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South Asia Food And Nutrition

Vol. 1 Issue 1 February 2012

Security Initiative

Knowledge Brief Fostering Cross-Cutting Action

MALAYSIA A MULTI-SECTORAL SUCCESS STORY IN REDUCING MALNUTRITION

Challenges for South Asia Despite the proliferation of nutrition programs in South Asia and

By effectively coordinating policy and implementation, Malaysia reduced malnutrition for children under 5 years of age by 8 percent between 1990 (25%) and 2004 (17%). Several elements contributed to the country’s success, including: (i) the role of international organizations in motivating policy changes; (ii) establishing an appropriate institutional framework for multi-sector action; and (iii) building proper implementation arrangements that clearly defined the role of each ministry.

rapid economic growth, malnutrition rates remain stagnant and multi-sectoral facilitation of

a

national plan of action is rare. It is estimated that South Asia loses 2-3% of GDP annually due

History

to

A National Plan of Action for Nutrition of Malaysia (NPANM) was developed after consultations at the International Conference on Nutrition, Rome, in December 1992. Policies towards the development of this plan were formulated based on reports from nine working groups formed in order to discuss strategies to improve nutrition through multi-sectoral and multi-ministerial collaboration. These reports were presented and discussed at two multi-sectoral workshops in Malaysia.

Malnutrition

creased

labor

through

de-

capacity,

in-

creased healthcare costs, and diminished school attainment. If steps are not taken to reverse these trends, the results will prove even more costly.

Lessons for South Asia Rampant malnutrition has been

The goal of this knowledge brief

The plan mandating inter-ministerial collaboration was adopted by the parliament in order to provide a separate and distinct budget for the nutrition agenda. The National Coordinating Committee on Food and Nutrition (NCCFN), made up of top officials in various ministries, was thereafter established and the Directorate of Nutrition was set up in the Ministry of Health (MOH). From this parliamentary edict; existing regulations were strengthened, labeling of nutritional facts on food items was mandated, and professional nutrition/dietics associations were officially delineated from non-professionals.

series is to document those

Institutional Architecture

successfully addressed by initiatives in Malaysia, Thailand, Vietnam, China and in Latin America through

the

development

of

nutrition initiatives. Such initiatives have proven to have not only a substantial and positive impact on nutrition outcomes, but also outcomes in other sectors such as health and education.

relevant experiences in order to extract usable lessons and transfer them to the South Asian context. Several learning opportunities have presented themselves in this report, which can enable the replication of these dramatic successes stories in South Asia.

The structure of the institutions established by NPANM is innately multi-sectoral. The NCCFN is headed by the Deputy Director-General of Public Health of the MOH, includes six other officials from the MOH, and is assisted by a full time secretariat under the MOH Division of Family Health Development. Yet, this body goes beyond public health and it further includes representatives from; the Economic Planning Unit of the

Office of the Prime Minister; the Implementation Coordinating Unit of the Office of the Prime Minster; the Institute for Medical Research, the Ministry of Agriculture Research and Development Institute, the Nutrition Society of Malaysia, a WHO Clinical Nutritionist, local universities, and a number of other Ministries and sub-units. Crucially, the role of each ministry was clearly defined and provided with a clear terms of reference. To ensure sustainability this committee has met at least once every six months in order to keep the agenda moving. The program is currently implemented through the ten year plans. National and State Delineations The NPANM utilizes organizational structures at national, state and district levels. The various ministries, agencies and institutions have set up appropriate sectoral mechanisms to prioritize, develop, implement and monitor the related components of the NPANM. The aim was to get the different —and often siloed— Ministries to work towards nutrition outcomes in their respective sectors in order to achieve an outcome greater than the sum of its parts, while keeping in mind inherent administrative barriers. Moreover, in Malaysia, ministries do not have jurisdiction over state level activities (which do not take up the topic) and so central government officials were physically posted to the state and local offices for technical guidance and outreach. Hence decentralization was carried out not by providing subnational governments with more resources but through the placement of central government nutrition specialists at the state and local offices.


