The U.S. government's global hunger and food security initiative, Feed the Future, has prevented 2.2 million children from experiencing malnutrition in sub-Saharan Africa, according to new research led by Stanford Health Policy's PhD candidate Tess Ryckman.

The researchers compared children’s health in 33 low- and middle-income countries in sub-Saharan Africa. In 12 of those countries, Feed the Future provided services such as agricultural assistance and financial services for farmers, as well as direct nutrition support, such as nutrient supplementation. 

The study, published online Dec. 11 in The BMJ, found a 3.9 percentage point decrease in chronic malnutrition among children served by Feed the Future, leading to 2.2 million fewer children whose development has been harmed by malnourishment.

“What we see with stunting rates is striking,” Ryckman said. “I would argue that 2 million fewer children stunted over seven years is major progress and puts a substantial dent in total stunting levels. And that’s 2 million children who will now have the levels of physical and cognitive development to allow them to reach their full potential.”

Stunting, or having a low height for a particular age, is a key indicator of child malnutrition. Children who aren’t properly nourished in their first 1,000 days are more likely to get sick more often, to perform poorly in school, grow up to be economically disadvantaged and suffer from chronic diseases, according to the World Health Organization.

A Controlled Study

Feed the Future is thought to be the world’s largest agricultural and nutrition program, with around $6 billion in funding from USAID (plus more from other federal agencies) between 2010 and 2015. Despite its size, much remains unknown about the effectiveness of the program.

The researchers analyzed survey data on almost 900,000 children younger than 5 in sub-Saharan Africa from 2000 to 2017. They compared children from the Feed the Future countries with those in countries that are not participants in the program, both before and after the program’s implementation in 2011.

The researchers found the results were even more pronounced — a 4.6 percentage point decline in stunting — when they restricted their sample to populations most likely to have been reached by program. These included children who were younger when the program began, rural areas where Feed the Future operated more intensively, and in countries where the program had greater geographic coverage.

“Our findings are certainly encouraging because it has been difficult for other programs and interventions to demonstrate impact on stunting, and this program has received a lot of funding, so it’s good to see that it’s having an impact,” Ryckman said.

Multifaceted Approach to Nutrition

Experts are divided about the best way to help the world’s 149 million malnourished children: Is assistance that directly targets nutrition, such as breastfeeding promotion or nutrient supplementation, more effective? Or is it also beneficial to tackle the problem at its root by supporting agriculture and confronting household poverty?

The authors, including Stanford Health Policy’s Eran Bendavid, MD, associate professor of medicine, and Jay Bhattacharya, MD, PhD, professor of medicine, a senior fellow (by courtesy) at the Freeman Spogli Institute of International Studies and a senior fellow senior fellow at the Stanford Institute for Economic Policy Research, said their analysis supports the value of a multifaceted approach to combating malnutrition among children, namely leveraging agriculture and food security interventions.

“Independent evaluations of large health policy programs such as Feed the Future help build the evidence base needed to tackle persistent patterns of undernutrition,” said Bendavid, an epidemiologist. “The widespread prevalence of stunting and chronic undernutrition is among the most common and yet most stubborn cause of underdevelopment in the world, and learning what works in this space is sorely needed.”

The researchers, including Stanford medical students Margot Robinson and Courtney Pederson, speculated that possible drivers of the program’s effectiveness include three features of Feed the Future’s design: its country-tailored approach; its focus on underlying drivers of nutrition, such as empowering female farmers; and its large scale and adequate funding.

The authors hope their independent evaluation of the program might lead to more funding and support for it. At the very least, they said, it should demonstrate to people working on Feed the Future and the broader global nutrition program community that programs focused mostly on agriculture and food security — indirect contributors to malnutrition — can lead to success.

Value Unknown

Feed the Future has been scaled back in recent years — it once served 19 countries and now reaches only 12. The program’s budget also remains somewhat murky.

“While there isn’t much data on the program’s funding under the Trump administration, the program appears to have been scaled back, at least in terms of the countries where it operates,” Ryckman said. “It’s possible that some of these gains could be lost, absent longer-term intervention from Feed the Future.”

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The researchers also did not look at whether the program provided high value for the money spent.

“While we find that it has been effective, it hasn’t led to drastic declines in stunting and it is unclear whether it is good value for money,” she said.

Ryckman also noted that USAID’s own evaluation of its program is tenuous because it looked only at before-and-after stunting levels in Feed the Future countries without comparing the results to a control group or adjusting for other sources of bias, which is problematic because stunting is slowly declining in most countries.

“These types of evaluations are misleading,” Ryckman said. “The U.S. government really needs to prioritize having their programs independently evaluated using more robust methods. That was part of our motivation for doing this study.”

