Macroeconomic Growth Barriers in Uzbekistan
Nutritional Focus
Mahoko Kamatsuchi
Nutrition Specialist
Health, Nutrition, Population Unit
Human Development Network (HDNHE)
The World Bank
May 2006
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
1
Macroeconomic Growth Barriers in Uzbekistan
Nutritional Focus
I. SUMMARY ______________________________________________________________________ 3
II. OBJECTIVE AND SCOPE_________________________________________________________ 3
III. TRENDS AND CHARACTERISTICS OF MALNUTRITION IN UZBEKISTAN __________ 4
1. Child Undernutrition in Uzbekistan __________________________________________________ 4
2. Regional and Geographic Comparisons_______________________________________________ 6
3. Overweight and Obesity among Adults _______________________________________________ 7
4. Micronutrient Deficiencies ________________________________________________________ 8
a)
Iron Deficiency Anemia ____________________________________________________ 8
 Anemia among Children _______________________________________________________ 8
 Anemia among Women of Reproductive Age _____________________________________ 9
b) Vitamin A Deficiency _______________________________________________________ 10
c) Iodine Deficiency __________________________________________________________ 10
IV. POSSIBLE CAUSES OF MALNUTRITION IN UZBEKISTAN ________________________ 11
V. COST-BENEFIT CONSIDERATIONS FOR INVESTING IN NUTRITION______________ 14
1. Economic losses due to malnutrition ________________________________________________ 14
3. Economic losses if no investments are made in nutrition _________________________________ 15
4. Economic gains from investing in nutrition___________________________________________ 17
5. Cost-benefit analysis _____________________________________________________________ 17
6. Long-term effects of not investing in nutrition _________________________________________ 17
VI. NUTRITION ACTIVITIES IN UZBEKISTAN ______________________________________ 19
a)
Iron-folate supplementation – Anemia reduction and prevention for women and children_____ 19
b)
Flour fortification – Anemia reduction and prevention among women and general population _ 20
c)
Vitamin A Supplementation – Vitamin A deficiency control and prevention _______________ 20
d)
Salt Iodization - Iodine deficiency control and prevention _____________________________ 20
e)
Breastfeeding Promotion – Overall malnutrition prevention for infants ___________________ 21
f)
Integrated Messages at the Community Level _______________________________________ 21
g)
Growth monitoring Promotion (GMP) _____________________________________________ 21
VII. INSTITUTIONAL ARRANGEMENTS FOR NUTRITION IN UZBEKISTAN __________ 21
VIII. RECOMMENDATIONS AND CONCLUSIONS ___________________________________ 22
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
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Marcroeconomic Growth Barriers in Uzbekistan
Nutritional Focus
I. SUMMARY
Uzbekistan’s economic situation has improved significantly, where GDP growth averaged 2.9% between 1998
and 2003, and accelerating to 7.7% in 2004.1 The 2002 Uzbekistan Demographic and Health Survey reports
that overall underweight status among young children has decreased from about 18%2 in 1996 to about 8% in
2002. However, alarming rates of micronutrient malnutrition, especially among children under 2 and women
in reproductive age, need closer attention.
Improving nutrition is in itself an MDG target, and the key indicator used for measuring progress as an nonincome poverty goal is the prevalence of underweight children under the age of five.3 The prevalence of
moderate and severe stunting among Uzbek children under-five is 21%4. Micronutrient deficiencies among the
same age group are even higher. Micronutrient malnutrition peaks especially among children between 12-23
months, where 70% of the children in that age group are anemic with iron deficiency, and 61% with vitamin A
deficiency. Uzbekistan also has one of the highest prevalence of anemia (over 60%) among women of
reproductive age in Central Asia. In addition, Uzbekistan suffers from an upward shift of overweight and
obesity among the adult population, and the trend is likely to be further aggravated by the ongoing changes in
lifestyles and an increasingly aging population.
