely the data on under-5 mortality, it became clear that while deaths in the older children of the 1 to 5 years of age had declined significantly, the pace of decline in deaths of infants below one year of age was slower, and at the neonatal period it was very slow indeed.
Thus the bulk of under-5 deaths in developing countries – nearly a third or more were concentrated in the neonatal period. We were beginning to see a similar pattern in developing countries as we saw in the industrialized countries where most child deaths occur in the neonatal period.
It seemed we had already plucked the “low-hanging fruits” of the more easily achievable reductions in child deaths, and were now confronted with the harder to achieve reductions in neonatal deaths.
Neonatal deaths were, of course, very closely linked with maternal health and nutrition, and there really had not been any notable breakthrough in those areas.
All indicators suggested that countries with the highest burden of mortality and ill health made the least progress on MDGs 4 and 5.
On MDG-5, for example, there had been some progress in reducing maternal deaths in developing countries, but not in the countries where giving birth was the most risky.
There were three separate multi-agency partnerships in the 1990s, early 2000s – one dealing with child survival, another with safe motherhood, and a third one aimed at saving new-born lives.
Each of these partnerships was contributing to some progress, but none of them was making a dramatic enough dent to achieve their stated goals. Sometimes they were seen as competitive rather than collaborative.
In the early 2000s, in a series of special editions, the British medical journal, The Lancet brought out compelling evidence and analysis showing how much more progress could be made to reduce maternal, newborn and child mortality using already existing low-cost solutions.
This evidence challenged and inspired many of us involved in the three partnerships that further progress required us to adopt a different approach, which came to be known as the “continuum of care”.
“Continuum of Care” and PMNCH
So some of us from UNICEF, WHO, UNFPA, the World Bank, USAID, the Canadian CIDA, the Norwegians, the UK’s DFID, the Gates Foundation, etc. got together several times to map out a strategy for pursuing the “continuum of care” idea that would encompass maternal, newborn and child health in a seamless continuum.
Eventually we agreed to merge the three existing partnerships and create a new one, called the “Partnership for Maternal, Newborn and Child Health, or PMNCH.
As you know, it is not easy to dismantle existing organizations to create a new one. There are strong vested interests, as well as some real strengths and merits of more focused partnerships that can be lost in broader, less focused partnerships.
It requires some courage and vision, and real spirit of compromise and willingness to sacrifice some small advantages for the sake of the larger good.
I was made the convening Chair for PMNCH to help conceptualize its mission and mandate, structure and working modalities. After prolonged but productive negotiations over a two year period, and securing the support of the heads of all participating agencies, we launched PMNCH at UNICEF HQ in New York, and established its Secretariat at WHO HQ in Geneva in 2005.
I remained the Chair of PMNCH Board until I retired from UNICEF at the end of 2007.
Besides, UN agencies and key bilateral donors, we also involved a number of developing countries, and NGOs such as Save the Children, Family Care International, FIGO, and some academic institutions in the Board of PMNCH.
Tracking progress of countries towards the achievement of MDGs 4 and 5 is an important part of PMNCH and its members. A key to this undertaking is the Countdown to 2015 Initiative which measures progress towards MDGs 4 and 5 in 68 priority countries which represent 97% of all global maternal and child deaths.
The Initiative also monitors coverage of basic health services proven to reduce maternal and child mortality, and assesses allocation of domestic and donor resources, the strength of health systems, the status of policies related to maternal, newborn and child health, and how equitably health services are distributed.
The Countdown also works to create accountability amongst governments and development partners and identifies knowledge gaps and proposes new actions to reach MDGs 4 and 5.
PMNCH got early visibility and support as we helped when British Prime Minister Gordon Brown launched the International Health Partnership, and the Norwegian Prime Minster Jens Stoltenberg spearheaded a Global Campaign for Health MDGs.
Global Strategy for Women’s and Children’s Health
More recently, United Nations General-Secretary, Ban Ki-moon launched the ‘Global Strategy for Women’s and Children’s Health’ that sets out how we can work together to accelerate progress to save the lives and improve the health of women and children.
