Pakatan Harapan must address previous government’s shortcomings in tackling child stunting — Derek Kok
MAY 15 — The implications of stunting are extremely serious, both for the child and country, if left unaddressed by the present government.
Under the previous administration, only two government initiatives addressed children in the crucial first 1,000 days of their life, but neither address child stunting. Full cream milk powder distribution and Program Pemulihan Kanak-Kanak Kekurangan Zat Makanan (PPKZM) both only address severely wasted and underweight children from poor households. These initiatives are also too narrowly focused on providing food assistance and do not sufficiently address the underlying multipronged causes of stunting.
This is in spite of figures highlighted by the Institute of Public Health’s National Health & Morbidity Survey which puts Malaysia’s stunting prevalence at 20.7 per cent, far worse than West Bank and Gaza (7.4 per cent) and comparable to Iraq’s stunting rate (22.6 per cent) at the end of the American invasion.
The new Pakatan Harapan administration in November 2018 announced that the government will tackle malnutrition through the National Child Wellbeing Roadmap. In its 2019 Budget, the government has allocated RM50 million for treating rare diseases, hepatitis C cases and stunted growth among children.
However, details on these initiatives have been scant beyond the initial announcements.
Stunting is the inability of children to reach their potential height for their age. Beyond just height however, stunting is a serious manifestation of malnutrition that adversely impacts the health, education, and productivity outcomes of children in the future. These consequences of stunting can go beyond one lifetime and transcend future generations. Stunted girls grow up to become stunted adult women, who then give birth to stunted children, thus repeating a vicious cycle of stunting and malnutrition.
Stunting also carries serious social and economic costs for the country. Studies estimate that adults who were stunted as children earn 20 per cent less in their working life than those who were not, while calculations show that countries incur, on average, a 7 per cent per capita income penalty because of stunting.
In my recently published paper ‘Stunting in Malaysia: Costs, Causes and Courses for Action’, I argue that the government must pay more attention to the underlying causes of stunting and not just its direct causes. This is because gaps exist in terms of the mother and child’s access to: (i) household food security; (ii) adequate care and feeding practices; (iii) access to health services; and (iv) the presence of a healthy environment.
With regards to household food security, a recent Unicef study found that 12 per cent of children living in urban low-cost flats have less than three meals a day. 97 per cent of these households say that high food prices prevent them from preparing healthy meals for their children. 1 in 2 households report they did not have enough money to buy food in recent months, with 15 per cent experiencing this frequently.
Care and feeding practices are also unsatisfactory. High anaemia rates suggest that nutrient requirements for women are not being met. On the other hand, 19.2 per cent of Malaysian children aged 6-23 months do not achieve the prescribed minimum meal frequency of two meals a day, while 33.6 per cent of Malaysian children do not consume at least four food groups daily.
On access to health services, only 69.1 per cent of women were booked for antenatal visits in the first trimester, which is a key period for early risk identification. Regular height or length monitoring of children is crucial for stunting detection and prevention, but our interviews indicate this is not always carried out.
Malaysia has an impressive overall performance when it comes to access to water and sanitation, yet gaps still do exist, for instance, in Orang Asli communities.
So what should be done by the Pakatan Harapan government?
It must ensure that any policy intervention to address stunting must address the underlying causes of stunting; be multi-sectoral in approach; and focus on the first 1,000-days of the child.
Firstly, the government must make fighting child stunting a matter of national priority by establishing high-level political mechanisms to drive solutions. These mechanisms should include the involvement of the Prime Minister as chair of a multi-agency steering committee to address child malnutrition; and the establishment of a bipartisan Parliamentary standing committee to monitor the government’s implementation of the National Children’s Wellbeing Roadmap.
Secondly, I propose that the Malaysian government look to implement an unconditional cash transfer programme targeting all children below the age of two years old. A positive link between cash transfers and child nutritional outcomes was found in Brazil, Colombia, Ecuador, Mexico, Philippines, South Africa, Sri Lanka and Zambia.
Cash transfers would impact nutritional outcomes by simply making additional financial resources available for all the underlying determinants of stunting. This is pertinent as the direct financial costs of childrearing are not insignificant. The Employees’ Provident Fund calculated that having just one child in the Klang Valley raises the minimum expenditure needed for a reasonable standard of living by nearly 30 per cent. Common misconceptions surrounding cash transfers, such as how cash promotes dependency and leads to abuse, have also been debunked by extensive evidence.
We should give this cash transfer to children from all households, not just from B40 households for a number of reasons. First, stunting in Malaysia is high across all income levels, not just households in the B40 quartile. Second, targeting all children within the 1,000-day window regardless of household income will prevent exclusion errors that are prevalent in poverty-targeting schemes. A study reported that even the best programme excluded more than half of the poorest 20 per cent of households; others exclude even more. Furthermore, unintended consequences can arise from poverty targeting as seen in the Philippines, where stunting rates rose an average of 11 percentage points among non-beneficiary children who were excluded from the cash transfer scheme due to income.
A universal scheme would indeed cost more than a poverty-targeted initiative. However, it is not necessarily expensive. Unicef Malaysia’s calculations of a universal transfer of RM 200 monthly do not even reach 1 per cent of Malaysia’s GDP and government expenditure. Such a scheme can be financed by reallocating current fuel subsidies, ring-fencing revenue from the recently announced sugar tax or other ‘sin’ taxes, and the consolidation and abolition of costly but ineffective existing programmes.
The ‘invisibility’ of stunting in Malaysia coupled with Malaysians’ poor health literacy also highlight the need for a nationwide mass communications campaign on stunting and nutrition. Current nutrition campaigns rarely explain stunting, its impact on children’s health and development, nor the 1,000-day critical window. Instead, there is a heavy focus on obesity and non-communicable diseases. That only 6 per cent of Malaysians possess adequate health literacy hint at the ineffectiveness of these campaigns.
A low-cost but highly effective tool to complement a large-scale communications campaign are home-based growth charts, also known as length mats. Length mats provide parents, caregivers and healthcare workers with a visual aid to see if a child is growing healthily for their age.
Length mats are no substitute for regular height monitoring and plotting, but can be an excellent tool to raise awareness on nutrition and stunting. In Zambia, researchers reported that stunting rates were reduced by 22 percentage points when parents were provided with full-sized growth charts that included information about nutrition. In contrast, the same study reported that community-based growth monitoring with nutritional supplements did not have a statistically significant impact on stunting rates, despite it being led by trained health professionals who provided food supplements and nutritional advice to caregivers.
While complex, stunting rates can be reduced. Evidence shows that even short-term nutritional improvement within the first 1,000-days can result in a mean gain in adult height of 8 cm greater than mean parental height – in just one generation.
Our children are the leaders of tomorrow, but our work to guarantee that needs to start today.
* Derek Kok is Research Associate at the Jeffrey Cheah Institute on Southeast Asia and the Jeffrey Sachs Center on Sustainable Development. The full paper ‘Stunting in Malaysia: Costs, Causes and Courses for Action’ is available to read here or at www.jci.edu.my.