China made dramatic progress in improving maternal and child nutrition and reducing undernutrition during the MDGs period from 2000 to 2015. This study examined the scientific literature and reports on nutrition policies and programs in China during the MDGs era, and conducted key informant interviews with government and NGO officials and academics to document successes, challenges and lessons learned from the leading national nutrition intervention projects. The aim was to understand the experiences improving maternal and child nutrition in China that could help achieve the nutrition-related 2030 SDGs in China. Lessons learned could also be used by other developing countries facing similar health problems to China to improve maternal and nutrition and achieve the nutrition-related SDGs.
Implementation of nutrition- related policies
During the MDGs, China promulgated six nutrition policies and regulations to promote nutrition and health conditions of Chinese woman and children. These nutrition policies not only focused on the nutritional needs of women and children of all ages, but also children at certain ages and economic conditions. For example, breastfeeding and complementary feeding improvement of infants, and the nutrition of school children from poor rural families. Additionally, the nutritional policies put forward specific nutritional goals to be achieved in certain years, identified and prioritized key areas and populations, as well as relevant technical guidance for nutrition improvement.
While progress was made, we also found a number of shortcomings of nutrition policies. First, the issued policies put most of the focus on undernutrition, complementary feeding and breastfeeding improvement, while goals and guidance for prevention of overweight and obesity was rare. Secondly, currently there are no laws to guarantee the effective implementation of relevant policies throughout provinces, cities and regions in China. For example, the China Nutrition Improvement Action Plan issued by the State Council in 1997 has not been implemented widely until 2003[40]. It is not possible to clarify the responsibilities of various departments, and guarantee the cultivation and maintenance of nutrition professionals. In contrast, Japan and the United States have made major breakthroughs in nutrition improvement programs. The US enacted a series of federal nutrition-related laws in the 1960s and 70’s to reduce hunger and to guarantee implementation, such as the National School Nutrition Lunch Act[41], and in Japan the school feeding law, nutrition improvement law and Nutritionist Law[42].
Experiences of nutrition programs and implications for achieving the Sustainable Development Goals
China implemented eight nationwide maternal and child nutrition intervention programs during the MDGs period. Several government sectors and NGOs were involved in developing and implementing each of the programs, for example, MoH, collaborated with MoF for Nutrition Package Program, and MoE, MoF, MoH and CDC worked collaboratively together for the Nutrition Improvement Program. Multi-sectoral collaboration among government sectors including health, finance, education sectors built a comprehensive implementation system for nutrition interventions. The collaboration between health-related NGOs including UNICEF, ACWF, CDRF, WHO, who had international experience and innovative ideas was one of strongest enabling factors for maternal and child nutrition improvement interventions in China. Additionally, we found that China prioritized and focused heavily on improvements to reduce child undernutrition.
For undernutrition, six programs have been launched by the Chinese government and NGOs, achieving positive results. These interventions have reduced the incidence and prevalence of maternal and child undernutrition including anemia, stunting, underweight and neural tube defects (table 2). But more progress needs to be made in undernutrition interventions, for instance, the target population has been mainly infants aged 6-24 months and primary and middle school students, with less attention on preschool children 24-48 months of age. Further, as shown in the qualitative analysis, the two key nutrition interventions in China continue to face challenges of insufficient local working funds, lack of monitoring and inadequate management. For undernutrition, the SDGs set four goals, including by 2025: 1) 40% reduction in children younger than 5 years who are stunted; 2) 50% reduction in prevalence of anemia in reproductive-age women; 3) 30% reduction in annual incidence of low-birth weight; 4) Reduce and maintain childhood wasting to <5%[12, 13]. According to report of Nutrition and Health Status Surveillance System of Chinese Residents (CNHSS)[14], in 2013 the wasting and stunting rate of children under 6 year were 2.0% and 8.1% respectively, and the low birth rate was 3.1%, the rate of lactating women anemia was 9.3% and that of pregnant women was 17.2%. The wasting rate has already reached the SDG target and the low birth rate is on target. For child stunting and anemia in women, policies and intervention programs have achieved positive results (table 2). Therefore, the SDG nutrition targets of child stunting, low birth rate and anemia in women in China could likely be achieved if the challenges mentioned above could be addressed with multi-sector approaches.