Better nutritional status in childhood has been shown to be strongly associated with improved physical health
and labor productivity, and improved cognitive development and school performance, both enhancing incomeearning potential later in adulthood5. Productivity losses from malnutrition ranges between 0.5% to 2.9% of
total GDP, totaling over $53 million to $292 million. If no investments were made to improve the nutritional
situation of the population in Uzbekistan, economic losses would be much higher if the nutrition status did
improve for the next six years. Due to the decease in the prevalence rate, the economic loss due to stunting
would be 1.1 % of GDP without the improvement, and 2% in anemia among under-five. The total loss from
undernutrition (anemia, iodine deficiency, stunting and underweight) shows more than 4% reduction in GDP
growth. Each two or three years delay in getting nutrition programs to pregnant women and children under two
means another cohort of children whose physical and mental development is stunted for life.
Because nutrition programs are fairly inexpensive to implement, cost-benefit ratios for many interventions are
low. Nutrition investments, especially in micronutrients, are shown to be one of the ‘best buys’ that
developing countries could make in reducing poverty ($0.02 for vitamin A supplementation, $0.06 for
breastfeeding promotion) and improving economic growth.6
The need to address malnutrition has been recognized by the government of Uzbekistan. Several activities and
nutrition interventions targeting young children and pregnant women have been carried out at different scales
with various partners7. At the central level, the Ministry of Health is seeking technical support to elaborate a
coherent nutrition policy with active programs, with a focus on integrating nutrition activities into a
comprehensive national framework to work towards a common goal and to go to scale to rapidly reduce and
prevent malnutrition problems, especially among children and pregnant women.
II. OBJECTIVE AND SCOPE
The overall objective of the review is to examine the nutritional situation in Uzbekistan to assist the
government to formulate a national nutrition policy framework and to improve the Bank’s investment on
ongoing and planned health, nutrition and population (HNP) operations in the country. The analysis will help
the government finalize its nutrition strategy, to be discussed in a second in-country partner roundtable meeting
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
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in late 2006,1 as well as lay the groundwork for the preparation of the Bank’s Analytical and Advisory
Assistance (AAA) for Uzbekistan, in particular in the area of health which will include a nutrition component.
The following review will provide: a) an enhanced understanding of the prevalence of undernutrition across
demographic and subregional groups, as well as those of overweight and risk factors for non-communicable
diseases; 2) a review of actual interventions in nutrition; 3) evidence of how malnutrition and improved
nutrition could impact the country’s socioeconomic development; and 4) some cost-effective program options
for interventions in nutrition.
III. TRENDS AND CHARACTERISTICS OF MALNUTRITION IN UZBEKISTAN
1. Child Undernutrition in Uzbekistan2
22.6% of children under-three years are moderately and severely stunted8; 6.1% are moderately or severely
wasted, and 8.8% are moderately or severely underweight (Table 1). In Table 1, both indicators of children
under three and children under five are provided to facilitate comparative analysis later throughout the paper.
Table 1: Percentage of Children Under 3 and Under 5 Years of Age Malnourished
MALNUTRITION TYPES
Children Under-THREE
Moderate/Severe (<-2SD)
Children Under FIVE
Moderate/Severe (<-2SD)
Stunted
Low height-for-age
Wasted
Low weight-for-height
Underweight
Low weight-for-age
22.8
6.1
8.8
21.1
7.1
7.9
Source: UHES 2002
The overall underweight status among young children has decreased from about 19%3 in 1996 to about 9% in
2002 (Figure 1) among children under three years old.4 The overall proportion of children under three who are
stunted declined by one-third, while the proportions wasted and underweight declined by one-half.
1
The first nutrition round-table meeting was held on February 17, 2006 in Tashkent, Uzbekistan at the Ministry of Health called
upon the initiative by Dilnara Isamiddinova, Operations Officer at the World Bank Uzbek Office upon the visit of Mahoko
Kamatsuchi, Nutrition Specialist from HDNHE.
2 The first UN Millennium Decade Goal is: To reduce underweight in Uzbekistan from 8.8% in 2000 to 4.4% by the year 2015.
United Nations Millennium Development Goals resolution adopted by the UN General Assembly at the 8 th plenary meeting in
Sources: UDHS 1996, UHES 2002
September 2000.