Support for the study was provided by the National Institutes of Health (grant P20-AG17253), the National Science Foundation and the Doris Duke Charitable Foundation.

The boy’s genetic disorder would have been terminal anywhere, but thanks to Wise and local health promoters, the boy’s family had years with him instead of months.

They found the doctor through the Guatemala Rural Child Health and Nutrition Program, a collaboration between Wise and the health promoters to eliminate death by malnutrition for children under 5.

While Wise spoke to the heartbroken mother, his Stanford research assistant Alejandro Chavez helped the promoters set up inside a local community center to measure the weight and height of local kids to determine their nutrition level.

Chavez and the promoters had worked together for months to create an app for tablets that will make it easier to find malnourished children.

The app they designed will decrease training time for new health promoters and allow the program to expand. The goal is to distribute the app globally to help programs in other countries tackle malnutrition.

Children in crisis

As recently as 2005, about one of every 20 children in this rural area of Guatemala died before their 5th birthday. Almost half the deaths were associated with severe malnutrition.

“The death of any child is always a tragedy, but the death of any child from preventable causes is always unjust,” said Wise, a Stanford Health Policy core faculty member.

Along with other faculty from the Freeman Spogli Institute for International Studies (FSI) and the School of Medicine, Wise created the Children in Crisis Initiative to save the lives of children in areas of poor governance. The program brings together Stanford researchers and students across disciplines.

Nowhere are their efforts better illustrated than in the rural communities around San Lucas Tolimán, in the central mountains of Guatemala.

The program’s effectiveness rests on a deep respect for the local communities merged with innovation by Stanford researchers.

“It’s absolutely essential to any program that the people in need be part of the solution,” said Wise. Unlike many nongovernmental organizations and health programs, Wise believes the way to create a sustainable health system is for the locals to run it, so the health promoters manage the program’s day-to-day activities.

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This leaves the Stanford team free to focus on innovation – such as the new app. They believe the technology could change child health programs around the world. Wise’s team has partnered with Medic Mobile – a nonprofit that creates open-source software for health care workers – which plans to distribute the app to other areas suffering from malnutrition.

The six Android tablets purchased by Children in Crisis are enough to monitor the program’s 1,500 kids through the app.

Role of nutrition

When done well, nutrition surveillance is very effective at decreasing child mortality in poor countries.

“Nutrition contributes enormously to health and well-being,” Wise said as he walked through Tierra Santa, a small community near San Lucas, making house calls. “So the focus of our work turned to improving young child nutrition. It’s not an easy thing to do in a place that’s extremely poor.”

Wise and his colleagues – Stanford medical student Tori Bawel and Stanford professor of pediatrics Lisa Chamberlain – made their rounds during their visit in March. Evidence of poverty was everywhere.

Here, clean tap water is a dream and even the sturdier homes often lack four walls or paned windows, though the children were neatly dressed in T-shirts or colorful traje, traditional Mayan clothing.

It’s hard to provide proper nutrition when most families can’t find enough work to buy adequate food. But a little help can make a big difference.

Bawel, a first-year medical student who plans a career improving health in areas of poverty, was struck by the impact the promoter program has had on the community.

“There are children who need supplements and nutrition to stay alive,” she said. “Without this program, that infrastructure does not exist.”

With FSI’s assistance, the nutrition program distributes Incaparina, a supplement of cornmeal, soy and essential nutrients. The sweet, mealy drink helps the program’s most malnourished children get back on track.

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Every two months, the promoters gather each community’s children to measure their weight and height. Children and their mothers sit patiently, waiting for their turn. The children enjoy a cup of Incaparina, and their mothers eagerly listen to the promoters’ tips for keeping their children healthy.

“It’s very important to me,” said Elsira Rosibel Samayoa, who brought her 2-year-old to be measured. “There are mothers who don’t understand the importance of monitoring their children’s weight, but I do.”

Since its implementation in 2009, the Stanford program has slashed nutrition-based mortality in the participating communities by about 80 percent and decreased severe malnutrition by more than 60 percent – saving hundreds of children’s lives.

However, nutrition surveillance and intervention isn’t easy. Tracking nutrition takes training and expertise, and when the local population rarely exceeds a fourth-grade education, learning these skills is especially challenging. Detailed graphs on a standard growth chart are essential to identifying malnourished children.

“The community health workers are extremely capable and smart, but some have never seen a graph before,” said Wise. “Think about what it is to try to explain a graph to someone for the first time.”

It takes the health workers about three years to learn to graph and then interpret the results for intervention.

Wise said, “So we all got together and said, ‘How do we make this easier to do?’”

The app was the answer.