Ministerial Participation

Ministry of Education (MOE)

Ministry of Agriculture (MOA)

Ministry of Health (MOH)

Ministry of Rural Development (MRD)

Ministry of Social Welfare and Rural

A MULTI-SECTORAL SUCCESS STORY IN REDUCING MALNUTRITION

Development

Ministry of Information

Ministry of Youth and Sports

Ministry of Domestic Affairs

Ministry of International Trade and Consumer Affairs

Ministry of Women, Family and

Civil Society’s Role

Community Development

Ministry of Housing and Local Government

Office of the Prime Minister, Economic Planning Unit/ Implementation Coordinating Unit

Division of Family Health Development

Ministry of Agriculture Research and Development Institute

Nutrition Society of Malaysia

Malaysian Dietitians Association

Malaysian Pediatric Association

Obstetric and Gynecological Association Malaysian Breastfeeding Advisory Association

Malaysian Society for the Study on Obesity

Malaysian Federation of Manufacturers

Private Hospital Association

Association of Registered Childcare Providers of Malaysia

Sectoral Action & Technical Response

Institute for Medical Research

NGO Participation

The private sector and NGOs were also involved in the implementation of the programs through seminars, consultations and workshops. In addition, several NGOs also actively participated in policy making. The private sector groups which participated include Malaysian Federation of Manufacturers and the Private Hospital Association. Ultimately, it was joint collaboration (but not joint implementation) amongst Civil Society and multiple Ministries that led to Malaysia’s Success.

Malaysian Lactation Advisors and Consultants Associations

The MOH and MRD were given authority to prevent and manage infectious diseases and improve nutrition through the promotion of improved water supply and sanitation. The National Environmental Sanitation Program (NESP) was implemented and safe water was provided to most parts of the country. The goal was to improve nutrition through the reduction of diarrhoeal diseases and other food and waterborne illnesses. This was implemented through environmental health programs that address safe drinking water and waste disposal. Mosquito and rodent control have also come under the jurisdiction of the NESP in order to prevent dengue and other diseases that affect nutrition outcomes. Through coordination between the MOE and MOH, school nutrition programs were also established to improve the nutritional status of children. Specifically, iodine deficiency disorders, vitamin A deficiency and Iron deficiency were addressed. Additionally, nutrition education was emphasized among mothers with infants, breastfeeding programs were promoted, and access to nutrition information among the population was given emphasis. Measurement of improvements in nutritional status was established through monthly nutrition assessment in health clinics and schools.

Like many others, Malaysia emphasized the “availability” dimension of food security by introducing policy measures to boost paddy and rice production under the National Food Security Policy, with the aim of increasing total rice consumption. Despite the introduction of National Plan of Action on Nutrition, agricultural projects somewhat neglected the core set of anthropometric indicators (“stunting”, “underweight” and “wasting”). Many of the policy measures were targeted at area expansion and yield increases, but it was suggested that the dominant path to achieve the self-sufficiency is through Research and Development (R&D) at specialized paddy and rice research centres. To this end agricultural/food R&D expanded in Malaysia during the past three decades. Most of the efforts to increase rice and food production were also carried out via a comprehensive set of market interventions in the form of input and output subsidies, production programs, Guaranteed Minimum Price for paddy, Paddy Price Support, and other production-based incentives. Total consumption of rice and other foods increased by over twenty percent since 1990 (MOA, Malaysia). However, since 2006 the impact of agricultural products on nutrition indicators is also being measured. Preliminary results are mixed, with some areas experiencing improvements in nutrition indicators, while others did not, despite increases in rice and other food consumption.


Results in Malaysia

Room for Growth

The evaluation of the program after the first NPANM in 2005 showed considerable improvements in the nutritional status of the population. Based on the surveillance data of the MOH, there was reported:

The Malaysian experience has many invaluable lessons for tackling malnutrition. However, there is still room for growth in the Malaysian context including:

7.7% reduction in Underweight Children under 5 between 1990 (25%) and 2004 (17.3%) 8.5% reduction in Anemia in female children under 6 between 1990 (29%) and 2000 (20.5%) 7.3% reduction in Anemia in male children under 6 between 1990 (25%) and 2000 (17.7%) 5.9% reduction in Vitamin A deficiency for female children between 1990 (10.4%) and 2000 (4.5%) 3.8% reduction in Vitamin A deficiency for male children between 1990 (6.3%) and 2000 (2.5%)

It is also noteworthy to report 99% of households had improved water and 96% had improved sewage systems by 2005, which heavily contributed in helping achieve nutritional gains.

