rapid decline in childhood undernutrition in brazil and the role of policies reducing inequality
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Eduardo A.F. Nilson Food and Nutrition Coordination Ministry of Health of BrazilTRANSCRIPT
Rapid decline in childhood undernutrition in Brazil and the role
of policies reducing inequality
Eduardo A. F. NilsonFood and Nutrition CoordinationMinistry of Health of Brazil
Decline in childhood undernutrition according to national inquiries in Brazil (children < 5 years old)
• Steady decline in stunting during the last 3 decades, but steeper in the last 10 years.
1975 1989 1996 2006
37.1%
19.9%
13.4%
6.7%
Height-for-age deficit
1975 1989 1996 2006
15.9%
5.6%4.2%
1.8%
Weight-for-age deficit
Sources: National population surveys (ENDEF, PNSN and PNDS)
Major causes of the decline in child undernutrition in Brazil through the last three decades
1975-1989:• Great expansion of the coverage of public services (education,
sanitation and health).• Moderate increase in family income.
1989-1996:• Gradual improvement of maternal education: universalization of
primary education.• Better access to basic health care (National Health System - SUS):
universalization of health care.• Expansion of public water supply.
1996-2007:• Combination of policies, but strongly contributed by purchase
power increase and the expansion of essential public services.
Stunting did not decline homogeneously
North Northeast Midsouth
20.4
22.4
7.5
14.4
5.97.1
1996 2006
Poorest 2nd 3rd 4th Richest
30.7
17.9
9.6
5.7 4.9
11.09.3
6.8
3.6 4.0
1996 2006
By region: By socioeconomic quintile:
• Gap reducing between regions and between poor and wealthy families: decline was greater in poor and more vulnerable communities.
(for children under 5 years old)
Sources: Demography and Health Surveys (PNDS)
But there are still differences in undernutrition rates
Brazil, 2006 North, 2006 Indigenous, 2008-09 "Quilombolas", 2006 Bolsa Familia, 2009
6.7
14.8
26.0
15.015.9
• Iniquities still remain.
(for children under 5 years old)
Sources: DHS 2006 (PNDS), 1st National Inquiry of Health and Nutrition on Indigenous Populations, Nutritional Call of Quilombola Populations 2006, Food and Nutrition Surveillance System (Ministry of Health of Brazil)
And overweight and obesity are increasing…
Boys Girls Boys Girls Men Women Men WomenOverweight Obesity Overweight Obesity
Adolescents Adults
3.9
7.5
0.1 0.7
18.6
28.6
2.8
7.88.3
13,8
0.72.2
20.5
40.7
5.1
12.8
18.0
15.4
1.82.9
41.0
.39,2
8.8
12.7
1975 1989 2003
Sources: National Study on Family Expenditure (ENDEF), National Health and Nutrition Survey (PNSN) and Family Budget Survey (POF)
… equally
Boys Girls Boys Girls20% poorest 20% richest
Adolescents (overweight)
1.6
4.6
8.0
10.3
3.3
8.1
16.6
17.8
9.6 9.9
25.3
17.6
1975 1989 2003
Sources: National Study on Family Expenditure (ENDEF), National Health and Nutrition Survey (PNSN) and Family Budget Survey (POF)
Causes of the decline in undernutrition in the last decade
Mater-nal ed-ucation 25.7%
Pur-chase power21.7%
Access to health care
11.6%
Water and san-
itation4.3%
Other factors36.7%
Source: Monteiro et al, 2009. Causes for the decline in child undernutrition in Brazil, 1996-2007.
Underlying determinantsPurchasing power of Brazilian families:
• Increase in average income combined with better income distribution – declines in families living below the poverty line: Economic growth and reduction in unemployment rates. Systematic increases in the official minimum wage. Cash transfer programs and social security.
1990 1999 2003 2008
5.5
7.48.1
12.1
Per capita income (US$ PPC)
1990 1999 2003 2008
16.2
10.2 9.13.4
51.3
33.8
27.1
12.5
Urban Rural
Population with less than US$ PPC 1.25/day (%))
Source: Institute for Applied Economic Research (IPEA)
Underlying determinants
Cash transfer programs in Brazil:• Firstly sectoral programs (health, education etc.) – 2001.• 2003 - unification of CCTs – Bolsa Família Program.
