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Enriching Lives: Overcoming Vitamin and Mineral Malnutrition in Developing Countries

The following Executive Summary is taken from the World Bank publication Enriching Lives: Overcoming Vitamin and Mineral Malnutrition in Developing Countries. Publication information and ordering instructions are available.

The control of vitamin and mineral deficiencies is one of the most extraordinary development-related scientific advances of recent years. Probably no other technology available today offers as large an opportunity to improve lives and accelerate development at such low cost and in such a short time.

Dietary deficiencies of vitamins and minerals—life-sustaining nutrients needed only in small quantities (hence, "micronutrients")—cause learning disabilities, mental retardation, poor health, low work capacity, blindness, and premature death. The result is a devastating public health problem: about 1 billion people, almost all in developing countries, are suffering the effects of these dietary deficiencies, and another billion are at risk of falling prey to them.

To grasp the enormous implications at the country level, consider a country of 50 million people with the levels of micronutrient deficiencies that exist today in South Asia. Such a country would suffer the following losses each year because of these deficiencies:

  • 20,000 deaths
  • 11,000 children born cretins or blinded as preschoolers
  • 1.3 million person-years of work lost due to lethargy or more severe disability
  • 360,000 student-years wasted (3 percent of total student body).

In terms of losses by type of deficiency, more than 13 million people suffer night blindness or total blindness for the lack of vitamin A. In areas without adequate iodine in the diet, five to ten offspring of every 1,000 pregnant women are dead upon birth or soon thereafter due to iodine deficiency. Severe iron deficiency causes as many as one in five maternal deaths, as well as the death of about 30 percent of children who enter the hosital with it and do not get a blood transfusion (those who do get the transfusion are exposed to other risks).

The World Bank's World Development Report 1993 found micronutrient programs to be among the most cost-effective of all health interventions. Most micronutrient programs cost less than $50 per disability-adjusted life-year (DALY) gained. Deficiencies of just vitamin A, iodine, and iron¾the focus of this book¾could waste as much as 5 percent of gross domestic product, but addressing them comprehensively and sustainably would cost less than 0.3 percent of gross domestic product (GDP).

The 1990 Summit for Children endorsed three micronutrient goals for the end of the decade: the virtual elimination of iodine and vitamin A deficiencies and the reduction of iron deficiency anemia in women by one-third. The goals were reaffirmed in 1991 at the Ending Hidden Hunger conference and in 1992 at the International Conference on Nutrition. The goals are achievable only if political will, state-of-the-art technology, and private, public, and international resources are marshaled for the effort.

The Need for a Comprehensive Approach

The alleviation of poverty and the strengthening of national health care systems alone cannot solve the problem of micronutrient deficiencies. Because the micronutrient content of foods is a hidden property, consumers do not automatically demand micronutrient-rich foods with increased income. Thus, food and agriculture policies need to watch over not only the quantity but the nutritional quality of the food supply and promote the production, marketing, and consumption of micronutrient-rich foods. Likewise, safety net programs, including refugee feeding, must respond to the total nutritional needs of target groups and not just to their calorie and protein needs.

An overall improvement in health system management will go a long way toward improving micronutrient malnutrition as long as programs train and monitor medical personnel for the prevention and management of micronutrient deficiencies, reach groups not currently using the health care system, and, through teaching and persuasion, transform consumers into a constituency for healthful diet.

Three Types of Approaches

Even with the most nutritionally enlightened economic development plan, developing countries must still take direct aim at micronutrient malnutrition through consumer education, aggressive distribution of pharmaceutical supplements, and the fortification of common foodstuffs or water.

Fortunately, all of these options are inexpensive and cost-effective. The particular mix of interventions chosen depends on country conditions. But the key constraints to achieving the summit goals are a lack of awareness and commitment of policymakers and consumers, a weak capacity to deliver supplements and education, and a lack of enforcement of industry compliance with fortification laws.

Social Mobilization

Policymakers must be motivated to take action against micronutrient malnutrition. They need persuasive information on the economic and social costs of micronutrient malnutrition and on the political salience and cost-effectiveness of micronutrient programs. Then, during implementation, good management information systems and public education programs designed into the overall initiative can make the public aware of the improvements resulting from the micronutrient programs and draw the connection to the responsible program managers and policymakers. That connection provides public support and reward for the initiative of the political leaders.

