Sri Lanka - Averting A National Nutrition Anomaly 2

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Sri Lanka: Averting a National

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.

In general, the areas with the highest rates of


maternal and child undernutrition are those districts
with the highest proportion of rural poverty
and vulnerability - including tea estate related
employment and conflict-affected populations. In
fact, the most recent nutrition data suggests that
there has been no change in the percentage of
stunted children under the age of five since 20061.

The strong connection between socio-economic


inequalities and malnutrition highlights the need
for an inclusive and multi-sectoral approach if
this nutrition anomaly is to be overcome.

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
4 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

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.

Excluding the Northern and Eastern provinces, the poverty


headcount fell from around 22.7% in 2002 to 6.7% in
Proportion of the population living in urban and rural areas:
2012/13 and then further reduced to 4.1% as of 2016.
However, against this backdrop, the persistence of serious
4.4% malnutrition in Sri Lanka appears to present a major
anomaly.

Underlying the impressive reduction in extreme poverty,


and taking into account the multiple dimensions of poverty,
18.3%
the most recent multi-dimensional poverty data suggests
that 15.2% of the population are either poor or living close
to the poverty line5. Furthermore, as the World Bank points
77.3% out, 40% of the population continues to live on under USD
2.75 a day, pockets of severe poverty exist (primarily key
districts in the north and east of the country) and it can be
seen that ‘the ability of low income households to access
basic services and public facilities has barely improved
since 20026’.

Analysis of differences across the country show that


a number of communities (including those in the war-
Estate Urban Rural affected North and East, rural communities dependent
on agriculture, plantation communities, people affected
by natural disasters and even people resident in the
Sri Lanka attained lower middle income country status in
Colombo’s poorest and most underserved urban
2010 and is currently working towards its national Vision
settlements) have not necessarily been able to benefit
20253 whereby the Government is aiming to transform
adequately from economic growth and improvements in
the nation into a high-income country, a services hub
service provision.

2. Government Statistical Data Sheet 2017.


3. http://www.pmoffice.gov.lk/download/press/D00000000061_EN.pdf
4. This positions it at 73 out of 188 countries on the HDI. In the framework of the MDGs, and despite relatively low levels of per capita income, Sri Lanka’s achievements have included
universal primary education, reducing both the under-five and infant mortality rates by two-thirds, universal access to health services and considerable reductions in maternal mortality.
file:///Users/abigailmasefield/Downloads/MDG-Country-Report-2014.pdf
5. UNDP (2016) Multi-Dimensional Poverty Index (MPI) www.lk.undp.org/content/dam/srilanka/.../Sri%20Lanka%20Explanatory%20Note.pdf
6. http://documents.worldbank.org/curated/en/996911467995898452/Sri-Lanka-Poverty-and-welfare-recent-progress-and-remaining-challenges. For example, while one in ten households
obtain drinking water from an unimproved source in the country as a whole this proportion rises to six out of ten households in the estate sector.
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 5

Undernutrition in Sri Lanka


The importance of nutrition as a foundation for good
MALN UTRITION COMES IN MANY FORMS
health cannot be underestimated. Nutrition influences
the ability to grow physically and emotionally, the
capacity to learn and develop intellectually, and is the
basis of productivity. Good nutrition is a human right
and associated with the realization of an individual’s full
potential. Beyond immediate risks to life, the effects of stunting wasting obesity
malnutrition (a term which includes child stunting and (people are too
short for their age)
(people are too thin
for their height)
(people are
overweight)
wasting, micronutrient deficiencies and overweight /
obesity – see definition below7) are devastating and lasting.
target set for nutrition by 2015. In 2012, member states of
Malnutrition also slows economic growth and perpetuates the World Health Organisation endorsed six global targets
poverty as a result of poor physical health, low levels of for improving maternal, infant and child nutrition with a
cognitive development and hence educational attainment timeframe of 20258. Sri Lanka’s own national targets are set
and increased health care costs. Despite having achieved within this global framework9 and an overview of the state
many of the targets associated with the Millennium of play is presented below - with red indicating being off
Development Goals (MDGs) Sri Lanka did not attain the course and green indicating on course to meet the target.

Form of World Health Assembly National South Asian


2006/7 2012 2016
Malnutrition 2025 Target Target 2020 Average

Stunting: Also known as chronic


malnutrition and referring to low 40% Reduction by 2025 9% 17% 13.1% 17% 34%
height for age.

