With 45 percent of Liberian children under age five chronically or acutely malnourished, experts say nutrition is a burning health problem, but NGOs feel the Ministry of Health is not as worried as it should be, and lacks the capacity to provide leadership in bringing about solutions.
According to the Ministry of Health's 2009 national nutrition policy 44 percent of child deaths are associated with malnutrition. Chronic malnutrition – also known as stunting – affects 39 percent of under-fives, and 6.2 percent are acutely malnourished or "wasted".
Kinday Samba, a nutrition adviser at the UN Children's Fund (UNICEF) in Monrovia, told IRIN: "Thirty-nine percent stunting is a serious problem. It causes learning ability problems and will affect the future production of this country." If nothing is done to address stunting, UNICEF estimates that Liberia stands to lose $130 million in economic development between 2007 and 2015.
Peripheral to health
UNICEF and health NGOs are trying to work with the Ministry of Health to push malnutrition up the health agenda. There has been some progress, and "The ministry of health is more aware of nutrition now ... but still sees it on the periphery of health," said Cherie Fulk, a nutrition adviser at Action Contre la Faim (ACF), an NGO supporting therapeutic feeding centres for malnourished children in the capital, Monrovia.
"Nutrition is often overshadowed by other medical conditions, like malaria or diarrhoea, despite the fact that malnutrition, combined with these conditions, can more often be fatal." A "severe acute malnourished child" is more than nine times more likely to die than a well-nourished one, she said.
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Health Minister Walter Gwenigale told IRIN that providing nutrition services is a "major priority for the government", and forms an important part of the National Health Policy. The health ministry aims to reduce the 39 percent chronic malnutrition rate by one-third by 2011.
UNICEF's Samba said the health ministry was trying to mainstream nutrition issues in its basic healthcare package, and had developed a nutrition policy in 2008, which was a good start.
The move reflects region-wide progress by West African governments to improve coordination and leadership in nutrition issues, said UNICEF's West Africa spokesperson, Martin Dawes.
Since September UNICEF has been working with the Liberian health ministry on ways to shift the core behaviours that cause malnutrition, including promoting exclusive breastfeeding, and access to appropriate complementary foods and micro-nutrients.
Samba said health messages should be passed on when providing antenatal care and delivering babies, providing post-natal care and immunizations, and during visits to sick and well children, as well as in community-based fora such as women's groups.
However, aid agencies said implementing such intensive behaviour change in a country with a health system eroded by 14 years of conflict would present a considerable challenge.
Samba estimates that "80 percent of the population needs to be able access healthcare services" to get these messages across. "Community health volunteers are asked to tackle everything – hygiene messages, HIV, public health, the environment - so you cannot rely on them 100 percent to have the time to discuss nutrition behaviours in depth," she noted.
The country has 5,000 full-time or part-time health workers and 51 Liberian doctors to cater to a population of 3.8 million, according to the 2006 health survey.
UNICEF's Dawes said more trained nutritionists were needed region-wide to sustain health ministry efforts. "A minimum of 24,000 is needed to ensure that there is the right professional advice and input at every level," he told IRIN.
Health minister Gwenigale agreed. "One of the ways of dealing with nutrition is to train and deploy nutritional officers in rural Liberia, where nutrition is a problem among under-aged children." He said the ministry was working with donors to train nutritionists.
The European Commission will commit US$2.1 million to nutrition in 2010, UNICEF is stepping up its prevention efforts, and the UN World Food Programme will continue providing supplementary food to acutely and chronically malnourished Liberians in several counties.
However, ACF is not convinced that enough funding will be available to support projects and build up the Ministry of Health's capacity to take on nutrition by itself; running ACF's Monrovia-based therapeutic feeding centres cost US$1.5 million for eighteen months.
Unless more immediate funding is put on the table, "there may be no [ACF] acute malnutrition treatment available in the future," said Fulk. ACF is hoping the Ministry of Health will imminently take on and house its Monrovia-based nutrition projects in government health clinics and hospitals.