ANNEX 1: PRE ASSESSMENT ANALYSIS OF THE LIKELY CAUSES OF UNDERNUTRITION IN THE DRY ZONE

Transcription

1 ANNEX 1: PRE ASSESSMENT ANALYSIS OF THE LIKELY CAUSES OF UNDERNUTRITION IN THE DRY ZONE HEALTH AND NUTRITION INDICATORS Estimates of annual infant and under-5 child deaths are between 10.6 and 16.9 per 1000 live births for infants and between 15.3 and 24.3 per 1000 live births for children under 5 (Township Health Profiles 2009) compared with 37.5 per thousand live births for the under 5s and 46.1 for infants (or 52.9 and 42.8 respectively for rural areas) (MICS 2011). This may be due to factors such as high immunisation coverage (MICS 2011), greater autonomy of women to make decisions about child care (WFP 2005) and fewer endemic and epidemic diseases compared with humid tropical areas. However, in this context of relatively low mortality, high levels of food insecurity and other factors give rise to rates of child wasting and stunting and maternal thinness that are considered poor or high according to international benchmarks (WHO 1992, 1995, 1995). Global Acute Malnutrition (GAM) rates among children under 5 years of age are broadly similar across the Dry Zone and can be categorised as poor according to the WHO classification (WHO 1992); 7.0% in Saigaing, 7.1% in Mandalay and 10.4% in Magway compared to 7.9% nationally (Weight for Height Z-score <-2 against WHO GS 2006, MICS 2011). Higher rates have been reported locally, e.g. in Magway in April/June 2005 (early rains) the rate was 12.8% (presumably against the WHO growth standards, although this is not stated, WFP 2005). Rates of Severe Acute Malnutrition (SAM) estimated from the MICS vary, at 2.5%, 1.7% and 3.2% respectively compared with 2.1% at the national level (WHZ <-3 against WHO GS 2006, MICS 2011). There is no data available on acute malnutrition diagnosed using Mid Upper Arm Circumference (MUAC). Oedematous malnutrition (the most deadly form of severe acute malnutrition) has not been recorded in the Dry Zone. The same pattern can be observed for rates of stunting which are classified as high nationally and across the divisions (WHO 1995): Mandalay 31.5%, Saigaing 38.6%, national average 35.1% (Height for Age z-score <-2 against WHO GS; MICS 2011). Underweight rates are closer to stunting rates than wasting, indicating the high proportion of underweight children who are classified as such because of linear growth deficit. National prevalence is 28.2% (Weight for Age z-score <-2 against WHO GS z-scores weight for age, and severe underweight (WAZ <-3) is 5.6% (MICS 2011). The rates in the three divisions are all lower: Magway 26.9% and 5.6%, Mandalay 20.7% and 3.4% and Saigaing 22.5% and 5.9%. However localised surveys have returned higher rates, e.g. in Magway rates of 39.15% for the 0-35 month olds and 40.99% for the month olds were recorded in 2005 (WFP 2005). These rates are classified as high according to the WHO (WHO 1995). Except for some evidence that stunting rates can be higher in boys than girls (e.g. WFP 2005), which is somewhat related to the construction of the growth references, there is no other evidence of a sex differential in malnutrition rates. Undernutrition prevalence varies by age. National data indicates that wasting prevalence is highest in children months of age (MICS 2011); local data from Magway shows a peak in the age group (SC 2009) and higher rates in children less than three years of age compared to those over (WFP 2005). This is consistent with the ages at which children are exposed to nutritionally inadequate and pathogen contaminated complementary foods. Stunting may be more common in older children; national data finds the peak in the month old age group (MICS 2011) whilst a local example finds peaks in the and month olds (WFP 2005). Given the cumulative nature of linear growth 1