Wasting: Also malnutrition and To attain a rate of less


10% 14.7% 19.6% 15% 15%
referring to low weight for height. than 5% globally

That there will be no


Child Overweight and Obesity:
increase from the 2012 <0.7% N/A 1% 2% 4%
Characterised by excess body fat.
6% baseline

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.

Low Birth Weight: A major


30% reduction from the
predictor of mortality and 15.2% 17% 18% 15.7% 27%
15% 2012 baseline
morbidity.

Exclusive Breastfeeding: The


practice of only giving an infant To achieve a rate of
>=90% 76% N/A 82% 60%
breastmilk for the first 6 months 50% at the global level
of life.

7. Global Nutrition Report 2015


8. These targets have then been partially incorporated into Sustainable Development Goal 2, target 2.2: By 2030, end all forms of malnutrition, including achieving, by 2025, the
internationally agreed targets on stunting and wasting in children under five years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women, and older
persons.
9. As underscored in the Government led multi-stakeholder consultative exercise: The National Strategic review of Food Security and Nutrition http://www.wfp.org/Sri_Lanka_Food_
Security_Review. The Strategic Review adds to the government’s initiative to nationalize the SDGs and the programmes already underway, such as the Public Investment Programme (2017-
2020), development of the four year Multi-Sector Action Plan for Nutrition (MSAPN 2017-2020), and the Food Production National Programme 2016-2018
10. Jayatissa R, Hossaine SMM. Nutrition and Food Security Assessment in Sri Lanka 2009. Medical Research Institute, Sri Lanka 2010.
6 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

Height for age (Stunting) Child Stunting

Child stunting refers to the largely irreversible outcome


of inadequate nutrition and repeated bouts of infection
during the first 1000 days of a child’s life. At 17% (around
300,000 children), the prevalence of stunting in Sri
Lanka remains significantly lower than other South Asian
countries where the regional average is 34%. However,
despite the significant progress with stunting reduction
in Sri Lanka since the mid 1980s, the lack of any apparent
progress in the course of the last decade, and the 4%
increase since 2012 is a major concern11.

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 Wasting Weight for height (Wasting)


In virtually all countries where there are high rates of
child undernutrition, rates of stunting (low height for age),
reflecting chronic deprivation, are invariably higher than
rates of wasting (low weight for height) which reflects
relatively short term and acute weight loss. In Sri Lanka,
however, the prevalence of both stunting and wasting are
at similar levels (with 2% severe acute malnutrition). In
2012 wasting even exceeded stunting while in 2016 at the
national level, wasting remained at the globally recognised
emergency threshold of 15%13.

In some districts, wasting is significantly higher reaching


levels that would generally be associated with near-famine
like conditions (for example 25.4% in Monaragala and
21.8% in Hambantota) Wasting is also highest among
infants under six months of age with severe wasting (known
as severe acute malnutrition) extremely high (6.6%) for
this age group. Wasting increases the risks of morbidity,
mortality, stunted growth, impaired cognitive development
and noncommunicable diseases in adulthood.

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

Anaemia in Women of Reproductive Age


These include: low birth weight; working mothers
Anaemia has a negative impact on the health and quality of being less able to provide optimal child care; mothers
life of millions of women globally (through greater fatigue themselves having been stunted as children; and
and reduced ability to work for instance) as well as the chronic poverty.
development and learning of their children. Therefore,
it is worrying that there appears to have been a slight Furthermore, among the tea estate population:
increase in the prevalence of anaemia among women of
reproductive age in Sri Lanka in recent years (from 22.2% i. less than one in three children between 6 – 23
to 33%). Data on anaemia among school aged children months were found to receive a minimally
indicated that prevalence of anaemia ranged from 16.3% acceptable diet (in terms of both meal frequency
among 5-9 year olds, 9.9% - 13.9% among 10-15 years and and dietary diversity);
54% among 12-16 year olds16.
ii. one in three mothers were found to be suffering
Low Birth Weight from undernutrition prior to becoming pregnant;

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.

In the Nuwara Eliya district, more than half the


district’s population of 711,644 lives on tea estates
where extreme poverty and vulnerability have been
experienced for decades. A recent World Bank Study
led to the identification of a number of risk factors in
the estate sector that lead to child undernutrition.

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/
8 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

Overweight and Obesity in


Sri Lanka
‘Food consumption patterns have changed, with more emphasis on processed food
instead of fresh fruits and vegetables; accordingly, the intake of sugar and salt has
increased. These variable risk factors have resulted in causing chronic
Non-communicable Diseases (NCDs) such as high blood pressure, high blood lipid levels,
high blood sugar and obesity. The NCDs have been identified as a major cause
of mortality in Sri Lanka.’
Ranil Wickremesinghe - Prime Minister18

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.