‘Let’s create an app’

Enter Alejandro Chavez, a recent Stanford computer science graduate and Stanford Health Policy research assistant. He developed the app to collect child health data, then determine the child’s degree of malnutrition and suggest intervention.

“The major goal was to lower training requirements and make programs like this simpler to start and maintain,” said Chavez, who now lives and works in Guatemala, where he gets daily feedback from the health promoters.

“I feel like they’ve been very honest with me about things I need to improve,” he said.

Cesia Lizeth Castro Chutá is a senior coordinator for the program who has worked with Chavez to ensure that the app meets the promoters’ needs.

“The tablet automatically generates the information we need to know,” she said. “It becomes easier to confirm that a child is malnourished and needs supplements.”

Looking forward

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With the app’s launch, it looks like training time for the promoters will be reduced from three years to less than six months. That means new communities can be incorporated into the program quickly, creating broader access to care.

Meanwhile, many health programs around the world are waiting to see how well the Stanford app works in Guatemala.

Josh Nesbit, a Stanford alumnus and Medic Mobile CEO, said, “As more health programs recognize the importance of nutrition and implement community-based interventions, screening and surveillance tools will be critical. We must learn from Dr. Wise’s success.”

China’s demographic landscape is rapidly changing, and the government has responded by launching ambitious social and health service reforms to meet the changing needs of the country’s 1.3 billion people. This week, officials approved a five-year plan to develop a comprehensive nationwide social security network.

Karen Eggleston, the Asia Health Policy Program (AHPP) director and a Stanford Health Policy fellow, discusses the success of China’s health care reforms—including its recently established universal health care system—and the long road still ahead.

Why is the overall health and wellbeing of China’s population important globally?

There are many reasons why the health of China’s citizens matters within a larger global context. On the most basic level, China represents almost 20 percent of humanity. But it is also a major player in the world economy and it depends on having a healthy workforce, especially now that its population is aging more. The government’s ability to meet the needs of its underserved citizens contributes to a more productive and stable China, and works towards closing the huge gaps we see in human wellbeing across the world.

China also potentially offers a model for other developing countries, such as India, that may want to figure out how to make universal health coverage work at a tenth of the income of most of the countries that have put it into place before.

What are some of the biggest changes in China’s health care system since 1949?

One of the most significant changes is that China has achieved very basic universal health insurance coverage in a relatively short period of time.  

Throughout the Mao period (1949–1978) there was a health care system linked to the centrally planned economy, which provided a basic level of coverage via government providers with a lot of regional variation. When economic reform came in 1980, large parts of the system—particularly financing for insurance—collapsed. The majority of China’s citizens were uninsured during the past few decades of very rapid social and economic development.

China’s overall population is changing quite dramatically, which means it has different health care needs, such as treating chronic disease and caring for an increasingly elderly population. The central government is trying to establish a system of accessible primary care—a concept that China’s barefoot doctors helped to pioneer but that fell into disarray—and health services that fit these new needs. 

How does China’s basic health care system work? Are there segments of the population still not receiving adequate coverage and care?

China has had a system where people can select their own doctors. Patients usually want to go to clinics attached to the highest-reputation hospitals, but of course, when you are not insured you almost always by default go to where you can afford the care. “It is difficult to see the doctor, and it is expensive” has been the lament of patients in China, so an explicit goal of the health care reforms has been to address this.

The term “universal coverage” has different definitions. China initially put in place a form of insurance that only covers 20 or 30 percent of medical costs for the previously uninsured population, especially in rural areas. Benefits have expanded, but remain limited. As with the previous system, disparities in coverage still exist across the population. China not only has a huge population with huge economic differences, but within that there is a large migrant worker population. It is a challenge to figure out how to cover these citizens and how to provide them with access to better care. The government is quite aware there are segments of the population not receiving equal coverage, and it continues to strive to resolve the issue.  

What are the greatest innovations in China’s health care system in recent years?

One of the most remarkable things China has achieved is really its new health insurance system. Even if the current coverage is not particularly generous it is nearly universal, and mechanisms are put in place each year to provide more generous coverage. China is also working on strengthening its primary care and population health services, infusing a huge sum of government money into these efforts. It is the only developing country of its per-capita income that has achieved such results so far.

Interestingly, a lot of people assume China achieved its universal coverage by mandate, while in fact the central government did so by subsidizing the cost for local governments and individuals. This reduces the burden, for example, on poorer rural governments and residents, and is one innovative way China is trying to eliminate the disparity in access to care.

Eggleston has recently published a working paper on China’s health care reforms since the Mao era on the AHPP website, as well as an article in the Milken Institute Review.

Gordon Liu, a Chinese government advisor on health care and the executive director of Peking University’s Health Economics and Management Institute, spoke at Stanford on May 29 on the future of China’s health care system.