Understanding Rwanda’s puzzling nutrition paradox

It’s October in Cyuve district, one of Rwanda’s most productive agricultural regions. Looking across the valley to the hills in the far distance, just one crop dominates. Climbing beans. The beans are not yet waist high. Instead, it is the many thousands of uniform two metre wooden stakes reaching into the sky that cover the entire landscape.

You’d be forgiven for thinking this was the work of a large scale commercial farmer. It is not. This is Rwanda’s Consolidated Land policy in action.

For some years the government has encouraged farmers in the same areas to grow one crop across their small half hectare plots in an effort to increase efficiency and production, improve land and crop management, and, ultimately, eradicate poverty.

And, to a large extent, it is working. Since 2007 when the policy was first introduced, the production of maize and wheat has increased by 6-fold, Irish potato and cassava has tripled and the production of rice and beans has increased by 30% in the past 4 years. In that time, Rwandan incomes have risen by almost 60 per cent ($380 GDP per capita in 2007 to $638 GDP per capita in 2013).

Immaculée Nyirahabimana, a farmer and single mother of four, can testify to the benefits of the policy. “Before you would cultivate a small piece of land, and you did not know how to manage your produce. After we started to learn the improved farming techniques, production has greatly increased.” She added, “Now I can pay for my children’s education thanks to farming.”

Yet, despite the governments forward thinking agricultural policies aimed at raising incomes, improving nutrition rates and providing food security, statistics reveal a puzzling paradox.

Agricultural intensification has not had the anticipated impact on reducing stunting rates.

Malnutrition and especially stunting levels in Rwanda are still unacceptably high – forty three per cent of children under five suffer chronic malnutrition, and stunting in some areas is as high as 60 per cent, according to the Comprehensive Food Security and Vulnerability Analysis (CFSVA) and Nutrition Survey 2012.

The paradox is especially acute in areas of extremely high agricultural productivity. In Cyuve district in the northern volcanic region where Immaculée lives, research shows that while most of its residents eat an adequate amount of food, stunting levels range from 44 to 66 per cent among children under five years old.

“This is an important lesson that challenges the assumption that simply increasing agricultural productivity will eventually lead to good nutrition outcomes. To adequately address stunting, we must rethink the pathways linking agriculture to nutrition,” said Mercy Lung’aho, a Nutritionist at the International Centre for Tropical Agriculture (CIAT).

A unique partnership

Understanding this puzzling paradox and the links between agriculture and nutrition is a challenge that has captured the attention of key players among the Rwandan government, development partners and researchers in their efforts to find solutions to malnutrition and food insecurity.

Partners, led by the Rwandan Agricultural Board (RAB), and co-led by the Division of Maternal and Child Health (MCH) under the Ministry of health, UN development partners and CIAT, have come together in a unique partnership to conduct a comprehensive study into the links between agriculture, nutrition, gender and markets called the Nutrition, Markets and Gender Survey.

As Professor Jean-Jacque Mbonigaba Muhinda, Director General of RAB, explains: “We realised there are some gaps in terms of the information we have. We don’t understand the link very well between nutrition, agricultural production, market access by farmers, and the gender composition of households to see how all those factors interact in terms of improving the nutrition condition of children under two and women of reproductive health – including pregnant and lactating mothers”

The three pronged survey is the first of its kind to be conducted on such a large scale and brings together such a cross-section of partners. Originally slated to cover three districts as a joint RAB / CIAT survey, under the Pan-Africa Bean Research Alliance (PABRA), it expanded to nine as new partners and funding came on board, including the Rwandan Ministry of Health, WHO, UNICEF, WFP and FAO.

Its aims are to determine the specific causes of stunting in children under two and help partners understand the links agriculture production and nutrition outcomes. The study will also establish a baseline for nutrition status among target groups prior to the implementation of a pilot nutrition programme  in selected districts to test a proposed package of interventions  (developed from a set of home grown solutions) that leverages agriculture for nutrition and health.

The immense task of data collection

Fast forward a year from the survey’s conceptualisation to October 2014 and the survey is in full swing, with CIAT providing the technical leadership.

