Sri Lanka - Averting A National Nutrition Anomaly 2
Sri Lanka - Averting A National Nutrition Anomaly 2
Sri Lanka - Averting A National Nutrition Anomaly 2
Nutrition Anomaly?
Case Study
International
Cooperation and
Development
2 S R I L A N K A : A V E R T I N G A N A T I O N A L N U T R I T I O N A N O M A L Y ? - C A S E S T U D Y
Introduction
S
ri Lanka has impressive socio-economic
indicators at national level in comparison to
many of its South Asian neighbours. However,
at the same time, significant income, health and
nutrition inequalities are evident, both between
different geographic areas and across wealth
groups. As a result, high rates of maternal and child
undernutrition, (in particular acute malnutrition
among children under five) together with rapidly
rising overweight / obesity and non-communicable
diseases, continue to present a major set challenges
in Sri Lanka.
1. Both DHS 2006 and DHS 2016 present stunting prevalence as 17.3%. This stagnation in stunting prevalence stands in marked contrast to many other countries in South Asia (such as India,
Bangladesh and Nepal for instance) as well as to the region as a whole, where these has been a significant decline in stunting over the course of the last decade.
S R I L A N K A : A V E R T I N G A N A T I O N A L N U T R I T I O N A N O M A L Y ? - C A S E S T U D Y 3
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Sri Lanka has a population of around and a niche manufacturing destination. As of 2016 Sri
Lanka has achieved a score of a 0.757, on the Human
21.2 million (20162). Almost four out of Development Index which puts the country in the “high
every five Sri Lankans live in rural areas, human development” category and demonstrates that
significant progress has been made in terms of growth,
around one in five live in urban areas, poverty reduction and key human development indicators
and 4% live and work in the tea estates. in recent years4.
Anaemia in Women of
Reproductive Age: Occurs when Reduced global
the number of red blood cells and prevalence 23.8% N/A 22.2%10 33% 49%
their oxygen carrying capacity is by 50% (to 15.2%)
too low.
Not only did the Government not meet its own Nutrition
for Growth commitment to reduce stunting to 8.4% by
2016, and 7.3% by 2018 but significant disparities persist
across regions and income quintiles12. For example, the
prevalence of stunting in Nuwara Eliya (where over half
the population live on tea estates) is 32.4%, while children
in the poorest families across the country are more than
twice as likely to be stunted (25%) than those who are
better off.
Child Overweight and Obesity For children age between 6 – 12 years overweight has
risen to 6.1% and obesity to 2.9%14. Furthermore, the very
While still appearing relatively low at 2% (and lower than high prevalence of overweight and obesity among women
the regional average in South Asia of 4%), it is clearly (now 45% - while it was 31% in 2006-7) suggests that
worrying that child overweight and obesity among the the situation may be rapidly deteriorating, as is the case
under-fives have doubled between 2012 and 2016. throughout the regions of South and South East Asia15.
11. While in 2012 , 13.1% of all children under five were stunted, the latest data from 2016 suggests that the prevalence of stunting has again increased to 17%, representing a deterioration to
2006/7 levels.
12. The WHA target of 40% stunting reduction translates into 200,000 stunted children under the age of five by 2025. https://www.globalnutritionreport.org/files/2014/11/n4gtrackingtable_
country.pdf
13. As defined by the World Health Organisation (2003)
14. https://docs.wfp.org/api/documents/WFP-0000020962/download/?_ga=2.30476154.414946011.1506583139-1232398748.1475213835
15. The average prevalence of overweight and obesity among women across the region of South Asia is 31%, significantly lower than Sri Lanka. (GNR 2017)
S R I L A N K A : A V E R T I N G A N A T I O N A L N U T R I T I O N A N O M A L Y ? - C A S E S T U D Y 7
There appears to be little sign of significant progress with iii. 92% of all water was found to have a high level of
regard to persistently high prevalence of low birthweight E. coli bacteria at source; and,
since 2006/7. Despite significant progress in many
iv. rates of alcoholism and domestic violence are
indicators for human development, it appears that Sri
high.
