97508 Knowledge Brief Health, Nutrition and Population Global Practice STAGNANT STUNTING RATE DESPITE ECONOMIC GROWTH IN PAPUA NEW GUINEA May, 2015 KEY MESSAGES:  Despite rapid economic growth during the past decade, the stunting rate for children under 5, one of the primary indicators for child under-nutrition, is estimated at 46 percent in Papua New Guinea.  An analysis shows that family wealth, quality of food and history of malaria incidence are highly correlated with the stunting rate.  Three key areas have been identified as critical to alleviating the persistent and detrimental stunting rate in Papua New Guinea: 1). Exclusive breastfeeding and complementary food; 2). Interventions by health workers; and 3). Nutrition education. Introduction Figure 1: Stunting Rate for Children Under 5 and GDP per Capita Growth from 2005 to 2010 In 2014, following a number of years of high growth, the gross 60 2500 GDP per capita (current US$) domestic product (GDP) per capita in Papua New Guinea (PNG) 45.7 Stunting ( height for age ,% of children under 5) reached 8.0 percent. However, despite the relative robust 50 43.9 2000 economic growth, maternal and child undernutrition remain 40 pervasive and damaging conditions in PNG. Undernutrition, 1500 30 which encompasses stunting, wasting, and deficiencies of 1000 micronutrients (essential vitamins and minerals), is one of the 20 most significant causes of child mortality and morbidity. The 10 500 stunting rate (low height-for-age, indicating chronic restriction of 0 0 a child’s potential growth) for children under 5 in PNG was 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 estimated at 46 percent in 2010. Despite GDP growth by 6.85 percent on average from 2005 to 2010 (Figure 1), the stunting Overall Male rate remained basically stagnant from the 44 percent in 2005. Female GDP per capita Stunting in early life can have both short and long-term impacts Data source: GDP is from World Development Indicators; stunting in on child and adult health. It is associated with poor cognition and 2010 is from HIES 2009-2010; 2005 stunting rate is from 2005 National educational performance in childhood. Nutrition Survey. Page 1 HNPGP Knowledge Brief  Stunting is also associated with low adult wages, lost Figure 3. The trend of stunting across different across productivity, and increased risk of nutrition-related chronic different wealth quintiles. diseases when accompanied by excessive weight gain later in life (Subramanyam, Kawachi et al. 2011). Key Findings: Evidence is critical to guide effective nutrition-related policies and improve the stagnant stunting rate in PNG. The latest national representative survey, PNG Household Income and Expenditure Survey (HIES) 2009-2010, was used to further shed light on the persistent determinants of under-nutrition across all socio-economic groups in PNG. This analysis found that the incidence of stunting was related to overall wealth, caloric intake, education level of household heads and incidence of diarrhea and malaria. Data source: HIES 2010 The stunting and underweight rate sharply rises in the first 24 Malnutrition in PNG is prevalent and severe, and varies across months. Stunting rate rises quickly from 6 month onwards to 2 the regions. Not only are the overall rates high; the severe cases years and remains stable till 59 months. Figure 2 shows the among the stunted, underweight and wasted children are also association between malnutrition and age for both boys and girls high at around 50 percent in each category (Figure 3). The under 5 years old. The nutrition status is worse for boys than for incidence of undernutrition is not evenly distributed across the girls. A closer examination of stunting and age by wealth regions. The stunting rate is high across all the regions but quintiles shows that the trend for the first 24 months is similar extremely high at 61.5 percent in the Highlands Region. across the five quintiles. However, the difference is that the richer quintiles are able to mildly bend the curve while the Figure 4: The Severe Stunting, Wasting, and prevalence of stunting rate plateaus for the poor quintiles (Figure Underweight for Children under 5 in PNG 3). This implies that even in the better-off quintiles, children suffer from suboptimal breastfeeding and complementary food in 70.00% the first 24 month. 60.00% Stunting (z- 50.00% score <-2) Figure 2. Stunting status of males and females. 40.00% 30.00% Severe stunting 20.00% (z-score <-3) 10.00% 0.00% Wasting (z- score <-2) Data source: HIES 2009-2010 In general, the regression results in Figure 1 shows that household wealth and geographic locations are all crucial factors that contribute to children’s malnutrition. More importantly, food quality, measured by protein intakes, has significant predicting power on child malnutrition. Food quality and geographic Data source: HIES 2010 locations are correlated because in general, diet in highlands is low in protein. Further, children’s health status, more specifically, the incidence of malaria, has a significant correlation with child malnutrition. Page 2 HNPGP Knowledge Brief  Policy Recommendations Future Agenda These policy recommendations are based on empirical findings, syntheses from broader international literature and local To move toward more committed actions it is critical to improve consultations. the political environment, aligning multiple actors, and advancing policies and legislation. The government has made some 1. Exclusive Breastfeeding and Complementary Food progress. The National Nutrition Policy was recently endorsed The main window of opportunity to prevent stunting is the intra- by a number of departments in addition to the National uterine and postnatal periods, from conception until 24 months. Department of Health in early 2015, highlighting the political The evidence suggests that in PNG, women lack knowledge of commitment of multisectoral interventions to improve nutritional quality feeding practices even among better-off households. The outcomes in the country. However, a much stronger political high fertility rate and close birth gaps also make it difficult to give commitment along with adequate financing are required to infants sufficient exclusive breastfeeding in the first six months. ensure the successful implementation of the policy. Monitoring Significant reductions in stunting can be achieved through a and evaluation of nutritional programs are necessary to gather comprehensive set of priority interventions during this critical latest evidence on the effective and efficient ways to improve development stage. nutrition across different regions in PNG. 2. Interventions by Healthcare Workers There is an imperative need to build human resource capacity in References PNG to combat malnutrition challenges. Health workers can National Department of Health. 2013. Consultancy National Nutrition and should play a critical role in educating the public on how to Policy. improve nutrition outcomes. However, it will be difficult to conduct large-scale nutrition invention and monitoring at the Omot, N. 2012. Food security in East Timor, Papua New Guinea and facility level because the country has a shortage of nutritionists Pacific island countries and territories (ACIAR Technical Report 80). A. C. f. I. A. Research. Canberra, Australia. to steer the campaign. The capacity gap analysis, as part of the nutrition policy review, notes such capacity deficits at all levels of Subramanyam, M., I. Kawachi, et al. 2011. "Is Economic Growth the PNG health system (National Department of Health 2013). Associated with Reduction in Child Undernutrition in India?" PLos Med 8(3). This initiative requires strategy, financing and PNG leadership’s commitment. Victora, C., L. Adair, et al. 2008. "Maternal and child undernutrition: consequences for adult health and human capital." Lancet 371: 340– 3. Nutrition Education 357. Lack of access to information on proper nutrition was an important factor contributing to the high levels of malnutrition in PNG (Omot 2012). However, PNG’s key challenge to This HNP Knowledge Brief highlights the key findings from a study by the World Bank on the “Stagnant Stunting Rate despite Rapid Economic conducting large-scale nutrition education programs remains the Growth Factors Correlated with Malnutrition among Children under Five significant shortage of nutritionists. Although there is a blueprint in Papua New Guinea” by Xiaohui Hou. for human nutritionists and dietetics, it is yet to be adequately Please contact Xiaohui Hou at xhou@worldbank.org for any inquiries on financed and implemented. this work. Financial support for this work was received from the Australian Government. The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, or on PNG go to: www.worldbank.org/health or http://www.worldbank.org/en/country/png Page 3