PMNCH played a key role in helping to prepare the Global Strategy which was launched at the time of the UN Leaders’ Summit for the Millennium Development Goals in 2010, where some US $ 40 billion were pledged in support of the strategy to drastically reduce child mortality and improve maternal health.
To show his seriousness in implementing the ‘Global Strategy for Women’s and Children’s Health’, the Secretary-General formed a Commission on Information and Accountability and an Expert Review Group that monitors progress on MDGs 4 and 5.
Every year the Secretary-General proposes to hold a high level meeting of leaders attending the General Assembly to hold them accountable for real progress. He makes it a point of reviewing progress on women’s and children’s health when he visits various countries.
Now, why would the Secretary-General of the United Nations pay so much personal attention to MDGs 4 and 5, when he has so many other pressing issues to deal with – from war and peace, human rights and economic issues, HIV/AIDS, to environment and climate change?
It is because he realizes, as we all do, how important it is to ensure the survival and development of children, and the closely linked health and nutrition of mothers – as the foundation for all other developments, for achievement of all other MDGs, and for the enjoyment of a good quality of life that we all desire and cherish so much.
Ensuring child survival is the first marker of human civilization. If you don’t survive, nothing else counts.
If parents cannot even protect the lives of their children, how can they be expected to care about protecting their community and their nation, the earth and the environment?
So ensuring the survival of mothers, newborns and children is therefore our first duty, above anything else.
Of course, we want our children not just to survive but to thrive. But whether or not a child will survive and thrive is determined long before the foetus is implanted in the mother’s womb.
Life-cycle Approach and the Golden 1000 Days
If a woman was herself born low birth-weight, stunted and malnourished, was married early and did not have proper nutrition and care during pregnancy, it is almost certain that her new-born baby will inherit similar characteristics and the cycle of ill health, malnutrition, poor educational attainment and a life in poverty will be perpetuated.
To turn this vicious cycle into a virtuous cycle, we need to take a life-cycle approach to improve maternal and child health and nutrition; with particular emphasis on the critical 1000 days “window of opportunity” from the onset of pregnancy to the first 24 months of a child’s life.
You all know better than I do, how poor nutrition in uterus and early childhood can lead to death, impaired brain development, poor cognitive and educational performance, poor physical growth, weakened immunity, higher incidence of chronic degenerative diseases of adulthood, diabetes, obesity, heart disease, high blood pressure, cancer and stroke.
The impact of poor nutrition and health can cause irreversible brain damage, diminished learning capacity, reduced economic productivity, diminished quality of life for the child, and high economic and social burden for the family and society.
MDGs 4 and 5 therefore must not be considered just as health goals, but as Mother of all MDGs, as the foundation for all development efforts.
If our leaders do not recognize that, they are ignorant, and it is our duty to try to impart this very basic knowledge to them.
So dear friends, please do not be satisfied with what you do as doctors and nutritionists performing highly specialized technical functions.
We all have a double duty – to do our professional jobs well, but also to perform a most important educational function as enlightened citizens to enlighten others on the vital and crucial importance of the continuum of care not just for maternal and child health but for broader human and national development.
Nepal’s Progress on MDGs 4 and 5
From this general global picture, let me now turn to Nepal, and our progress and challenges.
I know you are going to have some in-depth, specialized presentations on Nepal by highly knowledgeable experts during this pre-conference and conference in the next few days. I would therefore only touch upon a few general policy issues.
Nepal has made fairly good progress in terms of the child-related MDGs, with the exception of malnutrition.
In fact, it is one of the few least developed countries (LDCs) in the world that is on track to achieve most of the MDGs.
Four decades ago, the situation of Nepal’s children was among the worst in the world. While there is still much progress to make, the achievements made so far have been quite impressive.
The children of Nepal today are healthier, more educated, and more knowledgeable about the world, than in any previous generation.
In 1970, Nepal had the 12th highest child mortality rate in the world. By last year, we had moved ahead of 50 other countries, reducing U5MR down by 80% from 250 to 48 deaths per thousand live births.