For instance a child can be stunted in their earliest


years but then go on to become overweight, obese and
vulnerable to NCDs later in life20. Alternatively, a child or
Non-Communicable Diseases – the epidemic
an adult may be overweight, while at the same time also
responsible for three quarters of all deaths.
having severe micronutrient deficiencies (being anaemic for
instance). The nutrition transition is clearly captured among
In October 2015 the United Nations Interagency
young women between the age of 15 and 20 years where
Taskforce on NCDs conducted a mission to Sri Lanka
one in every five of these women is either overweight or
and concluded that the epidemic of NCDs has now
obese, while at the same time one in five is thin (low body
become a serious economic as well as public health
mass index).International Code of Marketing for Breast-milk
issue. A national study in 2013, found one third of the
Substitutes in the 1980s.
adult population in Sri Lanka to be hypertensive21.
Food consumption patterns have changed tremendously
in recent years, accelerated by rapid urbanisation and the According to WHO (2014)22, non-communicable
growing demand for highly processed (and less healthy) diseases (NCDs) cause more than three quarters of all
foods23. The aggressive marketing of unhealthy fast foods deaths in Sri Lanka, the top three causes of death in the
to children and young people is a particular concern and country being strongly related to diet, namely coronary
strongly linked to the rapid increase in obesity, overweight heart disease, stroke and diabetes.
and non-communicable diseases (NCD) as evidenced by

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)
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 9

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,

• Lack of knowledge on what makes a healthy diet, food


storage and preparation techniques etc.

Northern
Map of Sri Lanka showing variations in the ability 34
15
to afford a nutritious diet:

Using an analytical tool known as ‘Cost of Diet’25, the


Government of Sri Lanka, supported by WFP, was North-Central
27
able to identify the percentage of households across 4

different provinces who are realistically able to afford


either (i) the minimum amount of calories required % < Nutrient Poverty Line North-Western
or, (as per the definition of food security), (ii) a diet 30
5
Eastern
>40%
containing all of the essential nutrients required for an Central
48
9
>35-40%
active and healthy life. 33
4
>30-35%

>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

nutritious diet, while in at least four other provinces 32


5
Nutrient & Calorie Poverty Rates
around one third of households face the same
Southern
challenge. % below Nutrient Poverty Line
28
5
% below Calorie Poverty Line

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

Gender Inequality with steadily increasing temperatures and increased


intensity and frequency of extreme weather events such
As highlighted in the 2015 MDG report26, although Sri as erratic rainfall, tropical storms, floods and droughts.
Lanka has eliminated gender disparity in education, and This in turn, suggests a high degree of risk for agricultural
the proportion of literate women in the 15 to 24 age group production and reduced resilience for rural livelihoods.
exceeds that for men, these achievements have not helped
in increasing the share of women in wage employment -For example, in 2017 Sri Lanka experienced the worst
in the non-agricultural sector27. Moreover, the political drought faced in 40 years in which the main harvest
participation of women is very low, calling out for measures (known as Maha) was reduced by more than half and the
to encourage a substantial increase in the number of secondary harvest (known as Yala) was further impacted.
women in political offices, as well as in civil society and the
private sector more generally. As the drought period started already in 2016, this led to
negative coping mechanisms such as sale of productive
To empower women, they must be ensured more equitable assets, increased indebtedness and reduced food intake by
access to productive resources, income opportunities, many, but especially the poorest families who were hardest
labour and time saving technologies and greater voice in hit. Significant opportunities exist to enhance adaptation
decision making at all levels. measures including the introduction of drought resistant
crop varieties and more efficient water utilisation as well
To support more women to enter the labour force, it will as strengthening early warning systems and investing in
be necessary to create more equitable educational and research and development.
employment opportunities that are also compatible with
safe pregnancy and young child feeding. Non safe transport Social Protection
has also been identified as a key factor preventing women’s
mobility and therefore often making it more difficult to The Samurdhi (prosperity) scheme, established in 2004,
access higher education and employment opportunities28. involves a rather complex mixture of cash transfers, loans,
obligatory savings, training, dedicated banks and local
Land Degradation, Climate Change and Natural Disasters infrastructure spending to boost households’ ability to
secure basic rights such as the right to food and adequate
As a result of unsustainable land use, productive land with nutrition29. However, an important priority will be to ensure
fertile soil is becoming increasingly scarce. Significant shifts that these different components are evaluated adequately
are anticipated with regard to Sri Lanka’s future climate, in terms of their impact on nutrition outcomes.