3 Macro International, Uzbekistan Demographic Health Survey 1996. UDHS 1996 only measured children’s underweight
prevalence among children aged three (18.8%) and not among children under-five as done in the 2002 Uzbekistan Health &
Education Survey.
4 In the 1996 UDHS, children under the age of three years were measured in households selected for the nationally representative
sample. In the 2002 UHES, children under the age of five in the households were selected and measured. Since both surveys were
designed to be representative of the entire country, comparisons can be made between the indices of nutritional status obtained in
the two surveys for all children under the age of three years.
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
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Unde r-3 Malnutrition Tre nds Uz be kistan
be twe e n
1996 & 2002 Chidre n unde r-thre
e . (<-2 SD)
Stunted
31.2
Wasted (<-2 SD)
22.8
18.8
Underweight (<-2
SD)
11.6
Figure 1
35
Prevalence (%)
30
25
20
15
10
8.8
6.1
5
0
1996
2002
Sources: UDHS 1996, UHES 2002
If we take the poorest 40% and compare them with the top 40%, we see that the children in the poorest income
groups are twice as much at risk of being underweight than those in the highest income groups9. However,
anemia rates do not necessary show the same trends as with underweight, as anemia prevalence tends to
increase towards the upper quintiles (Figure 2).
Malnutrition Trend by Wealth Quintiles Children
Under-five, Uzbekistan
Prevalence rate (%)
40
38.8
35.7
32.4
35
33.9
28.5
30
25
19.5
20
20.6
18.3
15.3 16.1
11.7
15
16
15.4
8.2
10
10.1
5
ig
he
st
M
id
Stunting
Underweight
H
dl
e
d
Se
co
n
Lo
w
e
st
0
ur
th
2
Fo
Figure
Wealth Quintiles
Anemia
Source: World Bank (2003)
It is important to note that children aged 10-23 months are more malnourished than children in other age groups
in underweight and stunting indices (Figure 3). Moderate to severe stunting rises rapidly over the first year,
reaching a peak at age 10-11 months (35%). It remains elevated through age 36-37 months following with a dip
at 48-59 months.
Undernutrition among Children under 5 by Age Groups
Figure 3
40
35
35
27.1
25
25.2
Stunted
23.5
Wasted
20
16.1
15
10
8
7.1
5
3
5.9
3.4
6.1
12
-2
3
11.6
10
-1
1
Prevalence (%)
30
15.2
13
7.3
8.9
8.4
7.8
4.8
Underweight
8.4
6.1
48
-5
9
36
-4
7
24
-3
5
69
<6
0
Age (months)
Source: UHES 2002; MICS2 Uzbekistan (2000)
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
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2. Regional and Geographic Comparisons5
In Uzbekistan, there are urban-rural differences in rates of malnutrition. Stunting and underweight in children
are 1.5 times higher in rural areas compared to urban. Approximately 23.8% are stunted and 9.1% are
underweight in rural areas in comparison to 16.3% and 6.7% in urban areas (Table 2). Comparing the 1996
and 2002 national surveys, the situation in both urban and rural areas has improved, where we find a 65%
decline in urban areas in underweight in comparison to 53% in rural areas. Also, the improvement in stunting
has decreased dramatically by 50% in urban areas between 1996 and 2002, while it only decreased by 22% in
rural areas over the same period. The possible reasons why urban children are better off nutritionally could be
due to better access to healthcare, sanitation facilities, information and than what children in rural areas have
access to10. More research will be required in this area to find out the actual reasons for these urban-rural
differences in Uzbekistan.