Beyond the immediate political feedback they provide, programs to educate, persuade, and change the behavior of consumers are essential to the long-run elimination of micronutrient deficiencies. Subconscious consumer demand for micronutrients needs to be made conscious and directed to appropriate foods and pharmaceuticals. This demand will serve as a "pull" factor to bring the target groups to distribution points for supplements, to overcome resistance, and, if necessary, to induce consumers to pay a little more for a better (that is, a fortified, although unfamiliar) diet. Social marketing of micronutrients and micronutrient-rich foods is necessary in virtually all developing countries, even where health service delivery is good and the food industry is well developed.

Pharmaceutical Supplementation

Two key problems in pharmaceutical supplementation have been poor coverage of at-risk groups and inadequate supply management. To overcome the coverage problem, the delivery of supplements must break out of a single- clinic-based track and employ every possible avenue of convenience and opportunity, including school visits, workplace programs, and nutritional safety net programs.

The goals of supply management are to procure effective supplements that look appealing, have helpful packagig and labeling, come in the right doses, and are affordable; to store and transport them for maximal quality and preservation; and to deliver them to well-selected distribution points in adequate numbers of doses at an appropriate frequency. Achieving these goals requires committed program leaders, motivated and well-trained workers, good monitoring and surveillance, and a demanding public. The private pharmaceuticals market may have an important role to play in developing new products and delivering supplements in a cost-effective manner at the community level.

Effective Regulation and Incentives for the Private Food Industry

The food industry responds to both positive and negative policy signals. Broad legislation, followed by technical regulations, should require micronutrient fortification of basic foodstuffs and support a fair and honest regulatory system that monitors compliance and punishes the noncompliant.

This legislation should be joined by financial and political inducements to industry. Some of the incentives used in effective fortification programs have been tax relief, import licenses, loans for equipment, subsidies on fortificants, and positive press coverage.

A third component of any successful food control system is consumer awareness and pressure for industry compliance. Consumers can be mobilized through social marketing and consumer organizations to demand effective fortification. Without confidence in both the industry and the regulatory apparatus, enlightened consumers will not be willing to buy new products.

Developing Nutritional Awareness and Habits

Political sustainability comes from monitoring and communications as well as satisfaction of consumer demands. One of the greatest advantages of micro nutrient programs is that, because results are unambiguously attributable to specific interventions, policymakers can take credit for improvements.

Operational sustainability depends upon good management, continual oversight, the retraining of personnel, and the supervision of delivery systems (particularly the health system and food industry).

Behavioral sustainability will come only after consumers form good nutrition habits, whether that means eating carrots, taking a daily iron pill, or buying a fortified food.

Economic sustainability is a function of national and household ability to pay. Micronutrients are so inexpensive that, regardless of the form, they should ultimately be affordable by the intended beneficiaries. Fr equity reasons or in the short term, some form of targeted subsidy may be necessary to reach the poorest and to form habits among the desired beneficiaries. In the long run, however, financial sustainability will depend upon consumers' willingness to pay for the nutrients. It is the government's responsibility to choose the most cost-effective means of delivering micronutrients to the population.

The Need for External Start-up Support

Micronutrient interventions are among the most cost-effective investments in the health sector. Because fortification of water and foods is also extremely cost-effective, nontraditional sector involvement is desirable as well. Donors have a key role to play in assisting with program design and financing. Addressing micronutrient deficiencies globally will require an estimated $1 billion per year¾about $1 per affected person (all dollar amounts are U.S. dollars). That figure is equivalent to the economic costs of endemic deficiencies of vitamin A, iodine, and iron in a single country of 50 million people. Most of these costs will ultimately be borne by consumers when purchasing food with higher nutritional quality.

In the short run, however, donors and governments may have to assume a major financial burden for project preparation, start-up costs, and recurrent costs in the early years. The economic and social payoffs from micronutrient programs reach as high as 84 times the program costs. Few other development programs offer such high social and economic payoffs.

December 1994

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