The Effects of High Prevalence of Childhood Malnutrition in Egypt
Section A. Scope of Childhood Malnutrition in Egypt
Childhood malnutrition is prevalent in low- and middle-income countries (LMIC) around the world, with disproportionate effects in countries in sub-Saharan Africa. Early malnutrition is associated with poorer health outcomes, higher risk of infectious diseases, and impaired mental and physical growth.[1] Childhood malnutrition is prevalent in Egypt and can be attributed to education and socio-economic disparities created by a poorly funded and inaccessible healthcare system. According to the International Budget Partnership, Egypt’s government allocated 5.4% of total budget towards the healthcare sector in 2015, which is one of the lowest percentages in the North African region.[2] In 2014, 21% of children under five years of age were stunted, 8% were classified as wasting, and 6% were underweight.[3] The prevalence of childhood malnutrition, specifically stunting, is a public health issue in Egypt and is worsened by existing healthcare disparities.
Section B. Literature Review
B1. Childhood malnutrition is a general health condition that includes undernutrition, wasting, stunting, underweight, and overweight. According to the World Health Organization (WHO), malnutrition is classified as deficiencies, excesses, or imbalances in an individual’s intake of nutrients. There are two broad groups that are organized under the term malnutrition- undernutrition and overweight. Undernutrition includes stunting, wasting, underweight and nutrient deficiencies.[4] Stunting in nutrition is defined as a low height for age and wasting is considered low weight for a given height.[5] As of April 2020, the WHO estimates that 159 million children under the age of 5 are stunted and 50 million are wasted. The high rate of childhood malnutrition is concerning because it accounts for half of all childhood deaths worldwide and is most prevalent in sub-Saharan Africa and South Asia.4 According to the millennium development goals (MDG) evaluation, the rate of underweight children decreased by 10% globally from 1990 to 2015. However, this decline was not seen in sub-Saharan Africa. In fact, between 1990 and 2013, sub-Saharan Africa experienced an increase of stunted children by approximately one-third. Globally, sub-Saharan Africa accounts for one third of all undernourished children.[6] According to the results of the Global Disease Burden, undernutrition is considered a key risk factor for childhood mortality due to respiratory infections and diarrheal deaths associated with the condition.[7]
Childhood malnutrition is a public health issue that is associated with poorer health outcomes later in life. The United Nations (UN) Sustainable Development Goals highlighted the issue of global malnutrition through their zero-hunger initiative. This goal aims to end all forms of malnutrition by 2030. The United Nations plan on doing so by focusing their efforts on the nutritional needs of girls, pregnant and lactating women, and older individuals. By 2025, the organization aims to reach the internationally accepted targets on stunting and wasting in children under 5 years old.
Malnutrition is a prominent global health issue because it is considered an intergenerational emergence, as it can arise within an individual’s life course and span several generations. In a systematic review published by Wells and colleagues, maternal undernutrition and nutrient deficiency increases the risk of childhood malnutrition. The development of a malnourished child often results in the onset of illnesses later in life. When a child experiences deficiencies in early development, they are strongly associated with less lean mass, elevated markers of inflammation, and abnormal growth patterns.[8] A study conducted by Lelijveld et al. highlights the intergenerational effects of malnutrition. A cohort study was conducted on 352 Malawian children who received inpatient treatment for severe acute malnutrition around the age of 2 years old. The researchers assessed this group of children for anthropometric measurements one year and seven years after receiving treatment. The results revealed that in households where children were treated for severe malnutrition, they continued to exhibit stunting in a seven year follow up. The children also exhibited poorer school performance, strength deficits, and decreased physical capacity compared to the control group.[9] The continued effects of malnutrition in early childhood result in an intergenerational cycle that develops as a result of systematic social and health disparities. A systematic review of 49 studies found that the most prevalent factors associated with childhood malnutrition are low parental education, low socio-economic status (SES), low birth weight, unimproved source of drinking water, and geographical region of residence. The most consistent factor associated with malnutrition was low parent education, which has also been identified as a strong indicator for low SES. In low- and middle-income countries, households are more likely to spend less on nutritious foods due to the financial burden and experience nutritional deficiencies at an increased rate.[6]
