www.thelancet.com 65 Maternal and Child Undernutrition 4 Maternal and child undernutrition: effective action at national level Jennifer Bryce, Denise Coitinho, Ian Darnton-Hill, David Pelletier, Per Pinstrup-Andersen, for the Maternal and Child Undernutrition Study Group* 80% of the world’s undernourished children live in just 20 countries. Intensified nutrition action in these countries can lead to achievement of the first Millennium Development Goal (MDG) and greatly increase the chances of achieving goals for child and maternal mortality (MDGs 4 and 5). Despite isolated successes in specific countries or for interventions—eg, iodised salt and vitamin A supplementation—most countries with high rates of undernutrition are failing to reach undernourished mothers and children with effective interventions supported by appropriate policies. This paper reports on an assessment of actions addressing undernutrition in the countries with the highest burden of undernutrition, drawing on systematic reviews and best-practice reports. Seven key challenges for addressing undernutrition at national level are defined and reported on: getting nutrition on the list of priorities, and keeping it there; doing the right things; not doing the wrong things; acting at scale; reaching those in need; data-based decisionmaking; and building strategic and operational capacity. Interventions with proven effectiveness that are selected by countries should be rapidly implemented at scale. The period from pregnancy to 24 months of age is a crucial window of opportunity for reducing undernutrition and its adverse effects. Programme efforts, as well as monitoring and assessment, should focus on this segment of the continuum of care. Nutrition resources should not be used to support actions unlikely to be effective in the context of country or local realities. Nutrition resources should not be used to support actions that have not been proven to have a direct effect on undernutrition, such as stand-alone growth monitoring or school feeding programmes. In addition to health and nutrition interventions, economic and social policies addressing poverty, trade, and agriculture that have been associated with rapid improvements in nutritional status should be implemented. There is a reservoir of important experience and expertise in individual countries about how to build commitment, develop and monitor nutrition programmes, move toward acting at scale, reform or phase-out ineffective programmes, and other challenges. This resource needs to be formalised, shared, and used as the basis for setting priorities in problem-solving research for nutrition. Introduction Each of the first three papers in this Series on maternal and child undernutrition has important but different implications for those working at national and subnational levels in countries where the burden of undernutrition is high. Black and colleagues report 1 that more than a third of deaths of children under the age of 5 years and disability-adjusted life-years worldwide can be attributed to undernutrition. These estimates make undernutrition the largest risk factor in any age-group for the global burden of disease. 2 Victora and colleagues’ findings 3 are a wake-up call to finance ministries and development agencies in countries with a high burden of undernutrition, showing that adequate nutrition in early life is essential for human capital formation. Undernourished children are more likely to be below average height when they reach adulthood, to have lower educational achievement, and to give birth to smaller infants than are those who are nourished adequately. Maternal and child undernutrition is also associated with lower economic status in adulthood, with effects that spill over to future generations. 3 These findings reinforce existing assertions about the positive economic outcomes of good nutrition and its importance as a prerequisite for economic development. 4,5 Published Online January 17, 2008 DOI:10.1016/S0140- 6736(07)61694-8 This is the fourth in a Series of five papers about maternal and child undernutrition *Members listed at end of paper Johns Hopkins Bloomberg School of Public Health (J Bryce EdD); WHO, Geneva, Switzerland (D Coitinho PhD); UNICEF, New York, NY, USA (I Darnton-Hill MBBS); and Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA (D Pelletier PhD, Prof P Pinstrup-Andersen PhD) Correspondence to: Jennifer Bryce, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD, 21205, USA jbryce@jhsph.edu Key messages • 80% of the world’s undernourished children live in just 20 countries. Intensified nutrition action in these countries can lead to achievement of the first Millennium Development Goal (MDG) and greatly increase the chances of achieving goals for child and maternal mortality (MDGs 4 and 5) • Nutrition should be a priority at national and subnational levels because it is central for human, social, and economic development • The period from pregnancy to 24 months of age is a crucial window of opportunity for reducing undernutrition and its adverse effects. Programme efforts, as well as monitoring and assessment, should focus on this segment of the continuum of care • There is a reservoir of important experience and expertise in individual countries about how to build commitment, develop and monitor nutrition programmes, move towards acting at scale, reform or phase-out ineffective programmes, and other challenges. This resource needs to be formalised, shared, and used as the basis for setting priorities in problem-solving research for nutrition • Interventions with proven effectiveness that are selected by countries should be rapidly implemented at scale • Nutrition resources should not be used to support actions unlikely to be effective in the context of country or local realities • In addition to health and nutrition interventions, economic and social policies addressing poverty, trade, and agriculture that have been associated with rapid improvements in nutritional status should be implemented Series