Table 2: National Prevalence of Undernutrition in Children <5 years in Urban and Rural Areas
Urban
Rural
Stunted
(low height for age)
Moderate & Severe (<-2SD)
1996
2002
32.6
16.3
30.7
23.8
Source: UDHS 1996 & UHES 2002
Wasted
(low weight for height)
Moderate & Severe (<-2SD)
1996
2002
10.2
6.7
12.2
7.9
Underweight
(low weight for age)
Moderate & Severe (<-2SD)
1996
2002
16.6
5.8
19.7
9.1
If analyzed by geographical breakdown, stunting is highest in the East (Namangan, Ferghana and Andijan
Oblasts) (25.7%), and underweight is highest in the East-Central region (Samarkand, Dzhizak, Syrdarya and
Tashkent Oblasts) (13.4%) (Figure 4). The eastern-central region has almost twice the rate of underweight
compared to all the other regions in the country. The high indicator of wasting in Tashkent City is
questionable, since underweight (which is only 3.5%) is an immediate measure of malnutrition that combines
wasting and stunting figures.
Figure 4: Undernutrition in Children Under 5 years-old by regions (%), Uzbekistan
Undernutrition of children under-five by regions
30
25.7
23.2
Prevalence (%)
25
19.5
20
17.3
Children
Stunted (<2SD)
15.3
13.4
15
9
10
5
Children
Wasted (<2SD)
11.6
5.6
3.9
6.8
7.2
5.75.5
3.8
Chidren
Underweigh
t (<-2SD)
0
Western
Central
EastCentral
Eastern
Tashkent
City
Source: UHES 2002
5
Uzbekistan is a landlocked country located in Central Asia, with a territory covering 448,900 km2. The country consists of 12
administrative regions (oblasts), one Autonomous Republic of Karakalpakstan, and Tashkent City. Each region is divided into
administrative districts (rayons), totaling 162 districts, and 118 cities and towns.
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
6
As for comparison with other Central Asian countries, Uzbekistan is at similar levels with other countries in
the Central Asian region in terms of stunting rates, but shows the highest in wasting which reveals the current
malnutrition situation of children (Table 3).
Table 3: Comparison of Prevalence of Stunting and Wasting Rates in Children under-three in Uzbekistan
with other Central Asian Countries
Country
Kazakhstan11
Kyrgyz Republic12
Tajikistan13
Turkmenistan14
Uzbekistan15
% Stunting
(<-2SD)
9.4
24.8
30.9
22.3
22.8
% Wasting
(<-2SD)
1.7
3.4
4.9
5.7
6.1
% Underweight
(<-2 SD)
4.7
11.0
n.a.
12.0
8.8
3. Overweight and Obesity among Adults
Underweight among women (BMI <18.5) (See Box 1 for BMI explanation) does not seem to be a problem in
Uzbekistan where only 6% fall in the category of being undernourished16. On the contrary, there is a tendency
of overweight and obesity in the adult population. However, even though the tendency shows adult women
being more overweight, they show extremely high anemia prevalence with 60.4% among women of
reproductive age (15-49) (See section on Iron Deficiency among Women, p. 8.)
Between 1996 and 2002, there was an upward shift of overweight and obesity among women in Uzbekistan
(Figure 5). 3 out of 10 women and men are either obese or overweight (28% and 32% respectively). 54% of
women aged 45-49 years are overweight/obese in comparison to only 8% of women 15-19 years old, which is
an increase of six-folds. Most overweight or obese adults are in Tashkent City (34%) compared to the next
highest region in East-Central (28.9%) (Figure 6).
Conditions which are possibly related to being overweight or obese are growing in the country. Though the
reliability of the self-reported data could be biased and can result in higher levels of hypertension17,
hypertension levels were higher among overweight/obese subjects compared with those of normal weight18.
The hypertension rate among overweight/obese women (BMI ≥ 25) was 16% as compared with 3-4% among
women who were thin or normal weight (BMI < 18.5-24.9).19
Where high prevalence of underweight among children exist, as in the East-Central region (13.4%), high
prevalence of overweight/obesity among adult women also exists (29.1%) (Figure 6). There are currently no
data available on overweight /obesity prevalence among Uzbek children to be able to conduct a comparative
analysis of overweight and underweight children in the same regions.
Figure 6
Figure 5
Overweight/Obese Women & Underweight Children by Regions
40
Women of reproductive age (15-59 yrs.)
