There is abundant literature that examines the household related factors that are associated with child undernutrition. The literature becomes scarce when it comes to the relationship between societal (or state) related factors and child undernutrition. This paper focuses on these state and macro-economic factors by giving emphasis on quality of governance, public health expenditure and urbanization, and their implication on child undernutrition.
In this study, governance (government effectiveness, control of corruption and regulator quality) is one of the major factors associated with child undernutrition in Ethiopia. The role of good governance to reduce child undernutrition appears substantial in this study, and we confirm that it has significant contribution to reduce child stunting and underweight in Ethiopia. Similar to our study, good governance significantly reduce the under-five mortality rates (U5MR) in the worst five countries with regards to U5MR [8].
Such positive contribution of good governance to reduce child undernutrition brought the agenda at the top frontline. There is an increased recognition that the ability of governments to be responsive and responsible is crucial to bring a profound influence on a number of factors that determine nutrition status [14]. Similarly, Smith and Haddad (15) suggested increased investment to improve governance, in addition to key infrastructure development investments, in order to accelerate reductions in undernutrition. The finding from a global project of dataset of 96 countries, which comprises 91% of the global population, shows that the higher the country’s level of adherence to the rule of law, the better the population health would be. The conclusion is that poor progress in rule of law may constitute a structural barrier to health improvement in the country [15].
The overall aspect of having good governance is to bring an effective strategy that enables the society to exercise its right and adhere with its responsibility and participation in the country utmost effort to realize the country ownership and development endeavor. In a new study revealed out from 139 low and middle-income countries (LMICs), only 39.6% of them had policies to address both undernutrition and overweight/obesity. Strong nutrition governance in LMICs was associated with low magnitudes of stunting, wasting and underweight [16].
Healthy and a well-developed population are more energetic and productive to the nation. Good governance in the country in general and in the health sector in particular can contribute towards this objective. Having a good policy alone, unless supported with a well-functioning governance structure to implement the policy, cannot guarantee for maintaining health and nutrition of the population. In most of the developing countries, lack of clear nutrition policies together with poor governance hinder attempts to address the dual burdens of malnutrition. These also explain some of the slow progress made so far in these countries in addressing childhood undernutrition [17].
Moreover, according to Eran Bendavid (2014), in a study encompassing 54 countries between 1995 and 2012 found a relationship between under-5 mortality rate reduction and slow progress in good governance in LMICs [18]. Likewise, good governance can be important for improving equity in child mortality, at least in LMICs [19]. Existing studies argue that governance matters for child survival through the channel of providing public goods, including public health interventions [20, 21]. In this regard, a study carried out in 149 countries between 1996 and 2010 showed that countries with better governance are likely to have health policies that benefit the social determinants of health [22]. By combining governance and public health spending, Rajkumar and Swaroop (2008) report the variation on the effect of PSH across different governance qualities. They indicated that 1% increment in the share of PSH from the GDP lowers under-five mortality rates (U5MR) rate by 0.32% in countries with good governance, 0.20% in countries with average governance, and has no impact in countries with weak governance [2]. Such a variation on the effect of PSH across governance qualities is potentially associated with the inefficiency of governments to convert public health spending into key health and nutrition outcomes. Similarly, a study using data from 110 countries for the years between 1996 and 2007 indicated that corruption causes a decrease in genuine wealth per person, and this implies that corruption affects sustainable development negatively [23].
Urbanization is another factor that is associated with child health and nutrition outcome. Our model result did not demonstrate a significant association between urbanization and child undernutrition. According to Tord and Susan (2008), better housing and living conditions, access to safe water and good sanitation, efficient waste management systems, safer working environments and neighborhoods, food security and access to services such as education, health, welfare, public transportation and child care are social determinants of health that can be addressed through good urban governance. In this way, a failure of governance in the cities has resulted in the growth of informal settlements and slums that constitute unhealthy living and working environments for one billion people [24]. And this has a negative implication on health and nutrition in the developing world.
A study done in Nigeria showed that urbanization has significantly negative relationship with health sector; however, the lagged value of the population living in the urban areas according to Urban Populations Outreach Program (UPOP) is positively related to infant mortality rate (IMR) and U5MR. This is not surprising in a country with poor institutional facilities. Such a system can encourage rent seeking behavior and poor enforcement of rule of law, and may discourage long term planning with respect to urban planning and provision of social infrastructures to match population growth rate and government efficiency [25]. The result of government spending and increasing urbanization accompanied with proper urban planning and rule of law through quality institutions can have positive health and human capacity development outcomes. Conversely, the absence of such an integrated system will result in deteriorating health status of the citizens and poor human capital development [25]. Evidence documented that there are interplays on the factors that affect a given health outcomes. In a certain circumstance, income influences health through improved nutrition, housing, and access to water and sanitation and literacy as a few exemplified points for our argument [4]. The study has some strengths and limitations of this study. Several factors where elucidated such as good governance, urbanization, public health spending and other socio-economic variables that explain under nutrition in the country and the research was based on highly representative pooled data. However, this study has a limitation of a cross-sectional design that should be interpreted cautiously due to difficulty to distinguish cause-and-effect relationships and reporting and recall bias should be considered as some of the events asked retrospectively.
In conclusion, this study indicates that good governance in the country can play a significant role for childhood undernutrition along with other socio-demographic parameters. It is vital to stress the fact that countries require integrated nutrition and health policies and good governance to effectively address all the dimensions of child undernutrition. Concerned bodies should focus on producing a quality policy and monitoring its proper implementation adherence for its policies and strategies.This paper also highlighted the important role of the private sector in the reduction of child undernutrition.