2 faltering these patterns warrant further investigation to be fully understood. The pattern for underweight nationally is for highest prevalence in the oldest group (48-59 months) (MICS 2011). A local example from Magway indicates similar rates in the under 3s compared to the over 3s (39.2% and 41.0%) with a peak at and months, interpreted as consistent with highest stunting rates in older children and highest wasting rates in youngest children, with stunting and wasting contributing to underweight prevalence (WFP 2005). The MICS includes estimates of Low Birth Weight (LBW) prevalence, indicating rates of 9.8%, 9.9% and 7.1% respectively in Magway, Mandalay and Saigaing, although less than a quarter of mothers had records. There is very limited information on women s nutritional status. A nutrition survey in Magway in 2005 found a third of 351 non pregnant women of reproductive age were chronically undernourished with a BMI <18.5 kg/m 2 (33.6%, 95% CI %; mean 19.7), with women years of age having lowest BMI. Whilst this rate is flawed by the inclusion of women under 19 years of age for whom BMI is not a valid indicator (and also the analysis did not take in to account the clustered nature of the data), this rate is classified according to WHO standards as high and suggests a problematic situation (WHO 1995). There is also very limited information on micronutrient status. The same nutrition survey found no night blindness among children 2-5 years of age, and with vitamin A coverage of 91% this was deemed coherent. Visible goitre was recorded in 7.4% of children which was deemed low but worrying given that 82% of households had iodised salt; it could be a result of deficiency or excess consumption. IMMEDIATE CAUSES Disease Cough/ARI, malaria, diarrhoea and dysentery are the most common illnesses/symptoms according to township morbidity reports. ARI is equally common in Magway and Saigaing (c7500 cases per 100,000 <5s) and far less common in Mandalay (3342 cases per 100,000). Diarrhoea morbidity reports are lowest in Mandalay (582 cases per 100,000) and highest in Saigaing (918 cases per 100,000) and the reporting of dysentery follows the same pattern at lower prevalence (Township health reports 2009). Survey estimates for diarrhoea prevalence vary by source and season of data collection but are much higher than the morbidity reports because of the focus on the under 5s and presumably also because of limited health seeking for this illness; from very low in the 2011 MICS ( %) and higher in a survey among the under 2s in 4 townships in the southern Dry Zone during the rains in 2009 (16.5%) (SC 2009). Malaria is endemic in pockets and is more common in Saigaing (malaria morbidity reports are six times more common in Saigaing at 1962 cases per 100,000 than in Mandalay and twice as common as in Magway) (Township health reports 2009). The rate of general clinic attendance is highest in Saigaing (26.4%), and lowest in Mandalay (18.8%) with Magway in the middle (24.8%). This pattern is consistent with a picture of higher sickness prevalence in Saigaing and lowest in Mandalay, although it could also be determining the figures. Data from the MICS indicates that appropriate treatment for diarrhoea with ORS varies but seems to be at least a third of cases. Knowledge of (two) danger signs for pneumonia is variable but likely not more than 10%. i.e. there are known deficiencies in knowledge and practice of appropriate health behaviours. 2