35
Prevalence (%)
30
27.5
29.1
34.1
29.1
25
23.5
20
15
Overweig
ht/ Obese
(B M I >25)
Wo men
(15-59)
13.4
10
5
9
5.5
5.6
3.8
0
Western
Central
East-Central
Eastern
Tashkent
Underwei
ght (<2SD )
C hildren
under-5
City
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
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Box 1. Consequences of Overweight / Obesity
Overweight and obesity are leading risk factors for multiple chronic diseases, including hypertension, type 2 diabetes,
coronary heart diseases, and certain forms of cancer (WHO, 1998).
The body mass index (BMI) is a measure of a person’s energy reserves (thinness or obesity) and is defined as weight in
kilograms divided by the square of height in meters (kg/m2). A BMI value of less than 18.5 is considered an indication
of chronic energy deficiency among non-pregnant women and men, based on cutoffs set by the WHO (WHO, 1995).
Values of 25.0-29.9 indicate that a person is “overweight,” while values of 30.0 and higher indicate “obesity.” In a
woman with a BMI of 26, the risk of coronary heart disease is twice the risk compared to women with a BMI of less
than 21. The risk of diabetes is 4 times higher in obese men and 8 times higher in obese women; and the risk of
hypertension is 2-3 times higher in obese individuals. It has been estimated that about 64% of male and 77% of female
cases of maturity-onset diabetes could possibly be prevented if no person had a BMI over 25 (CDC, 2005)
In Uzbekistan, 28% of women and 32% of men are overweight or obese.
4. Micronutrient Deficiencies
a) Iron Deficiency Anemia
[Goal: Reduce the prevalence of anemia (including iron deficiency) by one-third by 2010. (Declared at the
UN General Assembly during the Special Session on Children, May 20026)]

Anemia among Children
Iron deficiency anemia is high among Uzbek children under age of five (49.2%), and it is especially high
among children in the 12-23 month age group (70.2%)78 (Figure 7). Prevalence of anemia is considered a
moderate public health problem if prevalence is more than 20% in any group; while it is considered a severe
public health significance when the prevalence is more than 40%20. In comparison to other countries in
Central Asia, Uzbekistan shows an overall high rate of anemia among children under five in level with Kyrgyz
Republic and Tajikistan (Table 4).
Anemia and Vitamin A deficiency among chlidren (6-59 months)
by Age, Uzbekistan
80
Figure 7
70.2
70
Prevalence (%)
60
58.6
50.6
47.7
50.2
50
40
38.1
61.4
55.4
54.5
44.5
38.1
53.1
49.2
35.5
Vitamin A
deficiency
(<20 µg/dl)
30
20
Source: UHES 2002
Anemia
(Hb <12g/dl)
10
0
6-9
10-11
12-23 24-35 36-47
Age (months)
48-59
TOTAL
6
Declared at the UN General Assembly in the Special Session on Children, May 2002. The renewed micronutrient goals set out
in May 2002 aim to achieve the sustainable elimination of iodine-deficiency disorders by 2005 and vitamin A deficiency by 2010;
reduce by one third the prevalence of anemia, including iron deficiency, by 2010; and accelerate progress toward the reduction of
other micronutrient deficiencies through dietary diversification, food fortification, and supplementation.
7 Severe anemia is considered a public health problem if prevalence is >20% in any group
8 UHES data uses hemoglobin levels below 120 g/l as cut off points to indicate children aged 6-59 months as being anemic, while
WHO’s standards uses Hb <110 g/l as presence of anemia among the same age group (WHO/UNICEF/UNU, 2001).
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
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Table 4: Anemia in Children under-five and Women in Central Asia
(Sources: DHS Surveys)
Prevalence (%) among Children
under-five (Hb<12g/dl)
Prevalence among Women
(15-49 years) (Hb<12g/dl)
36.3
49.8
48.0
35.8
49.2
35.5
38.0
44.0
47.3
60.4
Kazakhstan21
Kyrgyz Republic22
Tajikistan23
Turkmenistan
Uzbekistan9

Anemia among Women of Reproductive Age
Uzbekistan has one of the highest prevalence of iron deficiency anemia among women of reproductive age
(15-49 years old) in Central Asia with 60.4% (Table 4). Though no nationwide anemia surveys were
conducted for women in 2002, we can presume to take this figure as representative especially where no anemia
reduction interventions were conducted since 1996. Anemia rates among women are extremely high in the
West and in the East regions (Figure 8). The explanations of the causes of the high rates require further
research. Data of the various malnutrition measurements for children and women are plotted together on the
below graph (Figure 8) to portray the different malnutrition prevalence existing within the regions.