Four decades ago, 400,000 children were born every year, but 100,000 of them died before reaching their 5th birthday. Last year, 730,000 children were born, but less than 34,000 died.
Nepal is on track to achieve the goal of reducing maternal mortality ratio by 3/4ths, with MMR having gone down from 850 per 100,000 live births in 1990 to 229 in 2010.
Increased use of contraception, improved access to antenatal care and delivery care by trained health workers, and easier access to abortion services, among other things, seem to have contributed to the good progress in reducing MMR.
In 2010 Nepal even received a UN award for its success in reducing MMR.
It is especially remarkable that Nepal made great strides in reducing both maternal and child deaths even in the middle of a violent conflict in the last decade.
Thanks to this progress, Nepal is on track to reach MDGs 4 and 5, to drastically reduce under-5, and maternal mortality.
In our life time, we have seen dreaded diseases like smallpox and polio eradicated; deaths due to measles drastically reduced; goiter disappear, and immunization services for children becoming virtually universal.
That is the good news. But like we saw globally, we have now plucked most of the “low-hanging fruits” of more easily achievable health and nutrition interventions. We now have the toughest tasks ahead to make further progress.
NNMR at Centre-stage of U5MR in Nepal
Between 1991 and 2010, Nepal’s U5MR went down from 153 to 54 deaths per 1000 live births, and thus Nepal has already achieved MDG 4, five years ahead of the deadline. We can celebrate this good news.
In terms of IMR, it went down steadily from 102 to 46, but it will be quite challenging to reach 34 by 2015, which is our sub-target for MDG-4.
In the case of NNMR, it declined from 46 to only 33. But even this progress was uneven – as it actually went up from 46 to 50 between 1991 and 1996, and it has remained stagnant at 33 between 2006 and 2011.
It will be extremely difficult, if not impossible, to reduce the NNMR down to our MDG-4, sub-target of 15 by 2015.
As we can see, NNMR’s share of U5MR has been steadily increasing, and currently NNMR accounts for 52% of U5MR. To achieve any further significant reductions in U5MR in the future, we have to learn how to tackle some of the most key determinants of NNMR.
There are some social, medical and nutritional interventions that are key to further progress in reducing NNMR.
Key social interventions would include raising the status of girls and women in our society; ensuring that more girls go to school and stay there longer, thus reducing the chances of early marriages and teenage pregnancies which increase the risk of untimely death of both the mother and the child.
As there are huge disparities in the levels of MMR, U5MR and NNMR among people of different geographic regions, income groups, and sometimes caste and ethnic groups, we also need a more equity-focused development approach to make further progress in reducing NNMR.
Among key medical interventions that need to be further improved, we can list:
– control of infections which seems at the top of the list as the major killer in the neonatal age group,
– significantly increasing institutional delivery (currently 81% of births take place at home),
– increased deliveries assisted by skilled birth attendants (currently only 19%),
– the need to scale up birthing centers and birth preparedness packages,
– improved emergency obstetric care services,
– and you would know better than I, other important medical and surgical interventions.
But a key point I would like to emphasize is the need to follow the “continuum of care” approach both in terms of timing of interventions for the survival and health of newborns, access to health care for young children and their mothers before, during and after pregnancy, and to ensure that the health care system reaches women at home, in the community and in basic health facilities.
Malnutrition – the Greatest Challenge for Nepal’s Development
Perhaps the biggest and most critical set of interventions needed, are in combating malnutrition which account for a quarter of all perinatal deaths. And it increases the risk of overall child and maternal mortality by some 60% in poor countries like Nepal.
Malnutrition also diminishes learning capacity, and lowers economic productivity of the affected individuals as adults in later life, ultimately reducing GDP of poor countries like Nepal by at least 3%.
Malnutrition needs to be tackled in a serious, life-cycle approach, and in a multi-sectoral manner, as it encompasses issues of poverty and cultural practices, the status of women, inadequate household food security, poor maternal intake, poor maternal nutrition status, inadequate foetal growth, stunting, micronutrient deficiencies and proper infant and young child feeding.
For this, Nepal needs to systematically adopt and apply interventions that are considered critical during the 1000 days “window of opportunity” to tackle malnutrition.