3 Inadequate diet The MICS indicates relatively good Infant and Young Child Feeding (IYCF) practices including timely complementary feeding 1 (between 84.6% and 85.7%) and continued breastfeeding to months of age and beyond, particularly for the rural poor, which is almost universal. There is a lack of data on meal frequency, although the four township survey suggests that prevalence of minimum meal frequency is also reasonable; 73.8% among children 6-23 months, highest for the youngest within that age group (SC 2009). Poor practices include a low rate of exclusive breastfeeding, although there is conflicting information about how poor this rate is: the 4 township survey estimated prevalence of 7.9%, the MICS between 28.9% and 34.9% (higher than the national average of 23.8%, but in line with the trend of better exclusive breastfeeding practices in rural areas); whilst the Magway survey conducted in 2005 returned an unlikely estimate of 71%. Water is commonly given to children to quench thirst and complementary foods are introduced between 2 and 4 months of age for many children. Whilst colostrum is given to the newborn baby, the 4 township survey suggests that other liquids are commonly given during the three days after birth. There is very limited information on children s dietary diversity and nothing on the diets of women, the four township survey suggests this is poor for young children, with only 29.4% of children 6-23 months receiving 4+ food groups (i.e. achieving the recommended minimum), with low consumption of iron rich foods also (32%). There is reliance on cereals, roots and tubers and legumes. Diets lack dairy foods, vitamin A rich fruits and vegetables and fruits, eggs and meat (and with the portion sizes actually consumed, this could be even less than estimated) and other fruits and vegetables. The diet practices suggest risk of deficiencies of B vitamins, iron, folate, zinc and vitamin A. A Minimum Adequate Diet (a composite indicator taking into account feeding frequency as well as dietary diversity) was achieved by only 23.6% of children in the four township survey, influenced largely by the low diet diversity. The MICS reported on a non-standard indicator of adequate diet for children 0-11 months, with rates of % compared to 41.0% nationally. UNDERLYING CAUSES POOR PUBLIC HEALTH ENVIRONMENT Health access As a measure of health service access, dividing the number of rural health clinics by total population in each division reveals a very large difference in accessibility of health services, with 1 Rural Health Centre : 1,680 population in Magway, 1:31,990 in Mandalay and 1:23,725 in Saigaing (Township Health Reports 2009). Midwife records for vaccinations given and vitamin A supplementation coverage during the last 6 months indicates mixed coverage of preventative health interventions; the MICS estimates from midwife record books/child immunisation cards that between 97.3 and 100% of children have had all their vaccinations (BCG, DPT 1, 2 and 3, polio 1, 2 and 3 and measles) (MICS 2011); 90% of children under 2 in the 4 township survey had a BCG scar, although in the same survey measles vaccination coverage was only 60% according to mothers recall (only 25.8% with documentation), which is a concern given the 90% needed for herd immunity (WHO 2012). Vitamin A coverage for the under 5s 1 Prevalence of children 6-9 months receiving breastmilk and solid/semi solid food 3

4 was 61.6% in Saigaing, 43.9% in Mandalay and 81.2% in Magway. Coverage of vitamin A for post partum women was reported to be reasonable, between %. There is very limited data for deworming treatment coverage, e.g. in the 4 township survey coverage for the children months was only 18.5%. Midwives, auxiliaries and TBAs are involved in provision of antenatal and postnatal care and supporting delivery. According to the MICS, ANC coverage by a skilled provider is high at above 80% in all divisions, as is coverage of iron and vitamin B1 supplementation in all cases except the latter in Magway at 74.5%. Contraception use among ever married women (mostly modern methods) is between 38.0% and 45.7%. Water, Sanitation and Hygiene (WASH) Access to water is highly variable; according to the MICS water is available on the premises of 41.0% of households in Mandalay, but only 29.2% in Magway and 5.6% in Saigaing. Distances to water for those who do not have it on the premises also varies, between 7 and 13 minutes and women are traditionally the water collectors. Water purchase is necessary during times of water shortage, when ponds dry up and people have to buy water from deep tube wells (e.g. WFP rapid assessment in April 2013 suggests cost of kyat/day, two hour walk). The secondary data consistently suggest that household use of protected water sources is reasonable and likely above 80%. Access to improved sanitation is even better and above the rural average of 80.4% of households in all divisions, reaching 91.1% in Mandalay. Consequently household access to both a protected water source and improved sanitation is good, 79.3% in Magway to 86.6% in Saigaing. The four township survey found lower rates of latrine and protected water source coverage at about 60-65%, but also in investigating the use of latrines for disposal of faeces found that this occurred in only 38.9% of households. Similarly, access to soap was good (98.4%) but only 35.5% washed their hands with soap in the preceding day and water treatment was low (worst in Saigaing at 21.8%, 43.6% in Magway). These indicators highlight poor hygienic practices regardless of reasonable access to sanitation. INADEQUATE CARE ENVIRONMENT The 2005 survey in Magway asked questions on decision making about food choices, child health care and birth spacing and found mothers were primary decision makers in these areas: 88% of households said that the mother was the main decision maker for food choices followed by 11% grandmothers; 76% said that the mother was also the main decision maker for child health care, followed by fathers 7% of the time. The four township survey undertaken in August 2009 (a time of low labour demands) indicated that 60% of caregivers of children under 2 years of age (mostly mothers) spent <2 hours away from their infant; grandparents were the most common secondary carer when the caregiver was away from home (child was taken <10% of the time). More than 20% of mothers with infants <6 months reported doing paid work; 22-31% for other age groups to 24 months 4

