MALNUTRITION: Rwanda: Uniting to Uproot Malnutrition
BY DR. AGNES BINAGWAHO, 11 DECEMBER 2012
While Rwanda has made dramatic progress in decreasing child mortality over the past ten years, reducing the rate of deaths from 183 per 1,000 live births in 2000 to 54 in 2011, chronic height-for-age malnutrition (or stunting) has remained too high among children under the age of five.
Earlier this year, His Excellency President Paul Kagame challenged the nation to eliminate the root causes of stunting by working together through a multi-sectorial approach from the community to the central level and across sectors.
The rate of stunting among children under the age of five years was found to be 51 per cent in 2005; by 2010, it was still far too high at 44 per cent. Over the same timeframe, the prevalence of underweight had declined by roughly 30 per cent, from 18 per cent to 11 per cent of children. Based on this and numerous studies by the Ministries of Health and Agriculture, it was clear that the driver of persistent malnutrition was not a lack of sufficient food, but a complex set of social, cultural, and economic factors interacting to prevent many children from accessing a healthy diet.
This challenge necessitated a multi-pronged approach to identify and combat the fundamental causes of malnutrition with significant emphasis on prevention. The most important strategies identified as priorities for action were the diversification of food sources, systematic growth monitoring of children at the community level, early detection of malnutrition, access to clean drinking water, and, most importantly, widespread awareness about the kinds nutritious diets children need and how to prepare them.
Existing programmes to promote access to a balanced diet among the most vulnerable have been strengthened, and new initiatives have been launched to fill gaps. The Ministry of Agriculture has continued to provide leadership in the national Girinka (One-Cow-per-Family) programme, Akarima k'igikoni (kitchen gardens), and One Cup of Milk per Child programs, and the central government has supported these initiatives by doubling the agriculture budget between 2006 and 2011.
More than 200,000 cows have now been distributed to families categorized as ubudehe socioeconomic 1 and 2 (equivalent to the poorest households), and these animals have begun to bear offspring which recipient families then pass along to their neighbors who have yet to receive a cow.
With the support of local communities through monthly umuganda communal work days, kitchen gardens consisting of nutritious vegetable and fruit plants have continued to be scaled up across the country among ubudehe 1 and 2 families. Schools in 14 of 30 districts now receive one liter of milk per 3 each week, and this programme will be expanded to cover every school in the nation in the near future.
To ensure that children who do become malnourished - whether through severe or moderate growth shortfalls, underweight, or stunting - are linked to the health system and provided with appropriate treatment (from Plumpy'nut Ready-to-Use-Therapeutic Food to multivitamin supplementation), the Ministry of Health has incorporated monthly growth monitoring into the national community health system.
The country's 45,000 community health workers (responsible for child health, reproductive health, and health promotion) now make regular household visits and can report children found to be malnourished to their local health centre, district hospital, and the central level via the cell phone-based RapidSMS system. Referrals of malnourished children have begun to occur much more rapidly than in years past, and preliminary data from the Ministry's community health information system (SISCOM) show that moderate malnutrition has fallen by half between January and November 2012 - from 1.2 per cent to 0.6 per cent at the community level.
To contribute to improving the population's access to potable drinking water, in addition to the work done by the Ministry of Infrastructure, the Ministry of Health has worked with partners to provide water filters to nearly 2,000 households in ubudehe1 and 2 across the country, with plans to scale up to the 600,000 poor households across the entire country
In addition to existing forms of filtration and purification (such as chlorination tablets), these filters help to improve hygiene and hence minimise children's exposure to pathogens that cause diarrheal disease. Furthermore, recent international data from the United Nations project Rwanda to be on track for Millennium Development Goal 7, which includes key indicators for access to water and sanitation.
These developments are crucial to the fight against malnutrition, as persistent diarrheal disease prevents children from absorbing the nutrients they need and makes them feel sick so that they do not eat enough. This is another reason why the Ministry of Health worked with the GAVI Alliance to roll out the rotavirus vaccine for the prevention of one of the most dangerous causes of diarrhea this May, and preliminary data show nearly 95 per cent coverage among infants.
All of these interventions will be essential if Rwanda is to succeed in our goal of dramatically reducing the prevalence of all forms of malnutrition. With the bounty of agricultural resources our land provides and the wisdom of the Rwandan farmer, we have all the tools we need to keep every child healthy and growing.
But ensuring that improved availability and diversity of food sources translates into better health outcomes for the most vulnerable children requires more than accelerating production - it necessitates a revolution in the way that families prepare their children's food and understand the importance of their children receiving nutritious diets for a brighter future.
For this reason, the government has started a massive educational campaign on "how to cook," and pamphlets have been distributed across the country detailing the kinds of foods that children need, how to cook them, and the importance of proper hygiene and exclusive breastfeeding for children under the age of six months.
Demonstration kitchens are being rolled out in districts across the country, to show families recipes that make use of local foods in such a way as to maximise their nutritional value to children using traditional cooking methods.
Each umudugudu will hold a meeting to strategise on ending malnutrition on December 27 of this year, and these meetings will result in the publication of comprehensive local plans.
To conclude, Rwanda has made great progress this year towards the goals we have set as a people under the leadership of our President. But our job will not be finished until every single child is assured a healthy and balanced diet, until no mother worries about how to feed her baby, until no household goes without a clean water source or a hygienic and sustainable toilet.
From scaling up drugs for HIV to reducing child mortality, our nation has proven that we have what it takes to achieve what some have called impossible, and I have absolute faith that together we will successfully apply this same sense of purpose to the fight against malnutrition.
I can guarantee you that your public servants in the Ministries of Agriculture, Gender and Family Promotion, Local Government, Education and Health are spending sleepless nights working with our colleagues and partners to devise, scale, and monitor solutions to the root causes.
If you have specific complaints about the response to malnutrition or suggestions on how to improve, I urge you to engage with us via Twitter through @RwandaMOH and my personal account @agnesbinagwaho. Be specific -name names, share exact locations, and we will explore every claim. Furthermore, the next #MinisterMondays Twitter and SMS (via 0788386655) discussion on Monday, December 17 will address the state of the malnutrition response, and I look forward to your participation.
The writer is the Minister of Health of the Republic of Rwanda.
After service in the British SAS Regiment the author became a physician and then an orthopaedic surgeon.
He has held professorial positions in Canada, Vietnam and the United States, practiced and taught orthopaedic surgery in three continents and in several wars.
He has extensive experience as an expert witness in court. Somewhere along the way, time was found to operate a four hundred acre mixed farm, a one hundred seat restaurant and to obtain a licence as a flying instructor.
The author's books are available from bookstores, the publishers, or from on-line bookstores such as Amazon, Barnes and Noble, and Indigo/Chapters.