- 96 - TRENDS IN THE NUTRITIONAL STATUS OFBATSWANA B.N. KGOSIDIN'l'SI, P.L. Ith of 1984. - 97 .....; 'lhe:'rtost ~y-usE!dindicatorofnutritional status in IhtsWana ':lsthe ,~ight prEWal:enceof Ut1derfi ve children (i.e.t11oSe diilm-en whose we:lghts'fall below eo percent of the Harwrd "St.~,.:. Children are convenient for IlDnitoring the nutri tional st.atus of the population because they are particularly" vulnerable to acute and chronic malnutrition as a resul t of shOrt. arid long term food shortages. '!hus, changes in the nutritional status of yalng children provides an early indication of likelyd1anges'in theoJerall population. In addition to urrlerweight prevalence, other useful indicators of nutritibrlalst.atustri'tne"oontext 'Of 'soci~anic developnent inclUCle tr~ th infant and child D)rtality as well as preValence of 1& birthweight. Such imicators often highlight the disparities" 'between urban and rural populations as well as regional differences which may be indicative of different levels of developnent. Ultimately, the IlDstcrucial factor affecting nutritional status is food availability at the household level, which must be vie1Ned. in light of developDents in agriculture. This paper will focus on trends in nutritional status and associatM factors~ parti'cularly in the last five years. To the extent that the direction of Change in nutritional status has been largely determined by the drought, its direct effects on household food security will also be considered. Nutritional Status of Children: 1980 - 1985 In a typical non~ought YEBr, the prevalence of underweight children declines by between two 'and four percent during the first half of the calendar YEBr, and then increases by a similar anount during the second half of the year. '!he increase during the secord half of the year maybe a result of household fOOd shortages which occur as supplies from the previous harvest run low, and decreases in the su~ly of milk as grazing conditions deteriorate. - 98 With the start of the newyear, one begins to see improvements in the nutritional status of Children. Interestingly, improvementsin nutritional status during the first quarter of non-drought years precede the harvest and is rrost likely due to the increased availability of: 1) rni lk as grazing conditions improve 2) wild nuts, fruits and vegetables; and 3) rural employmentow>rtuni ties. After the autumn(April-May)harvest, increased availability of focx:l at the household helps to continue the do.mwardtrend in the prevalence of underweightchildren in those districts where arable agriculture is feasible. In contrast to non-drought years, during the last foor drooght years, seasonal fluctuations have virtually vanished. With the onset of the current drought, prevalence rates began to climb beginning 1982. Initially, the increase was centered in those rural districts with arable agriculture (i.e. districts in the NOrth West and the North East regions of the country). In these regions, the typical non-drought decline in prevalence of underweigl1tchildren during the first half of the calendar year failed to materialize as milk supplies remained low, wild nuts, fruits and vegetables scarce, and yields from agriculture below normal. D.rring the initial two years of the current drought, prevalence rates from arable agricultural districts remained basically constant during the first three quarters of the year, but increased by one or two percentage points during the latter Part of the year. Fortunately, by the middle of 1983, relief efforts of the government facilitated by generous contriwtions of food from foreign donors, prevented further declines in the nutritional status of children, and in 1984 we begin to see declines in the prevalence of underweight Children in arable agricultural districts. - 99 - In contrast, the picture in those rural districts with little or no arable agriculture was quite different. In the South and South West of the country, the rural economy is alllOst exclusively dependent on livestock. Becauseof the relatively good rains of the previous year, grazing oonditions .provided adequate fodder for livestock throughout the first year of the drought. The nutritional status of children in these districts did not, therefore, deteriorate during 1982. Unfortunately, by 1983 grazing conditions had deteriorated substantially. This resulted in decreases