Lanka has a slightly higher average (17%) than the global
average (15%), although remaining below the average for The study also identified traditional beliefs and lack
South Asia (27%). District distribution shows that LBW of knowledge about the importance of introducing
is high in districts where the proportion of population complementary foods into the diets of young children
participating in agriculture is high, and in particular where as key drivers of undernutrition. While the study’s
women’s participation in the labour force is also high. recommended policy priorities included provision of
nutrition supplements (including multi-micronutrient
Exclusive Breast Feeding
powders and supplementary food ‘Thriposha’ during
Exclusive breast feeding has the single largest potential pregnancy), deworming and behaviour change
impact on child mortality and provides babies with the communication), the study also found problems
perfect nutrition required for healthy growth and brain with the existing approach to nutrition counselling
development. Sri Lanka has an impressively high prevalence due to the fact that materials were not produced in
of exclusive breast feeding which appears to have improved the local language.
in the course of the last decade and is almost double the
However, in addition to the priorities identified by this
global average of 40% and considerably higher than the
study, other reports17 further highlight the extent to
regional average in South Asia of 60%.
which the low wages and poor health of tea workers
This is likely to be associated with the fact that Sri Lanka also constitute major drivers of undernutrition. For
was one of the first countries to adopt the International instance, from already low monthly salaries of tea
Code of Marketing for Breast-milk Substitutes in the 1980s. workers, can then be deducted pension payments,
welfare funds etc. leaving insufficient income to cover
the cost of even a minimally adequate nutritious diet
based on locally available ingredients.
Insights on Nutrition from the Tea Estates
This in turn can lead to the need to take loans for
More than 900,000 people, or about 4.5% of Sri consumption purposes, with indebtedness then
Lanka’s population, live on estates, (primarily tea further exacerbating vulnerability.
estates) located in isolated areas prone to drought,
landslides and other environmental challenges.
16. http://files.unicef.org/srilanka/2012_SL_Nutri_Desk_review.pdf
17. See for example https://globalpressjournal.com/asia/sri_lanka/fighting-poverty-sri-lankas-tea-estate-workers-demand-pay-increase/
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The term ‘double burden’ is used to refer to the co- rising overweight and obesity in Grade 10 children which
existence of undernutrition (including micro-nutrient has increased threefold (from 2% to 6%) in the decade from
deficiencies) along with overweight, obesity and associated 2007 – 2016. In Columbo, 12% of the population as a whole
diet related NCDs19. The increased use of this term – has high blood pressure, and 9% has diabetes.
reflecting the fact that the world is in the grip on a complex
and highly problematic nutrition paradigm – describes At the same time Sri Lanka is going through intense
precisely the situation found in Sri Lanka, where the double demographic change and rapidly becoming an ageing
burden can be found in the same national population, middle-income country, which implies an even faster rise in
communities, households and even individuals. the proportion of the population expected to have NCDs24.
18. http://www.searo.who.int/srilanka/documents/national_ncd_action_plan_sri_lanka.pdf?ua=1
19. http://www.who.int/nutrition/publications/doubleburdenmalnutrition-policybrief/en/
20. In fact, available evidence shows that children who are stunted are more likely to be at risk of overweight and obesity than children of normal height. See for example https://www.
medscape.com/viewarticle/845132
21. Katulanda, P et al (2014) http://www.tandfonline.com/action/showCitFormats?doi=10.3109%2F10641963.2013.863321
22. http://www.who.int/beat-ncds/countries/sri-lanka/en/
23. A diet that includes a lot of highly processed foods, generally containing high levels of sugar, fat, and salt, can raise the risk for overweight, obesity, type 2 diabetes, and heart disease.
24. For example, while the national prevalence of diabetes is 5.7%, it is 17.3% for people over 60 years of age. (DHS 2016)
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Explaining Malnutrition in
Sri Lanka
As always, there can be many different drivers of In addition to tackling these key drivers of malnutrition,
malnutrition including: there are several additional challenges that need to be
factored in to strategies for overcoming malnutrition in the
• Poor food security (as a result of low income to buy Sri Lankan context:
food, production of food, rising food prices etc.) due to
inadequate quantity and diversity of food and resulting Employment Insecurity
in a nutritionally inadequate diet (see map below);
Over 60% of employment is in the informal sector implying
• Several factors that prevent and restrict adequate relatively low pay and little or no social security benefits
care and feeding practices for infants including the such as maternity benefits, sick leave, retirement schemes
challenges faced by caregivers in balancing their etc.) The share of informal sector workers, especially
workload with child care (and ensuring child care women, is especially high in the agriculture sector. As
centres), as well as challenges in affording adequate a result of growing livelihood insecurity in rural areas,
complementary foods coupled with poor knowledge (related to basic causes such as unequal access to land and
on feeding practices (especially during illness); other resources, higher education etc.) migration to urban
areas is on the increase which can in turn have a negative
• Lack of regular access to safe water, adequate impact on the rural economy and incomes.
sanitation, hygiene services etc; and,
Northern
Map of Sri Lanka showing variations in the ability 34
15
to afford a nutritious diet:
>25-30% Uva
Worryingly, the analysis shows that in Eastern Province Western 38
8
virtually half of all households are unable to afford a <25% 18
1 Sabaragamuwa
25. http://documents.wfp.org/stellent/groups/public/documents/ena/wfp271911.pdf?iframe
10 S R I L A N K A : A V E R T I N G A N A T I O N A L N U T R I T I O N A N O M A L Y ? - C A S E S T U D Y
26. http://www.lk.undp.org/content/srilanka/en/home/library/mdg/The-Millennium-Development-Goals-Report-2015.html
27. According to the Department of Census and Statistics 2015 Labour Force Survey Data, of the working age population, only 35.9% of females were engaged in the labour market compared to
nearly 75% of males.