Undernutrition of children under-five & Women of reproductive
age by Regions
90
Figure 8
80
Prevalence (%)
70
60
C hildre n
S t unt e d ( <2SD )
50
40
C hildre n
Wa s t e d ( <2SD )
30
C hidre n
Unde rwe ight
( <- 2 S D )
20
10
A ne m ia in
wo m e n ( H b
<12 g/ dl)
0
Western
Central
East-
Eastern
Central
Tashkent
City
A ne m ia in
C hildre n
( H b<12 g/ dl)
Source: UDHS 1996, UHES 2002
Box 2. Consequences of Iron Deficiency
Iron deficiency causes anemia and reduces activity levels and productivity in whole populations. Iron is necessary for
the production of hemoglobin—the source of the red pigment in blood—which carries oxygen to the tissues. Because
less oxygen is delivered to cells, people with iron deficiency anemia are easily fatigued and become more susceptible to
infection. Iron in the body is regulated mainly by absorption. There are some substances that inhibit absorption of iron
into the body, such as tea and coffee, as they contain an iron absorption inhibiting element called tannin.
Children 6 to 24 months of age and pregnant women are most at risk for iron deficiency anemia, followed by all women
of reproductive age. Anemia among children between 6 to 24 months disrupts the normal development of the brain.
Effects on children include stunting, sickliness, poor school attendance, and lower levels of concentration and memory.
Anemia among pregnant women increases the risk of hemorrhage and overwhelming bacterial infection during
childbirth. These women may give birth to babies who suffer from infections, weakened immunity, learning
disabilities, and impaired physical development and, in severe cases, death. Infants will be anemic if they do not
receive important iron stores from the mother during pregnancy and during delivery.
Due to iron deficiency anemia in Uzbekistan,
 60% of the nation’s 6 to 24 month-old children are at risk of disrupted brain and physical development.
9 For women, UDHS 1996 figures are used. For children, UHES 2002 figures are used.
 Approximately 5,000 Uzbek infants a year are at increased risk of death in the period immediately before or after
birth.
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
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b) Vitamin A Deficiency
[Goal: Achieve the sustainable elimination of vitamin A deficiency by 2010. (UN General Assembly
declaration, May 2002)24]
Currently, over half of the children under five (53.1%),10 or 2 million Uzbek children, suffer from vitamin A
deficiency (VAD) in Uzbekistan. VAD rate peaks among children aged 12-23 months (61.4%). This peak
also coincides with the high anemia rates among the same age group (Figure 7). Children in the 12-23 month
age group are a high priority for nutrition interventions to prevent and treat any type of malnutrition since this
is the age when any form of malnutrition does the most irreparable damage to the child25.
Box 3. Consequences of Vitamin A Deficiency
Vitamin A deficiency damages immune systems among young children so that illness and infections becomes more
common, and the children’s ability to resist diseases such as diarrhea, measles and acute respiratory infections is greatly
hampered. Lack of vitamin A can also cause eye disease and can lead to blindness. Increasing the vitamin A intake of
populations with vitamin A deficiency (VAD) can decrease childhood deaths from such illnesses by 23%, or nearly a
quarter of childhood deaths.
Half of Uzbekistan’s children (53%) are growing up with lowered immunity, leading to frequent ill health and poor
growth due to vitamin A deficiency.
c) Iodine Deficiency
[Goal: Achieve the sustainable elimination of iodine deficiency disorders by 2005. (UN General Assembly
declaration, May 2002.)]