B2. Non-communicable diseases (NCDs) account for 82% of all deaths in Egypt, higher than the global average of 70%.[10],17 According to the WHO, NCDs are responsible for the mortality of 41 million people each year and the majority of these lives lost are from low- and middle-income countries.[11] NCDs are a general group of diseases including diabetes, cardiovascular disease, cancers, and pulmonary diseases. In a journal addressing the role of nutrients and risk of NCD development, Bruins et al. reported that hypertension is responsible for 40% of all cardiovascular deaths. Due to the multifactorial nature of hypertension, adequate interventions must address lifestyle factors, diet, and physical activity. Risk factors that can significantly increase the rate of NCDs are unbalanced diets, including nutrient deficiencies, and lack of physical activity.[12] In a study reviewing the NCD prevalence in Egypt, Amin et al. describes the consistent rates of cardiovascular disease. In Egypt, cardiovascular disease is responsible for the most NCD deaths and the rate has increased 35.9% from 2007 to 2017. The risk factors most responsible for the rise in NCD prevalence in Egypt is poor diet, hypertension, malnutrition, obesity, tobacco usage, and hypercholesterolemia.[13]
Evidently, the risk factors that result in NCDs are preventable and can be altered with improved dietary practices. According to the 2016 Egypt World Social Science Report, the high prevalence of NCDs and childhood malnutrition are interconnected and worsened by gender, income, education, and geographic inequalities among the population. Families with higher socioeconomic statuses receive access to prenatal care, quality healthcare, and spend less on health costs than families with lower socioeconomic statuses and those living in rural areas of the country.[14] Laila Kamel, in an intervention study conducted in two Upper Egypt regions, implemented a community-based initiative, proving that childhood malnutrition must be addressed with community-based interventions concentrating on parental education, socio-economic status, and access to healthcare.[15] While there were positive changes in education from intervention, other needs were uncovered. Unfortunately, Egypt suffers from the double burden of malnutrition and non-communicable diseases due to the deeply rooted health and social disparities.
B3. In recent years, Egypt has had an increase in the prevalence of stunted children. Egypt has the largest number of stunted children under 5 years old in the Middle East and North Africa and ranks 12th worldwide.[16] Egypt has a stunting rate of 22.3%, which is considerably higher than the United States’ rate of of 3.4%.[17] Children who are stunted can suffer from several health complications associated with stunting syndrome. The changes characterized by this disease are abnormal cognitive development, reduced physical capacity, and increased risk of illnesses in adulthood. Additionally, due to the intergenerational effects of malnutrition, an individual who was stunted as a child is more likely to birth a child with stunted growth and development impairments. There are many different risk factors for stunting including maternal malnutrition, childhood caloric and nutrient deficiencies, and recurrent infectious illnesses as a result of poor living conditions. These risk factors are particularly worsened based on an individual’s geographic location.[18] A cross-sectional study in the Sohag district of Upper Egypt researched the risk factors and prevalence of stunting. The researchers randomly selected an urban and rural public school from the district and a total of 1786 children between the ages of 4 and 12 years old were enrolled in the study. Based on the laboratory and anthropometric measurements, 329 were stunted and 76 were classified as severely stunted. Analysis between child characteristics revealed that anemia, parasitic infections, familial stature, vitamin deficiency, and BMI were highly correlated with stunting.[19]
B4. The risk for developing non-communicable illnesses such as diabetes and heart disease increase with childhood malnutrition. As mentioned in a previous study, early exposure to malnutrition imposes a metabolic load on the body by encouraging physical survival through energy sparing.[9] When an individual uses these energy reserves, they are overusing certain tissues and organs more than others. This survival adaptation for an individual with malnutrition affects their growth and body composition. Low birthweight, childhood stunting, and wasting are all responsible for depletion of the body’s metabolic capacity. Similarly, research has shown that early childhood malnutrition is associated with chronic inflammation in late childhood and early adulthood, which is a strong risk factor for NCD development.[20]
Grey et al. performed a review of NCD outcomes in survivors of severe acute childhood malnutrition in 8 studies conducted in LMICs. Their research identified mechanisms of child stunting that can predispose a malnourished child to central fat deposition in adulthood, which could increase the risk of NCDs. The researchers evaluated the impact of malnutrition by studying the following criteria: glucose metabolism, cardiovascular disease, dyslipidemia, physical capacity, metabolic syndrome, chronic kidney and liver disease, and anthropometric measurements. The sample group was then reevaluated throughout their lives following severe acute malnutrition. The data confirmed that exposure to severe malnutrition in childhood was associated with an increased risk of cardiovascular disease, impaired glucose sensitivity, and increased risk of developing metabolic syndrome.[21] This emphasizes the intergenerational effect of childhood malnutrition and the serious consequences of the condition into adulthood. The burden of malnutrition could be considered a cyclical process because it can often go unnoticed in families that experience poor nutrition at their baseline.[22]