1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th
5.1
3.8 3.7 3.7 3.8 3.64.2 4.4 4.4
3.53.2 3.42.9 2.8 2.5 2.8
1.9 1.71.3
0.7
13.5
12.3 12.111.3
10.910.3
9.7
8.8
7.9
6.9
1993-1998 1998-2003 2003-2008
Average annual growth in household per capita income per day (US$ PPC) by tenths of income distribution
Source: Institute for Applied Economic Research (IPEA)
Underlying determinants
Bolsa Família Program:• Well targeted, capable of reducing the percentage of extremely
poor families, transfers are mostly used for buying food.• 2010: 12.5 million beneficiary families.• Conditionalities oriented to guarantee universal rights (health
and education) – over 99% of families fulfill the health conditionalities and over 97% of children and adolescents attend at least 85% of school classes.
• Registration can also be used for intersectoral policies and to target the most vulnerable families for other complementary programs: adult alphabetizing, school reinforcement, professional education, familiar agriculture, microcredit.
Underlying determinants
Maternal education
• Progress in primary school enrolment and completion (90’s).
• Policies designed to ensure universal access to primary education and to improve the quality of schools.
Poorest Richest
Poorest; 1996; 5.6
Richest; 1996; 73.5
Poorest; 2006; 29.4
Richest; 2006; 92.5
Maternal schooling >=8 years
1996 2006
Source: Demography and Health Surveys (PNDS)
Intermediate determinants
Access to health care:
• Brazilian National Health System (1988) Universal and integral health care: to guarantee the
Constitutional right for health. Decentralization of management and funding (specially
primary health care): municipalization and more equity in budget distribution.
Social control and accountability: health councils in the municipal, state and federal levels.
Intermediate determinants
Access to health care:• Family Health Strategy (1994) – reorienting and promoting
equity in access to primary health care:- Family Health Teams and Community Health Agents.- Dec. 2009: 30.3 thousand Family Health Teams in 5251
municipalities (population coverage of 96 million people -50,7% of Brazil’s population) – mostly low-income families.
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 20090
20,000,000
40,000,000
60,000,000
80,000,000
100,000,000
Population covered by Family Health Teams, Brazil.
Source: Ministry of Health of Brazil
Intermediate determinants
Access to health care:
• National Food and Nutrition Policy (1999) – directives to organize nutrition actions and services, specially in primary health care (prevention and control nutritional disorders, nutritional surveillance), and to promote intersectoral actions (food security) from the health sector perspective:‐ Vitamin A Supplementation Program (2003)
‐ Iron Supplementation Program (2006)
‐ Food and Nutrition Surveillance System – computerized in 2003 and improved in 2008 (on-line system).
Intermediate determinants
Decline in severe food insecurity at the family level
• Parallel to income redistribution and poverty decline.
• Intersectoral policies.
Quality of child care:
• Parallel to increase in maternal education and better access to health care:- Lesser children per family (1996: 4.0 / 2006: 3.4 people per
family)- Widening birth intervals- Access to contraceptives- Breastfeeding practices
Intermediate determinants (poorest quintile)
16.2 10.2
9.1
3.4
Modern contraceptive use; 1996; 51.1
51.3
33.8
27.1
12.5
Modern contraceptive use; 2006; 93.9
1996 2006
Proximate determinants
Decline in child morbidity and mortality• Immunizations are practically universal for children.• 90% decrease in the mortality rate by diarrhea.• 60% decline in overall infant mortality (1990-2008)• 10% increase in Family Health coverage corresponded to a 4.6%
reduction in infant mortality (1994-2002).
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 20080
10
20
30
40
50
Infant Neonatal Post-neonatal
Infant mortality, Brazil
Source: Mortality Information System, Ministry of Health of Brazil
Conclusions- Impact of overall economic progress and equity-oriented policies.- Change of agenda: assistancial policies give place to universal, rights-
oriented policies.- Critical effect of policies which promote income redistribution and
policies of universal access to education, health, water supply and sanitation services.
- If Brazil maintains the present decline rate (6.3% per year) in the next decade, stunting will no longer represent a public health problem.
- Challenge: to target the most vulnerable (traditional and isolated communities, indigenous peoples), because iniquities still exist.
Thank you!