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/
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 11

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

National Nutrition Council (NNC)


Cabinet HE the President, Ministers of relevant ministries and
selected MPs who will function as observers to the NNC

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

Implementation Technical Guidance & Monitoring

Steering Committee in each relevant ministry, department and province

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

by 25% of 2009 figures Six commitments No increase of overweight among


laid out in the draft
Re s u l t 2

children under five, adolescents


MSAPN for 2020³³ and pregnant women

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.
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 13

The EU as a Key Partner


At the Global level, and in the framework of the European Strategic Priority One: Enhancing mobilization and
Consensus on Development (2017) and Communication on political commitment for nutrition
Enhancing Maternal and Child Nutrition35 (2013) two bold
commitments have underpinned the strategic focus of the The EU ensures ongoing support to the Scaling Up Nutrition
European Union’s support for nutrition: movement in country as well as taking every opportunity
to strengthen both national and sub-national coordination
i. Averting at least 7 million children from being stunted mechanisms for nutrition. In addition, the Global FAO
by 2025; and EU partnership (known as ‘FIRST’) provides high level
policy expertise to support the strengthening of all sectoral
ii. Allocating Euro 3.5 billion to improve nutrition in systems to deliver better nutrition outcomes by drawing
priority countries between 2014-2020 on the national and international evidence base and best
practice.
The EU is an important development partner for Sri Lanka
and the EU commitment to nutrition in Sri-Lanka (through Strategic Priority Two: Scaling up actions at country level
the DCI Multi-annual Indicative Programme 2014-2020)
is underscored by the prioritization of investment in The ‘Support to Integrated Rural Development in the
Integrated Rural Development focal sector, which includes Most Vulnerable Districts of the Central & Uva Provinces
support to Food and Nutrition Security and Sustainable of Sri Lanka’ Programme 2016-2021 supports the poorest
Agriculture (FNSSA)36. and most vulnerable communities in four districts. The
programme centers on the mutually reinforcing objectives
The overall objective for the EU’s development cooperation of both employment opportunities / livelihood promotion
in Sri Lanka is to contribute to the eradication of poverty and improved health and nutrition of women and children.
in rural areas of Sri Lanka through sustainable rural Through the focus on the first 1000 days, Information,
development, including environmentally sustainable Education and Communication (IEC) initiatives promote
agriculture. One of the four specific objectives is to behavioural changes.
“Contribute to the enhancement of food and nutrition
security of communities in target areas through the In partnership with the World Bank, the ‘Modernisation
promotion of inclusive sustainable agricultural practices of Agriculture’ Trust Fund initiative38 seeks to promote a
that bring economic growth and improved climate change more productive, climate-resilient, market-oriented and
resilient livelihoods.” equitable approach to the sector. As the initiative will
increase the participation and competitiveness of the most
From 2014 – 2017 financial commitments in this sector vulnerable smallholder farmers, with 35,000 women as
currently amount to Euro 60 million, of which Euro direct beneficiaries, it is expected to bring about further
10.92 million has been allocated explicitly for nutrition37. progress with in nutrition.
Additionally, Euro 47 million are to be committed to FNSSA
by 2020. In line with the European Commission’s Action Further strengthening gender equality, EU funded
Plan on Nutrition, investments in Sri Lanka can be framed programmes39 such as ‘Enhancing gender inclusive socio-
on the basis of three strategic priorities: economic development in Central and Uva Provinces’

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.
14 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

(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

The Euro 4.2 million programme ‘Technical assistance to


the modernisation of agriculture programme in Sri Lanka’
is designed to ensure technical assistance to key ministries
including the Ministry of Agriculture, Ministry of Primary
Industries and Ministry of Finance. The focus of the
assistance is the support the government to strengthen
the national agricultural policy so as to facilitate structural
reforms for inclusive growth and human development as
well as strengthening systems for planning, budgeting,
service provision and data analysis for monitoring and
evaluation. Nutrition-sensitive agriculture will be promoted
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 15

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.
© European Union 2018

Published by Directorate-General International Cooperation and Development,


Directorate Sustainable Growth and Development, March 2018.

The contents of this publication do not necessarily represent the official position or
opinion of the European Commission. Neither the European Commission nor any
person acting on behalf of the Commission is responsible for the use which might
be made of information in this publication.

Directorate General International Cooperation and Development,


Rue de la Loi 41, B-1049 Brussels.
E-mail: europaid-info@ec.europa.eu
For further information:
http://ec.europa.eu/europaid/

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