In Egypt, malnutrition is also associated with the double burden of anemia. The UNICEF reports that 27.2% of children under five years of age have anemia and the high prevalence continues through adulthood.[23] A cross-sectional study of 33,150 children (ages 6–11) from seven different governorates was performed to evaluate the prevalence of stunting and its co-occurrence with anemia. Researchers found that anemia and stunting were more common to be concurrent in female children than male children. The co-occurrence of anemia and stunting in children is concerning because the reasons in which they present together are unknown. However, researchers found that low SES has a 29.7% association with stunting. Consistently, anemia with stunting has a higher prevalence in children from rural areas with low SES. This translates to an increased risk of children in these regions developing parasitic infections and growth hinderance.[24]
B5. Populations in Egypt with lower socioeconomic status experience higher rates of childhood malnutrition. The World Bank documents that in households with decreased access to healthy food, children are more likely to develop poor nutrition and health complications.[21] A study conducted in a rural neighborhood in the Fayoum governate of Upper Egypt researched the rates of malnutrition and its’ prevalence based on factors such as age, gender, parental education status and dietary differences. This specific village was selected because it is the largest village among the Fayoum Governate, with a population of 65,000 with five primary schools. Students were randomly selected from the primary, preparatory, and secondary schools and a total of 736 children were enrolled in the study. The parents of the participants were given several questionnaires assessing their sociodemographic, lifestyle, and dietary habits. Data was measured anthropometrically and to the set standards of malnutrition by the WHO. The results showed that rates of stunted growth were higher in the absence of mother education, irregular status of father employment, large family size more than or equal to five, and lower socioeconomic status. In families that reported low SES, the rate of stunting was 37.6% versus 22.1% in those of high SES. Additionally, the study found that the percent of underweight female children was 4.9% in comparison to 2.4% of male children. The rates of stunting and wasting were approximately the same in male and female children. The researchers explain the difference in underweight rates among genders by the cultural preference for boys in Upper Egypt, especially in rural areas, where males are considered the working group. The overall rates of stunting, underweight, and wasting in the Fayoum governate was 34.2%, 3.4%, and 0.9%, accordingly.[25]
In a similar cross-sectional study conducted in the Beni-Suef Governorate (south of Cairo), the prevalence of stunting and underweight was 53.2% and 10.0% respectively. This Governorate constitutes 3.2% of the total population in Egypt and 57.3% of its’ residents are less than 18 years old. The study aimed to highlight the nutritional status of 1,100 school aged children in Beni-Suef using WHO approved anthropometric classifications and structured questionnaires. The results revealed that the rate of stunting was higher in males from ages 5–10 in comparison to female children of this age group. Researchers have suggested that a possible explanation to the gender difference is the inconsistent rate of schoolgirls dropping out of school, leaving only the better-nourished children at school present in the data set.[26] This is consistent with studies in Turkey showing a higher prevalence of stunting in male than in female children. In accordance with other studies, low parental education level was found to be a major risk factor of childhood malnutrition as it directly relates to household income status.[27]
To understand the geographic effect of childhood malnutrition, a case-control study was conducted in Cairo to determine the presence of malnutrition in urban areas. This study recruited 200 malnourished children (6 months to 2 years of age) who were patients of the outpatient clinic of the Center for Social and Preventive Medicine. Researchers concluded that the lack of parental education and poor dietary practices were significant risk factors among children in Cairo.[28] According to the Egypt Demographic and Health Survey of 2014, the prevalence of childhood malnutrition is relatively equal in rural and urban parts of Egypt, but more prevalent in Upper Egypt (both urban and rural areas). Additionally, the survey showed that urban children of mothers with a minimum of secondary education were less likely to be stunted than children of mothers with less education and that wealth was not a strong indicator.[29]
B6. Childhood malnutrition has a high incidence in Egypt due to disparities in education level, SES, and social lifestyle choices. Though stunting does not vary greatly in prevalence between rural and urban areas, it has a higher occurrence in Upper Egypt. According to the UNICEF 2016 statistical digest, the percent of household and population access to unimproved sanitation facilities by residence was 15.6% in Lower Egypt and 5.4% in Upper Egypt. Additionally, the rate of children in poverty is 4.0% for urban Lower Egypt and 12.0% for urban Upper Egypt.[8] The disproportionate rate of childhood stunting in Upper Egypt is related to several other health and social inequities that children suffer from in that region of the country.[31] The disparity in Upper Egypt is concerning because of the known long-term consequences of childhood malnutrition. Besides having severe immediate effects on childhood development, preventing malnutrition has a role in the prevention of NCDs in Egypt. Addressing childhood malnutrition in Egypt will address the population’s risk of NCD development.