5 HOUSEHOLD FOOD INSECURITY Availability The seasons vary somewhat in the Dry Zone give the wide geographic area and different agroecological zones. There is a single rainy season starting between April and June and continuing for five months to between August and October. These rains are erratic, and whilst the limited irrigated areas have multiple cropping seasons, crops are limited (cotton and rice), whereas rainfed agricultural land has more diverse cropping patterns. The principal products include agricultural produce, particularly oil crops and pulse production. The main crops grown are rice (staple, main harvest December), oil seeds (sesame, groundnuts, sunflower) and pulses (pigeon peas, green gram, chickpeas). Some vegetables such as tomatoes and onions are planted, and fruit trees are common in the higher lands. Nevertheless the Household Economy Assessment (HEA) data indicate limited seasonal variation in availability and cost of food (although there is real variation in the foods available) (SC/Oxfam 2009). Despite this, there are lean periods preceding and following the rains, running mainly January to April/May (in some areas a bit longer in to the summer) and towards the end of the year, during October and November. The poorer experience the hunger gap most acutely before the rains in the hot dry season, when there are fewer opportunities for labour. Access Data from localised assessments (mostly in Magway) and surveillance indicate consistently that food sources are dominated by purchase across wealth groups, and for some (very few) poor households, and more middle income and better off households, from own production (SC/Oxfam 2009, Oxfam 2011). Payment in kind is also common in some areas. The poor rely on low paid wage labour for income and on market purchase for food access. They are highly dependent upon the market both in terms of what they buy (food and non-food goods and services) and what they sell (labour, prepared foods, etc.). HOUSEHOLD WEALTH/POVERTY The determinants of household wealth and livelihoods include land owned and whether this is irrigated or rain-fed, and livestock owned, particularly cattle for ploughing (SC/Oxfam 2009). Not all people in rural areas are farmers and there is a mix of farming households who have access to land and off-farm households who do not, although about 40-50% of the Dry Zone population can be classified as landless and the majority of these households (60%) earn a living labouring (JICA 2010). Labour is focused on agriculture production but wage labour migration is also very common, linked to the agriculture calendar, with migration to compensate for absence of agriculture labour opportunities mostly during January and May and also at the end of the year. Labour includes road and construction work, mining and factory labour as well as agriculture. Vulnerability to shocks affects demand for and the price of labour, ability to labour and prices of food and non-food items, and advanced wages are lower than wages paid for work done. Most labour is done by adult men, though women contribute significantly; child labour is rare. Constraints to production include traditional farming practices, poor seed quality, limited inputs and erratic weather. Cattle/buffalo are used for draught power. Livestock holdings are mostly limited to chickens and cattle for the middle income / better off households although there are some pigs and goats in certain areas. There are also other diverse income generation activities (e.g. weaving, sewing, jaggery production, petty trade and handicraft production, JICA 2010) as well as widespread use of credit. Credit access 5

6 is an important livelihood strategy for all wealth groups, through taking loans as well as mortgaging land, pawning and receipt of advance wages (SC/Oxfam 2009; Oxfam 2011). Expenditure is dominated by food and according to the two HEAs done in Minbu and Thazi townships, can be as much as 67% of total expenditure and, for the majority of rural populations, at least 50% (Oxfam 2011). However incomes are likely not enough to afford a healthy diet. According to a Cost of Diet assessment conducted in August 2009 in four townships in Magway (SC 2009), food expenditure was only 22% of the cost of a diet to meet recommended nutrient intakes, whilst total income was only 35%. Half, if not most, was spent on rice. The Household Economy Assessments undertaken in the zone indicate a strong correlation between total income and total food consumption, and also with diet quality and non-staple food purchase (SC/Oxfam 2009). In addition the 2005 Magway nutrition survey reported a big mismatch between the cost of food (a typical daily ration equivalent) and daily wage, with the example diet costing 43% of the daily wage. 6