• Stunting caused by malnutrition affects more than 149 million children around the world today.
  • New research suggests a focus on women’s rights, educating girls and hygiene are all effective ways to tackle the problem.

Nearly ten years ago, a paper in the journal The Lancet changed the way countries around the world approached improving nutrition.

The paper identified ten critical nutrition interventions – all of them direct nutrition interventions like micronutrient fortification, breastfeeding, and vitamin A supplementation. And it posited that if those interventions were scaled to reach 90 percent of children in the 34 countries where good childhood nutrition is most lacking, they would reduce stunting rates by 20 percent. These ten interventions became the standard roadmap to improving nutrition for health officials globally.

Over the last three years, my colleagues at SickKids, research partners around the world, and I have engaged in robust mixed methods research to determine how Ethiopia, the Kyrgyz Republic, Nepal, Peru, and Senegal achieved remarkable reductions in childhood stunting over the last 25 years. We expected to find that those same ten interventions identified in The Lancet would have been responsible for most of the improvement in stunting across each of these countries.

What we found was surprising.

Yes, direct nutrition interventions are critical and our research validates many of the findings of the Lancet article. But our evidence also highlights what the Lancet article didn’t capture – an equally powerful role for indirect nutrition interventions that are delivered outside of the health sector.

We estimate that these indirect strategies, such as interventions to improve women’s empowerment, girls’ education, poverty reduction and WASH, account for, on average, half of the stunting reduction those countries achieved. By country, these supportive nutrition strategies contributed anywhere from 33 percent of the stunting reduction in Peru to 63 percent in Ethiopia.

Effects of measures against stunting in selected countries

Consider the powerful forces we observed boosting nutrition in Ethiopia. Our quantitative and qualitative analyses found that– more than any other intervention – agricultural policies and programs drove the largest gains in Ethiopia’s stunting reduction through improved crop yields and, consequently, household food security. Other key drivers of stunting reduction in Ethiopia were also indirect interventions – better access to education, particularly for girls, and improvements to WASH – especially a reduction in open defecation which drove 17 percent of the reduction in stunting.

While many recent high-quality randomized controlled trials suggest caution around WASH as a tool to address stunting, our research shows meaningful contributions of WASH improvements to stunting reduction in four of the five countries studied (Ethiopia, Nepal, Peru and Senegal). And this points to the value of our methodology. While randomized controlled trials are, without a doubt, an important tool in evaluating cause and effect, for reasons that remain unclear, they have not been able to effectively capture the impact of WASH programs on nutrition. We hope our research demonstrates the value of WASH programming and provides the necessary evidence to support further investment.

Lastly, outside our purview, but worth mentioning is that each of the indirect interventions I’ve highlighted here, improvements to WASH, education, and agriculture interventions like increasing access to agricultural extension agents, better quality fertilizer, and improved seeds, have substantial knock-on effects that support progress toward other, non-nutrition related global goals. They increase incomes, make agriculture more sustainable, keep girls in school, reduce un-wanted pregnancies, and reduce the spread of disease. These multiple benefits should be considered when governments are calculating the return on investment for all of the indirect interventions, from girls’ education and women’s empowerment, to WASH and agricultural extension agents.

We hope that this evidence, which is available in full on the Exemplars in Global Health platform here, persuades health leaders around the world to work across sectors to develop powerful multi-sectoral strategies to reducing stunting, which still impacts 149 million children around the world today.

This article first appeared on Exemplars in Global Health, a new initiative incubated by Gates Ventures and its partners to research positive outliers in global health so that other countries might learn from them and improve health outcomes.