The disproportionate rate of malnutrition in Upper Egypt can best be explained by the social and economic conditions in that region. In 2015, the World Bank reported that rural Upper Egypt had a poverty rate of 58.2%, whereas rural Lower Egypt had a rate of 22.3%. In Egypt, families living in poverty have larger household sizes and live in small, overcrowded housing, increasing their risk for health conditions and malnutrition. The populations living in Upper Egypt are disadvantaged and have lower educational attainment, with 70% of young women unemployed. Additionally, Egypt’s poorest 1,000 villages are all concentrated within three governorates in Upper Egypt. Evidently, the SES and education disparities account for the higher prevalence of childhood malnutrition in this region.[30]
Section C. Theoretical Framework
The term “structural violence” was coined by Johan Galtung in the 1960s to describe social, economic, political, and religious structures that hindered individuals from reaching their full potential.[31] These structures are embedded in the organization of our society and cause physical and mental harm to people. The term accounts for the effects of racism, disease stigmatization, poor environmental conditions, and social barriers that prevent underserved communities from receiving necessary care.[32] The structural violence framework is a comprehensive lens that explains the methods in which social structures impact individual, community, and population experiences. This framework is a useful tool in understanding the social determinants of health that contribute to the rates of childhood malnutrition and stunting in Egypt.
The structural violence framework is relevant to understanding the childhood malnutrition disparity in Egypt since it accounts for the intersectionality of gender, age, socio-economic status, and geographic location. Examination of childhood malnutrition in Egypt reveals that rates of stunted growth are high in the absence of maternal education, irregular paternal employment status, and low-socioeconomic status. The 2014 Demographic and Health Survey in Egypt highlighted the role of maternal education on childhood malnutrition, as children’s rate of stunting is directly impacted by their mothers’ education level.[30]
The malnutrition-related harm against children in Egypt is worsened in Upper Egypt, where the environment perpetuates health disparities. The World Bank reports that Upper Egypt has a poverty rate of 58.2% and Lower Egypt a rate of 22.3%.[31] Families who live in poverty reside in conditions that increases their risk for health conditions and malnutrition. Additionally, in LMICs, households spend less on nutritious foods due to the structural financial barriers that create a burden on spending.[6] These environmental structures help to explain the disproportionate rate of childhood malnutrition in this area.
The intersection of poor educational attainment and low socio-economic status work in concert to continue the intergenerational cycle of malnutrition in families. A malnourished child will likely develop illnesses later in life and has an increased risk of maternal undernutrition. Accordingly, maternal undernutrition and nutrient deficiency increases the generational risk of childhood malnutrition.[9]
The issue of childhood malnutrition in Egypt is only partially explained by factors at the individual level. Childhood malnutrition has been a growing health concern in Egypt for decades and the poor social structures are largely responsible for its lack of improvement in recent years. Individual behaviors and lifestyle practices occur in contexts where structural violence hinders good health practices. The disparity between Upper and Lower Egypt can be explained by the lack of structures that allow communities to reach their full potential. Communities in Lower Egypt are geographically closer to major cities, have less poverty rates, and greater healthcare access. On the contrary, the lack of education, unsteady employment, and limited access to healthcare in Upper Egypt is a direct result of structural violence.
As with any theoretical framework, structural violence has its limitations as well. Specifically, its limitations are the removal of individual burden, the assumption that violence results from structural and not individual decisions, and the removal of responsibility from individuals in power. Approaching any health disparity with the use of one theoretical framework can risk oversimplification of the issue at hand. The structural violence framework underscores the social, economic, and political structures that account for individual harm. This does not address the downstream individual impact of employment, education, and lifestyle choices that can also perpetuate childhood malnutrition. Additionally, by placing the burden on societal structures, this framework has the potential to remove power from individuals. If the blame of a health disparity is placed solely on structures, individuals and communities can assume they have no power in their health and environmental conditions. Lastly, the structural violence framework analyzes issues based on the effect of structures on an individual. This framework falls short on addressing how the individuals and populations effect the social, economic, and political structures in their communities. Instead, the synergistic effect of individuals and the social structures that they live in should be examined to account for disease harm.