Due to its wide scope, data collection has been an immense task involving a cross-sectional survey of 2736 households across the nine districts including gender roles within the household, agricultural production and household marketing of produce; nutrition assessment including anaemia, height and weight measurements to determine health indicators; and a 24 hour recall survey to measure food intake of mothers and their young children. All in all, the data collected contains about 5,000 variables presenting a huge amount of information for researchers to sift through and search for answers.

Mugeyo is a small village 30 minutes north east of Kigali, in Gasabo district, one of the nine districts selected to take part in the survey.

It is late morning. The sun is strong and all but a few of the women and children waiting outside the local health centre have sought the shade. The air rings loud with the sound of wailing children. Inside, more women wait patiently with their young children, all under two years old, first, to have their names recorded in the register and receive their empty vials – two red, two purple – and secondly, to be called to the next room from where the screams emanate.

Each of the children and their mothers have been selected at random to have their blood taken to test for anaemia, and other iron status indicators, such as ferritin and Vitamin A. They have previously had their weight and body measurements taken.

Just across from the health centre in a compound containing three small homesteads, a field researcher and the head of the household, sit in the little shade afforded by the boundary wall. They talk quietly, the researcher regularly reading from the tablet in her hands and recording the responses she receives to her questions ranging from household food intake to household gender dynamics. This is the second part of the survey.

Perhaps the most challenging survey activity is the 24 hour recall, where random households with at least one child under two are asked to recall food intake and quantities over a period of 24 hours. This will enable researchers to determine if the right dietary mix of food is being eaten in the right quantities.

 

 

Analysis begins

Fast forward again to April 2015, and researchers are busy analysing the survey results to understand the paradox.

Initial results emphasise it. In households where agriculture is the main income activity, stunting is significantly higher. In the Northern Province, the risk of a child being stunted increases by 93 per cent if agriculture is the household’s main source of income. These results are much more telling for poorer households that significantly rely on agriculture for their wellbeing.

The findings, which will be released in three phases from May 2015, will inform Rwanda’s nutrition and agricultural policies into the future, and, it is hoped, provide guidance to the rest of the region on agriculture-led nutritional policy and programming.

Prof. Muhinda continues: “We are running programmes on school feeding – One cup per child – where we feed school children with milk twice a week. We have One cow per poor family where the government is supporting poor households to get dairy cows so that they can address nutrition issues but also so that they can increase the income at household level. This study will come to show the impact and the efficiency of these interventions so that we can inform the policymakers whether we need to reinforce these policies, adjust them or even reformulate and implement new policies.”

Despite the paradox, agriculture and nutrition training is making a difference among some communities. Augustine Shiragahinda is a farmer from Kidaho, Burera district in the north. He leads a cooperative of 40 farmers and passes on training he receives from RAB.

“I try to invite people knowledgeable in nutrition, like the health advisers, to come and advise the women”, he explains. “What I know about nutrition now is that a balanced diet must include what builds the body, for example, beans, potato, vegetables and water. If I compare with the situation today, before RAB and before I was trained, we did not give much thought to what we ate. We would eat beans alone, or we would take potato along with sweet potato. In those days there were many diseases. We would get sick very often. But now there is no problem. You can go for years without getting sick”

Malnutrition is costing Rwanda dearly. The Cost of Hunger Study conducted by key ministries in 2013 concluded that undernutrition in children costs the country 65 billion Rwf (around US$90 million) every year in related illnesses and healthcare needs, most of which is borne by families, one quarter by public health services. It also estimates that the reason 13.5 per cent of all students who repeated grades at school in 2012 was because of stunting, and that nearly half of all adults of working age in Rwanda suffered stunting as children, affecting their ability to contribute to the economy.

Prof. Muhinda ends: “What we want to see at the end of this study are results that can clearly guide the government in terms of efficient policies and their implementation. We want to see this study having a direct impact on the improvement of the nutrition outcomes and livelihoods of our people.”

——

For images visit our Understanding nutrition in Rwanda photo set on Flickr.