The uncomfortable truth: Child stunting high in the wealthiest households

by Tamara Billima-Mulenga, Felix Mwenge, Miselo Bwalya

When we think about malnutrition, we tend to associate it only with the poor. This is because globally, the poor suffer from higher rates of malnutrition than the non-poor. However, evidence shows that in Zambia, wealthier households are currently facing a high risk of malnutrition.

The 2013-14 Zambia Demographic and Health Survey (ZDHS) shows that as high as 28 percent of stunting cases are among the wealthiest households in the top 20 percent of wealth brackets. While it is lower than the stunting incidence of children in the poorest households at 47 percent, it is nevertheless high considering malnutrition is highly correlated to poverty. Effects of stuntingThis finding, which is counterintuitive, has important implications for policies that are aimed at ending malnutrition in Zambia. It also implies that whereas past interventions to end child malnutrition have mainly focused on the poor, they now have to include wealthier populations.

Malnutrition results from insufficient or excessive intake of nutrients. Undernutrition which is the insufficient intake of nutrients results in stunting, wasting and underweight. On the other hand, over-nutrition which is excessive intake of nutrients results in obesity. Globally, malnutrition is responsible for 35 percent of deaths among children under the age of five. In terms of economic consequences, it represents losses of 11 percent of gross domestic product (GDP) every year in Africa and Asia according to the 2016 Global Nutrition Report. In Zambia, the National Food and Nutrition Commission cites malnutrition as a major public health problem that contributes to a significant number of deaths among children under five.
Zambia’s biggest malnutrition concern for many years now has been stunting which is classified as low height-for-age. At 40 percent of all under-five children, Zambia’s stunting rate is categorised among the highest globally and implies that 2 in every 5 children under the age of five is too short for their age. The effects of stunting last a lifetime as it delays mental development in children which consequently affects school performance and reduced intellectual achievement. This may result in reduced economic productivity and earnings later in adulthood.

Worryingly, stunting developed during the first two years of life is generally irreversible. After the age of two, stunted children who experience rapid weight gain also have an increased risk of obesity later in life which may increase the chances of heart disease, hypertension, diabetes and stroke. This reality raises concerns about the high rates of stunting that Zambia has.

Wealthiest households are assumed to afford appropriate and adequate nutrition for their children and have access to what can be seen as the ‘best’ health care in the country through private health providers. To have children from wealthier households equally suffering from undernutrition as poor households, is of great concern and needs to be understood clearly.

However, very little is known from literature about stunting in wealthier households making it difficult to point out the causes. Notwithstanding, the general causes of stunting could be inappropriate infant feeding and care practices, poor sanitation, inadequate breastfeeding in the first 6 months of a child’s life, generational stunting and inadequate under-five health services especially in the private sector.

The focus on poor households in addressing undernutrition could imply that public health facilities tend to emphasize more on nutrition and under-five care compared to private health facilities. Anecdotal evidence shows a stark difference between the type of services provided for under-five care between private and public health facilities. Public health facilities provide a wealth of information to expecting and lactating mothers ranging from nutrition in pregnancy to information on a starter pack for expecting mothers.

The Government has also embarked on several nutritional programmes targeted at expectant mothers and infants such as the 1st 1000 Most Critical Days Programme, Management of Severe Acute Nutrition and Maternal, Adolescent, Infant and Young Children programme which extends beyond the expecting mothers and infants. All these efforts are made through public health facilities.

In conclusion, more attention must be given towards the feeding of children under the age of five in wealthier households as anecdotal evidence suggests that this is currently left to care givers who might not be very knowledgeable on nutrition. Further, the poor attitude towards under-five clinics and obtaining information on nutrition from health facilities among wealthier households has contributed to the prevalence of stunting.

Despite several interventions from the Government and Cooperating Partners, stunting has remained relatively unchanged since 1992. Concerted efforts must be made by both the Government and households to reduce child stunting. Targeting of interventions should include wealthier households and not only poor households. There is also need to strengthen the provision and coordination of under-five services, especially those on nutrition between private and public providers. Further, the World Bank recommends providing health and nutrition education and micronutrient fortification and supplementation as a shorter route to better nutrition. This must be promoted in both private and public health facilities.


The authors are researchers at the Zambia Institute for Policy Analysis and Research (ZIPAR). For details contact: The Executive Director, ZIPAR, corner of John Mbita and Nationalist roads, CSO Annex building, P.O. Box 50782, Lusaka. Telephone: +260 211 252559. Email: This email address is being protected from spambots. You need JavaScript enabled to view it..

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