Despite limitations, the structural violence framework is a useful tool when analyzing the prolonged issue of childhood malnutrition in Egypt. This framework can comprehensively view the many factors that result in health disparities and address the upstream determinants. Though individuals have their own roles and responsibilities for their health, disparities such as childhood malnutrition cannot be placed on individuals. The social and economic structures and agencies are responsible for the malnutrition disparity that has not improved for decades. Poor environmental conditions and lack of education are major contributors to the rate of childhood malnutrition and are the result of societal structures that do harm to individuals. Lastly, through the lens of this framework interventions can be implemented that account for community-level risk factors and differences in geographic areas.
Section D. Program Review
Due to the disproportionate rates of childhood malnutrition, there have been several government-led initiatives working towards the sustainable development goal of zero hunger. The United Nations’ goal aims to end hunger and improve access to nutritious food for vulnerable populations. The United Nations hopes to end all forms of malnutrition by 2030 and achieve the agreed targets of stunting and wasting in children by 2025.8 Most of the programs addressing this goal are supported by the World Bank and United Nations and use a government approach, rather than community-based initiatives.
Improving Household Food and Nutrition Security in Egypt by Targeting Women and Youth
The Food and Agriculture Organization (FAO) of the United Nations introduced a framework in 2018 to help Egypt reach their goals by 2030. The outline included “Improving Household Food and Nutrition Security in Egypt by Targeting Women and Youth.” This is a project that aims toimprove food security for women and youth. The initiative integrates the importance of nutrition and food production to educate populations about nutrition through behavior change plans.This program was implemented in Assiut, Aswan, Beni Sueif, Fayoum, and Sohag, five governates in rural Egypt. The program has five components, which addresses the various sectors that malnutrition operates within. The first component, home food processing, taught women food processing at home with fruits and vegetables collected from fields. For this portion of the program, 10 processing schools were used so that women in each of the governates had the opportunity to learn how to prepare, dehydrate, and process foods at home while maintaining their nutritional values.[34]
Another component operated through 15 community kitchens to teach women how to prepare healthy meals by modifying cultural traditional recipes. This initiative also incorporated education on meal planning and grocery budgeting. The third subsection aimed at empowering women with entrepreneurial skills. Women in this program were taught basic business skills and received financial support to head start small scale farming. The importance of farming was emphasized in the fourth component of the program, which taught women healthy agricultural practices, harvesting, and irrigation skills. Lastly, the fifth component, “women-friendly landless gardens,” taught women in the 5 governates how to create micro-gardens and utilize vegetables for household consumption to reduce family’s dependence on highly processed market foods.[34]
The FAO program served a total of 7,388 women and youth spanning 5 governates in Egypt. The education components on agriculture and food preparation empowered women with valuable skills. The program aimed to address the most significant risk factors of childhood malnutrition- maternal education and low-income. These risk factors are addressed in the FAO project through the various components that worked towards increasing health education in women. However, though a component provided a basic entrepreneurial skills lesson, it did not address how long-term income could be improved in these families.[33]
United Nations World Food Program
Another program which supports Egypt’s sustainable development goals is the United Nations World Food Program (WFP). WFP has been operating in Egypt since 1968, but has recently been focusing their efforts on responding to the nutrition insecurity. The WFP carries out initiatives with the assistance of government agencies and supports national goals to reduce malnutrition and poverty. A significant component of their work is providing school snacks and take-home meals to children from 16 governates in Egypt. The WFP created a Country Strategic Plan (CSP) from 2018–2023 to address the underlying causes of food insecurity and malnutrition. The CSP supports government interventions addressing food insecurity in vulnerable populations. One of their initiatives collaborated with the Ministry of Education and Technical Education to provide financial assistance to 27,000 families with school-aged children in 5 governates. This aimed to assist with food security in vulnerable populations. Another sector of the CSP intended to financially empower women. To do so, the WFP worked alongside the Ministry of Social Solidarity to provide 240 women with micro-loans to encourage income-generating projects. This program had the ability to impact 320,200 people in Egypt with the financial assistance of 3.7 million USD. [34]
Takaful and Karama Program
Other organizations, such as the World Bank, have assisted Egypt financially to help decrease their rate of malnutrition. The Takaful and Karama program was launched by the Ministry of Social Solidarity in 2015 with the financial support of the World Bank. The program goal is to build human capital in Egypt while supporting family’s ability to provide nutritious food and financial support for basic needs. The program is considered a conditional family income support because families must adhere to certain conditions to receive the support. In order to receive support, household children under the age of 18 must have an 80% school attendance record, mothers and children under 6 years of age must visit a health clinic four times a year to maintain growth records and attend nutrition education sessions. Households are given 325 Egyptian Pounds each month and an additional amount of money for each school-aged child in the household. Currently, 3.11 million households are registered with the Takaful and Karama program. The results of this program have proven that financial support is beneficial for families and has a role in reducing childhood malnutrition. Outcomes included increased monthly food consumption and the probability that a child under 5 years of age would become malnourished decreased by 3.7%.[35]
Section E. Recommendations
The programs mentioned in the previous section were implemented by the government and supported in various ways by other agencies including the United Nations and the World Bank. These programs involved supporting women financially through monthly payments and educationally through nutrition classes, food preparation courses, and agriculture lessons. A common theme within the current programs in Egypt are the temporary solutions that they provide towards the issue of malnutrition. Rather than addressing the upstream factors of the issue such as community conditions, income insecurity, and housing conditions, the programs offer initiatives such as providing children with healthy lunches and take-home rations. Though these types of surface level interventions are helpful to an extent, they do not address the underlying factors that cause high rates of malnutrition in Egypt or account for children that are taken out of school at a young age.