in the availability of milk and wild nuts, fruits and vegetables. Canbined with decreases in cash incane and employment opportunities as the condition of cattle deteriorated, the rural districts in the South and South West regions of the country experienced sharp increases in the prevalence of underweight children throughout 1983and 1984. Because of the difficulty of effectively distributing food aid in the western part of the country due to the limited transportation net\olOrk and large distances betweensettlements, government relief efforts were initially not as effective as they had been in the mre populated agricultural districts along the northern and eastern torders of Botswana. Forttmately, ho.vever, the dramatic drop in the incidence of underweight children over the last year indicate that the Government was able to overcane these obstacles, and the nutri tional status of children in the western part of the COUntryhas improved dramatically over the last year. Drooqht and Food Security Q1e of the mat signi ficant changes that haS taken place as a result of the current drought is the developnent of a National Food Strategy (NFS) which is coordinated by the Ministry of , ts the first FInance and Developnent Planning. The NFS represen ted issues throogh attempt to explicitly deal with drought re 1a . r goals include a National Developuent Plan (NDP-VI). Its ma]O , the Okavango delta and to exploit the irrigation potentlal of d' tr'bUtion several river flood-plains, to enhanCe food IS 1 - 100 - capacity whenrains fail and to train civil servants to assume particular responsibilities in times of drought. Currently, while the end of the drought is anticipated, there are several challenges facing the government. '!hese include a rapidly expanding population and a concanitant ri se in the denand for food. In addition, the drought has resulted in sharp declines in food production and rural incanes, especially aIlOng female-headedhouseholds, a;mers of small herds, Remote Area dwellers, those deriving a substantial proportion of their incanes form informal sector employment, the grossly under-employed and unemployed households with high econanic dependencyratios. The demandfor basic food grains has risen fran ar:proximately 100 000 tons in 1979 to 190 000 tons in 1985 and is expected to exceed 200 000 tons by the end of 1991. With the s'harp decline in food production during the drought, there has been an increased dependence on imIX>rted foods both fran canmercial sectors and fran donor agencies (see Table 1) • A large prOIX>rtionof traditional arable farms planted only two to three hectares on the average in 1985. This accounted for 3.3 percent of total agricultural production. Household food security is, therefore, greatly at risk for a significant proIX>rtionof the population. Currently, while the Drought Relief Programmeis on going, and "blanket coverage" of VUlnerable groups practiced, underweight prevalence of children has remained remarkably low. '!his is largely attributable to the extensive, relatively efficient and closely monitored food distribution and relief programme. '!he resultant progressive improvement in nutritional status observed since 1984 can thus be attributed to the effectiveness of food aid, increased cereal imports and the increas":! in rural incanes as a result of Labour-BasedRelief Projects (LBRPs). Althoogh food aid is distributed to over 60 percent of Botswana•s population, it must be noted however that this provides only 21 percent of caloric requirements of the beneficiaries. As a result, the Socio-Econanic Assessment of - 101 - Drought Relief reported that at least 90 percent of LBRP remittances were spent on food purchases. Table 1: Availability of Food in BotStllBna, 1981-84 Season 1981 1982 1983 1984 lXlmestic Cereal production (tons) 48,860 15,500 12,980 6,230 'lbtal Cereal imports (tons) 79,423 111,020 178,718 170,000 4,906 24,278 31,333 Food aid (tons) 9,248 'lbtal Cereals 126,520 169,698 176,230 avai lable (tons) 128,283 'lbtal Cereals 165 163 available per capita (kg) 136 130 'lbtal food aid per 24.2 29.0 capita (kg) 9.8 5.0 .' 