28. A 2015 survey commissioned by UNFPA revealed that 90% of women in Sri Lanka had experienced sexual harassment on public transport. https://reliefweb.int/sites/reliefweb.int/files/
resources/AR%202015_0.pdf
29. The state mission of Samurdhi is ‘“To empower poor, low income and needy other communities through provision of social security, social welfare, development of human capital,
promotion of livelihood development activities, provision of micro finance and to contribute significantly to protection and nourishment of the environment, the expedition of national
development and to build prosperous nation ensuring food security and social equity devoid of poverty.” http://www.samurdhi.gov.lk/
However, as of 2012 the World Bank reported that public spending on social safety net spending in Sri Lanka had fallen from 2.2% in 2004 to 0.3% in 2009.
https://www.centreforpublicimpact.org/case-study/samurdhi-programme-sri-lanka/
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Addressing Malnutrition
The Response of the Government of Sri Lanka
Sri Lanka joined the Scaling Up Nutrition (SUN) Movement The NNC is overseeing the update of the Multi-sectoral
in 2012 and the Government’s SUN Focal Point represents Action Plan on Nutrition (MSAPN) for the period 2018-2020
the Presidential Secretariat. The National Nutrition and which, upon finalisation, will be implemented across all
Council (NNC) - chaired by the President and bringing nine provinces (25 districts in total)31. Within the Ministry of
together seventeen government ministries (as well as chief Health, the national nutrition surveillance system has also
ministers from nine provinces and members of the national been strengthened to enhance the quality and timeliness
parliament) – serves as the multi-sectoral governance of data across the country32.
mechanism for operationalising Sri Lanka’s National
Nutrition Policy30.
Overview of the ‘Nutrition Governance’ System - ensuring that all key ministries are mobilised for improved nutrition outcomes
in Sri Lanka:
Progress
HE reporting
the President
Policy approval
and implementation
Recommendations on policy, strategy
Preparation of policy,
Implementation strategy and
update on progress
Presidential Secretariat
National Nutrition Secretariat (NNSSL)
Coordination &
Implementation
National Steering Committee on Nutrition (NSCN) Technical Advisory Committee on Nutrition (TACN)
Comprises Secretaries to Ministries represented at NNC, Technical experts,
Chief Secretaries of Provinces, International Agencies & International agencies,
Civil Society Representatives Civil Society
30. The National Nutrition Policy was developed by the Ministry of Health in 2010 and will be reviewed and updated in 2018/2019. The National Nutrition Secretariat of Sri Lanka (NNSSL) within
the Presidential Secretariat, acts on behalf of the NNC to support the formulation of plans, and monitor and evaluate progress with implementation.
31. The development of the MSAPN included several rounds of consultations with Government Representative at all levels as well as academics, key development partners and civil society.
32. The Nutrition Secretariat has also established the nutrition monitoring system to identify at risk households for malnutrition in support of the MSAPN implementation
12 S R I L A N K A : A V E R T I N G A N A T I O N A L N U T R I T I O N A N O M A L Y ? - C A S E S T U D Y
6 Result 6
10% increase in household access to
safe water, sanitation and hygiene
1 Result 1
Stunting reduced to 9% and wasting
6 to 10%
sult Re
Re su
l t1
5 Result 5
Household security reduced
2 Result 2
Result 5
4 Result 4
Prevalence of anaemia reduced es
3
R
ul t
in children to 8.8% and in women 4 lt 3 Result 3
to 23.8% Resu Prevalence of low birthweight
reduced to 15.2%
Double Burden – Triple Duty: obesity or diet related NCDs. For example, actions to
promote and protect breastfeeding in the workplace give
In 2016 Sri Lanka relaunched the National Multisectoral rise to positive outcomes for both sides of the double
Action Plan (NMSAP) for the Prevention and Control of burden.
NCDs 2016-2020, with an endorsement from the Prime
Minister34. Given the analysis above, a priority for nutrition The recently introduced concept of ‘triple duty’ actions
Governance will be to strengthen the linkage between goes even further in terms of highlighting the opportunities
actions addressing undernutrition and overweight / to tackle different forms of malnutrition at the same time
obesity. as addressing other pressing development challenges. For
instance, diversifying food production not only improves
The concept of ‘double duty’ actions refers to precisely the availability of nutritious food essential to address both
such an opportunity, in the form of policies and undernutrition and diet-related NCDs – but it can also
programmes with the potential to simultaneously reduce promote livelihoods for the rural poor, empower women
the risk or burden of both undernutrition and overweight, and bring about agro-ecological benefits at the same time.