To improve the issue of malnutrition in Egypt, programs must address the most common risk factors that increase rates of childhood malnutrition. Accordingly, programs should aim to improve maternal education level, household income level, and paternal job security. Women in rural Egypt governates have less education and suffer from structural violence both economically and culturally. School aged girls are taken out of school at an earlier age than boys and are pushed into homemaker roles at young ages. The lack of education they receive results in single-income households and poverty. As mentioned in section B5, women who have less education are more likely to have undernourished children and suffer from malnutrition themselves. In order to address the structural violence against women, universities should have initiatives that help support women from low-income households who want to enroll in higher education. Creating programs that offer families the ability to send their children to college can provide an enormous relief due to the financial burden of education in Egypt.
A comprehensive intervention to address childhood malnutrition in Egypt should include community-led initiatives in Upper Egypt. Malnutrition is a health condition that can be stigmatized by people who associate it with child negligence. If programs were led by people from the communities which experience malnutrition, less attention would be placed on the stigma. An existing program, the “Improving Household Food and Nutrition Security in Egypt by Targeting Women and Youth” teaches women how to process food and cook traditional meals with nutritional substitutes. A community-based approach to this program would ensure that women from the 5 governates were taught the skills necessary by program leaders, then become responsible for leading these classes in their own neighborhoods. Rather than having the educational classes run by public health program creators, women from each governate should be empowered to teach these classes themselves.
The intergenerational cycle of malnutrition explained in section B emphasizes the importance of addressing the upstream factors of malnutrition. When a poorly nourished woman in a low-income household becomes pregnant, her child is at a greater risk of experiencing childhood malnutrition. As that child ages, they suffer the long-term effects of malnutrition and are likely to have poorly nourished children themselves. Breaking this generational cycle of malnutrition can only be done by addressing the upstream factors that create poverty in families. Rather than allowing children to fall into the same lifestyle habits as their parents, they need to be empowered and supported to achieve higher education and thus, stable incomes.
An effective method to support children experiencing malnutrition is to provide and empower them with education. Programs should specifically target rural governates in Egypt, as they experience higher rates of childhood malnutrition than urban areas. Specifically, initiatives should be funded to support the financial coverage of education for girls under age 18 in rural governates. After supporting children to stay in school, programs can improve their experiences by providing nutritious meals. This initiative builds on the existing UN WFP, which provides healthy school snacks and take-home rations to children in 16 governates. With greater financial support from the WHO, the UN WFP can provide healthy lunches to school-aged children across Egypt.
Lastly, an improvement to the current Takaful and Karama program by the World Bank can be made to ensure that low-income families are receiving the support they need. As mentioned in section D, the current program has several conditions which families must adhere to in order to receive the monthly financial support. Currently, the conditions are centered around a required school attendance and health clinic visits. The program does not designate where these funds should be allocated and does not offer an educational component. Rather than providing families with general financial support, it would be beneficial if a certain amount of their spending was specifically allocated to grocery stores with fresh produce. Doing so would ensure that families are supporting their children nutritionally, as well as prioritizing their health. Additionally, it would be beneficial if the program supported an educational component for these families. An educational feature can range from learning about healthy eating, buying groceries on a budget, and understanding nutrition labels. Overall, the current programs in Egypt have the opportunity for improvement via the addition of community-based initiatives and by addressing the underlying factors of childhood malnutrition.
Section F. References
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