1981. Botswana Source: Botswana Agricultural Statlstlc~, 1984. Custans ann Agricultural Census, 1982, 1983d anstatistics (Gaborone), Excise Department, External Tra e ff of the Departmentof 1981-4; and data sUWlied by the staGo ernment and Lands, Food Resources, Ministry of r.ocal v Gal::orone • - 102 - It can be argued that the government has performed exceedingly well in rendering protection and assistance to the majority of the rural population during the drought. '!he greatest challenge, however, is that of providing the means of securing householrl incanes and food for vulnerable rural households after the drought. It is already evident fran escalating destitute figures that the prcductive resources of manyrural households have dissipated as a result of drought, and that many of them will not be able to take advantage of the numerous .l9ricultllral schemes intended to uplift farming households. Nutrition and Changesin Dietary Patterns During the past five years there has been migration to urban ',r.ei'l.S 'lss~i.:ited with diminishing agricultural prcrluction in !-,h.~ nlr;il iirws as a result of the drought. According to the !')81 census 17.7 percent of the population was considered clrban, and this is nowestimated to have risen tc' 21.7 percent h 1986. This is probably an underestimation since the projection did not anticipate the suh3tantial urban migration .iue to the drought. Dueto rapid rural urban migration, there has Q"en an incrwse in the numberof womenin the formal wage -'.wning sector. However rrore than 80 percent I of agricultural wf)rkis done by wanen. Despite unfavourable employment conditions and urbani sat ion dl1\)ng ~n, the prevalence of breastfeeding in Botswana has been founl. to be relatively high. According to the results of the ibtswana Family Health Survey conducted in 1984, oore than 90 percent of womenwere fOUndto breastfeed their children. The national medianduration of breastfeeding was found to be 18.9 rronths, with rural wanen breastfeeding slightly longer than urban wanen(see Table 2). The difference between rural and urban wanen is to be expected because of employment factors. Another difference in the duration of breast feeding is due to the level of education. FrMever, al though rural WOllen with little education tend to breastfeed longer than urban wanen, their children tern to becane underweight after - 103 - Table 2: Percentage of \'«:men Still Breastfeeding at Specified Intervals By Area of Residence M:>nths Urban Rural Total 3 96 96 96 6 91 93 93 12 69 74 73 18 37 53 49 24 7 19 16 36 1 1 1 Source: Botswana Family Health SurVey, 1984 - 104 - six IIOnths of age and seem less likely to catch up later. '!his is most likely due to inappropriate weaning practices especially anongst the rural poor where the cost of supplemenation of breastmilk maynot be met easily. '!herefore, while the duration of breast feeding in Botswanamay indicate a posi ti ve trend, suwlementary feeding practices fail to adequately complement breastfeeding. '!here is a widely observed damward trend in weight for age ratios with increasing age. It appears that manyBatswana children fail to maintain an adequate rate of grCMthduring the critical weaning period between the ages of six and eighteen months. rata from the Continoous Household Integrated Programme of Surveys Primary Health Care (arrps-POC) survey indicate that anong chi ldren under six IIOnthsof age, over 75 percent are above the 90 percent Weight for Age Index (WAr) value, and only 11 percent below the 80 percent WAr value. In contrast, amongst children older than twenty four IIOnths, only 30 percent have WAr values aoove 90 percent and over 35 percent are underweight. !.ow weight for age children consequently fail to maintain a healthy pattern of growth because of repeated episodes of diarrhoea and or inadequate calorie intakes. fio..1ever,by the age of three years, IIOSt children seem to have adjusted to adult diets and household eating practices, and are, therefore, able to cope with Sub-optimal intakes of energy and other nutrients. Only a small number of children under five are acutely malnourished. '!he majority are either small for their age or stuntoo. Nutrition SUrveillance data fram 1979 indicate that wasting (80 percent weight for hieght) was beltswana Family Health Survey, 1984. - 109 - 'Iable:6 Infant M:>rtality Rate Year Male Female Total 1971 103 91 97 1981 80.9 62.2 70.99 1984 74.79 58.32 66.41 1986 72.09 55.86 66.98 Source: Pqx.11ation Census, Central Statistics Office Table 7: Clli1d M:>rtali ty ( 60 mnths) Year Male Female Total 1971 166 139 152.5 1981 123.8 103.8 113.83 