33. To be monitored through an online system focused on bi-annual data for 200,000 vulnerable households and incorporating district level targets for service provision as well as annual
evaluation initiatives.
34. Sri Lanka’s Action Plan for NCDs specifies the country’s planned actions to achieve ten concrete time-bound commitments in four strategic action areas: (i) Advocacy, partnership and
leadership; (ii) Health promotion and risk reduction; (iii) Health system strengthening for early detection and management of NCDs and their risk factors; and, (iv) Surveillance, monitoring,
evaluation and research.
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35. https://ec.europa.eu/europeaid/enhancing-maternal-and-child-nutrition-external-assistance-eu-policyframework_en
36. As stated in the MIP, over 90% of Sri Lanka’s identified poor live in rural areas in the North, East and tea and rubber estates in Central and Uva provinces.
37. As per the Global SUN Movement methodology, also developed with technical support from the EU. http://docs.scalingupnutrition.org/wp-content/uploads/2013/12/RESOURCE_
TRACKING_METHODOLOGY_SUN_DONOR_NETWORK.pdf
38. The EU contribution to the World Bank Trust Fund consists of Euro 25 million
39. Additional programmes targeting Central and Uva Provinces include Integrated Economic Development of Central and Uva Provinces (Euro 7.3 million) and Enterprise (Euro 4.8 million) with
a focus on enhancing employment opportunities for vulnerable women, young people and their communities. Both programmes have a strong emphasis on greater access by the poor and
SMEs to business and financial services.
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(Euro 6.2 million) provide a wide range of services to in the framework of the technical assistance project.
strengthen and diversify the livelihoods of poor women in The INPARD research project (supported by the EU via the
rural and estate communities including access to veterinary South Asian Food and Nutrition Security Initiative known as
services, potato seed and spice production and processing, SAFANSI, and managed by the World Bank) has highlighted
vocational training and business support. Important the potential of multi-sectoral initiatives for nutrition at
complementary support is provided through actions and community level. One example, as shown below, involved
advocacy to advance wome n’s empowerment and the promotion of home gardens through school based
eliminate gender based violence. training and appropriate techniques to make this a viable
option even in areas with a long dry season, to increase the
On the basis of the crucial role that access to safe drinking regular intake of fruits and vegetables.
water, sanitation and hygiene (WASH) has for nutrition,
the EU has also invested around Euro 11 million in WASH A School Gardening Project in Ampara District
for improved health nutrition via two programmes also
targeting the rural poor and estate communities in Uva and The variations found across the country and between
Central Provinces. These programmes, which collectively different populations, reinforce the importance of
reach several million people, also contain significant disaggregated data and locally specific analysis to inform
components addressing cross cutting agendas such as the design of policies and programmes that are tailor
gender based violence and social and behavioural change made to deliver results on the ground. Therefore, the
communication. At the same time, the “Strengthening EU is also providing support to strengthen nutrition
Reconciliation Processes in Sri Lanka” programme aims information systems (including early warning systems)
to promote a just, peaceful and inclusive society in the and promoting investment in nutrition causal analysis to
country. This is especially important for nutrition in terms enhance the nutrition sensitivity of District Development
of the psychosocial assistance it provides as well as the Plans. Furthermore, by integrating capacity strengthening
support to enhance access to much needed public services, activities for civil society and local authorities across
including health and education for everyone. investments, the EU is reinforcing their contribution to
the development process by ensuring accountability and
Strategic Priority Three: Strengthening expertise and the inclusive policy-making.
knowledge base
Challenges Ahead
Persistently high levels of undernutrition in pregnant A concerted and collective effort is urgently required to
women and children under the age of five (especially better utilise all available data to understand the causal
wasting), the rising prevalence of stunting and alarming factors that continue to drive this national nutrition
increases in the prevalence of overweight, obesity and anomaly, in particular the extremely high levels of wasting.
NCDs, continue to have significant consequences for Sri Greater attention to inclusive growth, improvements in
Lankans - whether in terms of survival, health, quality of basic living conditions of people, their enhanced resilience
life, well-being in society at large and ultimately sustainable and ensuring adequate coverage and equitable access
and inclusive economic growth. to services will be key to ensure greater equality in both
nutrition, and at the same time development, outcomes.
Combatting all forms of malnutrition via ‘triple duty’
actions through the acceleration of coordinated efforts While such challenges may appear daunting, the hope is
involving multiple sectors, presents one of the key that they will be harnessed as an opportunity to embed the
challenges facing Sri Lanka today. commitment to eradicate malnutrition at the very heart of
national development.
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