Elements of Success Several salient features of Malaysia’s initiative have led to reductions in malnutrition:

Preventing & managing infectious diseases through improvements in water supply and sanitation is likely to reduce malnutrition

Lack of community feedback (demand side) was identified as a weakness and is being currently addressed through field visits by government personnel and internet communications.

Limited participation by the MOA especially with respect to: (i) incorporating measurements of nutritional status — through anthropometrics — in agricultural projects; (ii) crop diversification; (iii) effective dissemination of nutrition information.*

Policy Advice for South Asia An investment in nutrition now can prevent healthcare costs in the future. Inaction is costly and a policy response is necessary. Recommend steps to tackle this “intractable curse” include:

Emphasizing the role of several ministries in promoting nutrition-relevant projects such as; expanded health & nutrition education, behavior change components and R&D Preventing and controlling specific micronutrient deficiencies (e.g. Vitamin A) is effective in clarifying an attainable goal

Improving household food security and secure “access” through social and agricultural programs

Protecting consumers through improved food quality and safety

Promoting breastfeeding, appropriate diets and healthy lifestyles

Assessing, analyzing and frequently monitoring the nutritional status of populations through the measurement of anthropometric indicators (rather than consumption)

Incorporating nutritional objectives, considerations and components into development policies and programs must be widespread. Defined roles for each Ministry—agreed upon at a national conference of decision makers—helps achieve clarity in purpose. Earmarking a discreet budget for nutrition purposes in several ministries provides an incentive for multi-sectoral collaboration. Cross-Sectoral collaboration, (not necessarily joint implementation of projects), can be effective and efficient in delivering results from many sector-specific interventions. While ministries can act separately, they should do so with clearly defined roles, handed down by a National Plan of Action. Centralized program management at the federal level (without local participation) was pursued in Malaysia, although this approach is not likely to work in some South Asian countries, due to larger populations and areas, hence other approaches (i.e. decentralization with the assumption of authority/responsibility by local governments) may also need to be considered.

Engaging with international organizations in workshops to motivate multi-sectoral collaborations for nutrition has led to actionable and informed projects.

Encouraging the participation of NGOs and other community organizations is likely to positively affect nutrition outcomes.

*Incorporation of nutrition into select agricultural projects has begun. Preliminary results are expected by the end of 2012.

Technical Notes Stunting is low height-for-age Underweight is low weight-for-age Wasting is low weight-for-height Improved Water Source % of population with access Improved Sanitation Facilities % of population with access Anemia is a lack of healthy red blood cells resulting in decreased oxygen uptake, energy and health Vitamin A deficiency results in blindness and may increase the risk of child mortality

Caring for the Socio-economically Disadvantaged & Nutritionally Vulnerable through School Feeding & Nutrition Education


SAFANSI Knowledge Brief Series

Malaysia Malnutrition (underweight)

M AL AY S I AN R E S U L T S

 7.7% reduction in Underweight Children under 5 between 1990 (25%) and 2004 (17.3%)

 8.5% reduction in Anemia in female children under 6 between 1990 (29%) and 2000 (20.5%)

 39.1% reduction in the under-5 mortality rate from 16.1 (per 1,000)

Investments in Nutrition Count:

in 1992 to 6.3 (per 1,000) in 2010

An Investment in Nutrition Now can Prevent Healthcare Costs in the Future

TURNKEY SOLUTIONS

Water supply and sanitation

Crop Land Intensity

programs reduce diseases such as diarrhea which in turn is likely to reduce malnutrition.

Agricultural growth is Necessary, but not Sufficient! Crop Diversification and behavior change components must accompany such interventions.

Promotion of breastfeeding and proper infant and child care is necessary.

Agricultural Growth is Necessary, but Not Sufficient:

ADDITIONAL RESOURCES

Crop Diversification & Behavior Change Components Must Accompany Such Interventions

Assessing Food Security: A MicroStudy of 24 Villages in Malaysia

Projects in Malaysia

www.worldbank.org/safansi

Benchmarking of Irrigation

Food Security and Growth: Malaysia's Strategic Approach and Future Adjustments

Supported by:

The World Bank This volume was created by staff of the International Bank for Reconstruction and Development/The World Bank. The findings, interpretations, and conclusions expressed in this paper do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. This material has been funded by both AusAID and UKaid from the Department for International Development; however, the views expressed do not necessarily reflect these departments’ official policies.


MALAYSIA: A MULTI-SECTORAL SUCCESS STORY IN REDUCING MALNUTRITION