For breastfeeding interventions, we found although several policies and guidance for EBF improvement were issued, they have not been implemented well. According to the report of CNHSS, the EBF rate for infants aged 6 months in China in 2013 was only 20.8%[14], which is far away from the SDG goal of 50%[12-13]. On one hand, intervention actions on EBF improvement were few. The baby-friendly hospital is the only nationwide intervention program in China. On the other hand, although China started to establish baby-friendly hospitals in 1992, few evaluations have been conducted on its impact. In our literature search, we only found two hospital-based articles evaluating the effects of improved breastfeeding rates [43,44] and one survey[45] evaluating the comprehensive effect including improvement on EBF and breastfeeding rates, knowledge and neonatal morbidity, and no nationwide evaluations have been done. Sound monitoring and evaluation system has not been established to evaluate the effectiveness of baby-friendly hospitals, which may be one of the reasons why the EBF rate of infants aged 6 months in China have been low, despite that baby-friendly hospitals have been around for over two decades. More interventions and evaluation on breastfeeding improvement should be initiated in China to achieve the EBF SDG goal.
Regarding overweight and obesity, although China's childhood overweight and obesity rates were already at a high level (the overweight rate for children under 6 years in 2013 was 8.4 % and 3.1% for obesity[14]), few regulation and targets have been issued to prevent and control obesity, and nationwide intervention programs on prevention or treatment of child obesity are rare. The school-based program “Happy ten minutes” is the only nationwide intervention on child obesity. Furthermore, this program only targeted at primary students, without obesity intervention actions for children in pre and middle school. The SDGs for child overweight and obesity are no increase in childhood overweight[12-13]. From 2002 to 2013, the rate of overweight and obesity of children under 6 years increased by 1.9% and 0.4% respectively [14]. Therefore, more coordinated national overweight and obesity polices and intervention actions for pre and middle school children are urgently needed in order for China to achieve the SDG goal of no increase in childhood overweight.
Lessons learned from China for other developing countries
China's positive experience on reducing undernutrition provides several important lessons for other developing countries with high rates of undernutrition: 1) Achieving rapid reductions in undernutrition clearly requires high-level political attention. The Chinese government has realized the importance of nutrition, especially for children and women. During the MDGs era a large number of nutrition policies were promulgated, not only at the national level, but also poverty-stricken and rural areas. These nutrition policies are the basis for nutrition work; 2) Policies with priority targets are another reason for the progress and achievement made in China through the nutrition interventions. Prioritized nutrition, especially in poverty and remote areas, the focus on 0-24-month-old children and women is important for improving nutrition. Further more specific nutritional goals and technical guidance for nutrition policy are also essential; 3) Nutrition interventions play an essential role in improving maternal and child nutrition and require multi-sectoral collaboration of related government sectors and NGOs, and a comprehensive monitoring system. The implementation of nutrition intervention in China involves multiple sectors, such as finance, health and education, only by clarifying their respective responsibilities and cooperating with each other can the programs be implemented successfully. The NGOs, such as UNICEF and ACWF are important collaborators in conducting nutrition intervention pilots, disseminating nutrition knowledge and monitoring intervention effects. Governments need to establish public-private partnerships with NGOs. A monitoring system is essential for nutrition interventions, not only to evaluate trends and progress, but also help to identify gaps, problems and any unintended consequences. In addition, the challenges that China is facing, such as lack of local budgets, problems with monitoring systems, lack of a nutrition workforce and large population mobility, may alert other developing countries that when planning and implementation nutrition interventions, more attention needs to be paid to minimize and avoid similar problems.
In this study we reviewed the content of nutrition policies and projects in China during the MDGs, and the experiences, challenges and recommendations for the major national nutrition intervention projects. Nevertheless, several potential limitations should be acknowledged. Although we conducted a comprehensive review of maternal and child nutrition policies implemented during the MDGs era in China, we found the evaluation of policies are insufficient, and therefore we cannot adequately assess effectiveness or impact. Also, we only assessed the effects of nutrition intervention policies on nutrition improvement and evaluation of implementation and cost-effectiveness of the two projects is lacking. Our qualitative interviews were only for project leaders and managers. We did not interview the target populations of those two projects. Still, our findings will be beneficial in informing efforts to achieve the SDG nutrition goals in China and provide lessons learned for other developing countries in reducing the prevalence of malnutrition.