1984 114.3 95.6 105.8 1986 90.6 99.5 108.4 Source: Pqx.11ation Census, Central Statistics Office - 110 - Table 8: Birth Weights of Infants - Proportion of Birth Weights Under 25009 by Urban and ~al Facilities 1983-4. Tot. Livebirths % of National Total Total (2500g %(2500g) 1983 1984 1983 1984 1983 1984 1983 1984 Bots. 24,710 25,814 100.0 100.0 2,196 2,173 8.89 8.42 ~al 11,010 14,837 44.5 57.5 1,177 1,245 10.6 8.34 Urban 13,700 10,977 55.5 42.5 1,019 928 7.4 8.45 Source: Medical Statistics Unit, Ministry of Health Table 9: Malnutrition Case Fatality Rate Year Total t-1aln. MInn. Total Malo. Deaths Fatality Rate 1980/81 332 43 12.9% 1982 539 94 17.4% 1983 794 72 9.0% 1964 491 62 12.6% ~: Medical Statistics Unit, Ministry of Health - III - Table 9: Incidence of Diarrhoea in O1ildren (60 IIDllths) Year numberof NewCases 1982 29 327 1983 34 535 1984 33 351 1985 30 556 Source: Annual Report of Noticeable Diseases Tables 6-10 indicate a visible improvementin health indicators associated with nutritional status during a period when nutritional stress is expected to be at its highest due to the drought. '!his suggests that developmentsin the health sector have not been hampered by the drought especially in the rural areas. A striking indication of improvementin health indicators is the incidence of low birth weight (see Table 8). '!here has been a sharp increase in the proportion of births in the rural health facilities, indicating increased utilization of these faci li ties. There has also been a distinct narra.ring of the di fference in incidence of l~ birth weight in rural facilities and urban facilities fran a 3 point difference in 1983 to less than 1 point in 1984. fla,oIever,there is still a large proportion of hane deli veries not included in the reported statistics. The decline in the incidence of diarrheoa after 1983 may be due to both the extensive campaigns in the nt Use of hone oral rehydration solutions as well as goverruoo efforts to improve rural sanitation and the provision of POtable water. Improveoont in these indicators haS been attributed to a canbination of the foll~ing factors: - 112 - 1. Expansion of Primary Health Care Facilities thus better coverage. 2. Increased Food availability as a result of food aid. 3. Increased incane earning opportunities in rural areas as a result of Uihour Based Relief Progranunes(LBRPs). 4. Impact of Health Etlucation '). ~xpandedProgramof Immunizationand Diarrhea Control. 6. Improved.nutrition services for under-fives 7. ~~>nitaring of umer-fives and direct feeding of underweight chiljren thus improving their chance of survival and reducing hospital admissions due to malnutrition. Conclusion 1'hP Drought Relief Programhas no doobt succeeded in protecting pregnant WOmen,chi ldren and other vulnerable groups frem what OJUldhave ~~n devastating effects of the current drought. Simultaneous developments in the health, agriculture and other sectors have had a positive impact in sustaining encouraging trends in the improvementof heal th in the last five years. Faxl \1istrihution programmes have probably had the greatest impd.ctin mohilizing the population to seek health services, eSl~idlly wl1en agricultural activities were diminished. The challenge nCMfacing the goverrunent wi11 be to continue the positive trends in health indicators despite a rapidly grCMing population. Attention needs to be given to the special nutri tional probleI:ls of groups such as children in the weaning ages and pregnant teenagers. Relevant nutrition education canpaigns shoold be mounted. In addition, available, affordable and appropriate foods for various target groups should be prcuoted. BIBLIOORAPHY Burlte, SUsan, Dilts D.Y. am Hay, Ibger w. 1985 Socioecorx:mic Assessment of Drought Relief in Botswana. UNICEF/WIP/WOO. - 113 - Central Statistics Office 1981 Botswana Agricultural Statistics. Government Printer, Gaoorone. Botswana Agricultural Census, 1982, 1983 and 1984. Government Printer, GaOOrone. External Trade statistics 1981-84. Government Printer, Gaborone. 1985 Botswana Country Profile. Government Printer, Gaoorone. 1985 Chips Draft Report, Goverrurent of Botswana/tNICEF 1986 Situation of am Olildren in Botswana. 1986. Mason, J.B. 1982 "Nutritional Surveillance" Cornel Nutrition Surveillance Program. Ithaca. Ministry of Health Diseases" "Annual Reports of N::>tifiable Medical Statistics Unit