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!

eduardo@saude.gov.br