During a high level Scaling Up Nutrition (SUN) meeting at the United Nations in New York in September 2011, the Nepalese Prime Minister made a strong statement highlighting both the progress made to date and where additional efforts are needed.
He stated that nutrition is a high priority for Nepal’s national social and economic growth and achievement of the MDGs.
I sincerely hope that there really will be a sustained high level political commitment to improve nutrition in Nepal.
Frankly, so far I have found that very few of Nepal’s political leaders really understand the complexities of malnutrition. Many simply equate it with availability or lack of food. They often equate malnutrition with hunger and famine like situations.
But as we know, malnutrition is mostly invisible to the naked eye. And so many of our leaders neither appreciate the good progress made, nor are they alarmed by the gravity of malnutrition and its consequences.
It comes as news to many of our political leaders when they hear from foreigners that Nepal has a very good track record on micro-nutrients. It is one of the world leaders on high coverage of Vitamin A, household use of iodized salt, iron folic acid supplementation to pregnant women, and introduction of zinc supplements and multiple micronutrient powders.
Nepal has also made a good beginning in the therapeutic feeding and community based management of acute malnutrition, which needs to be significantly scaled up.
Most leaders of Nepal do not recognize that chronic and acute malnutrition in children remains at critical levels, with wide economic and geographic disparities.
So here again, those of us from the health and nutrition community have a major educational task to brief and convince politicians and policy makers of the vital importance of combating malnutrition.
To its credit, the Nepalese Government has recently taken some key steps to fight against the persistently high levels of malnutrition and growing nutrition inequity.
It has done so by adopting a multi-sectoral approach to address the immediate, underlying and basic causes of under-nutrition – with a particular focus to reach the marginalized, poorest and the excluded groups through social protection measures like child cash grant.
This is to be commended.
A comprehensive nutrition assessment and gap analysis (NAGA) back in 2009 had recommended that Nepal should build a National “Nutrition Architecture” for policy guidance, leveraging resources and monitoring effective implementation.
Another recommendation was to address the five determinants of malnutrition which are – food availability, food affordability and accessibility, quality of food, feeding behaviors, and care practices, and control of infections through a multi-sectoral approach.
As recommended by the NAGA study, recently a High Level Nutrition and Food Security Steering Committee has been formed under the chairmanship of National Planning Commission Vice Chairperson, with Secretaries of relevant ministries as members.
It has been proposed that at the district level, there will also be multi-sectoral nutrition and food security coordination committees housed within the District Development Committees.
Currently efforts are underway by Nepal to develop a multi-sectoral food and nutrition strategy under the leadership of the National Planning Commission but involving senior representatives of half a dozen ministries with specific division of labour.
This is a welcome development, strongly supported by a consortium of international donors.
Increasing inequality has now become the bane of Nepal’s development efforts in all sectors. Even where there has been good progress on average, for example, on the very high prevalence of stunting, we see very marked inequality.
Thus, while the overall stunting prevalence went down from 50% to 36% between 1996 and 2006, the reduction among the richest quintile was an impressive 65%, while there actually was an increase of 12% in stunting among the poorest quintile.
We notice similar disparities geographically – with stunting in eastern Terai at 37%, compared to a staggering 67 % in mid and far-western hills.
Indeed, of all the inequities in the world, the greatest inequity is found in maternal and child deaths.
Some 8.5 million children and women die every year in the world. If all those women and children were born and lived in the industrialized countries, 99 % of them would survive and thrive.
Surely the women and children of the 21st century deserve much better than such cruel death sentence on a mass scale.
We all owe it to them to marshal the best of science and technology, public policy and human solidarity, to help build a world that is truly fit for these most vulnerable members of our society now, and for future generations.
Let us all strive to make a compelling, moral, ethical, political, economic and human rights argument in support of the right of these most vulnerable women and children of the world whom all of us, and our governments must feel duty-bound and accountable.
Members of the Perinatal Society of Nepal, and their counterparts across the world are already playing a most constructive role in this regard, but I know we can and need to do more.
I wish you all great success in this noble mission.