Currently, 50% of the population in Uzbekistan suffers from iodine deficiency. Iodine deficiency disorder
(IDD) is a severe health problem in the most parts of the country, evidenced by inadequate urinary excretion of
iodine (<10 mcg/l),26 and the prevalence of goiter (15%) among the population. Thyroid goiter due to iodine
deficiency was prevalent as high as 40% in the Surkhandaria, Khoresm and Karakalpakstan regions.27 In 2002,
among the five prompted conditions of self-reported illnesses28, goiter was by far the most frequently reported
by women (13.6%), followed by anemia with 11.2%29. The Western region outnumbers the percentage of
women who self-reported goiter in comparison with other regions (Figure 9). In Uzbekistan, only 19% of
households consume adequately iodized salt30. The 80% of Uzbek households which are not consuming
iodized salt include 400,000 newborns that are not protected from brain damage each year.
Self-reported goiter among Women by regions
Figure 9
Percentage of goiter reported
Source: UHES 2002
45
40.2
40
35
30
25
20
14.2
15
12.8
6.4
10
7.8
5
0
Western
Central
East-
Eastern
Central
Percentage of
goiter reported
Tashkent
City
10
The study conducted limited to only Ferghana Oblast, a province in Uzbekistan where fruits and vegetables are particularly
abundant. If a problem with vitamin A were found in Ferghana Oblast, it was assumed that VAD problem exists elsewhere in the
country. UHES (2002).
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
10
Box 4. Consequences of Iodine Deficiency
Iodine deficiency is the world’s leading cause of mental retardation and brain damage, having the most devastating
impact on the brain of the developing fetus and young children in the first few years of life. Pregnant women are
most at risk because of the tragic effects of iodine deficiency on the developing fetus which may cause brain damage
to the unborn child. Some children born to iodine-deficient mothers suffer from extreme physical and mental
retardation manifesting in goiter (an enlarged thyroid gland), speech defects, deafness and cretinism. These children,
however, represent only the tip of the iceberg. Most children born to iodine-deficient mothers appear normal but
may have also suffered from brain damage and loss in an average of 10-15 IQ points, affecting their ability to
develop to their full potential. These seemingly normal children may have difficulty learning in school.
Iodine deficiency disorders (IDD) can be prevented with just one teaspoon of iodine—consumed in tiny amounts on
a regular basis over a lifetime through universal salt iodization (USI).
In Uzbekistan, an estimated 400,000 Uzbek babies are born each year with intellectual impairment caused by iodine
deficiency in pregnancy. Where goiter rate is estimated between 25-40%, more moderate forms of iodine deficiency
are estimated to be so widespread as to lower the average national IQ by 10 to 15 percentage points among schoolaged children.
Due to iron and iodine deficiency combined, an estimated 1.2% of GDP is lost due to lowered productivity of the
adult work-force in Uzbekistan (MI/UNICEF. VAM Damage Assessment Report, Uzbekistan, 2004.).
IV. POSSIBLE CAUSES OF MALNUTRITION IN UZBEKISTAN
The high prevalence of micronutrient malnutrition among young children and pregnant women can be due to
multiple factors, such as diseases due to diarrhea, infectious diseases, inadequate feeding practices, limited
access to water, hygiene and sanitation, and lack of education, especially among women. The country’s socioeconomic situation, leading to poverty and non-access to sufficient resources, could also be basic factors. The
conceptual framework of the causes of malnutrition were used for the analysis (See Annex. Figure 13.
Conceptual Framework).
1. Possible immediate Causes
As for infectious diseases, diarrhea and acute respiratory infections (ARI) are not common in Uzbekistan.
ARIs are extremely low and controlled, with only less than 1% of children under five with acute respiratory
infections, and only 5% had diarrhea in the preceding two weeks before the national survey31. 94% of children
with diarrhea received one or more of the recommended home treatments (oral rehydration solution or a
recommended home fluid), so home-based care can be considered adequate according to the household
survey32.
In dietary intake, as there are no nation-wide information on this, this factor cannot be analyzed. The low
levels of exclusive breastfeeding for 6 months, or other substances that young children are consuming could be
a triggering factor for the high levels of iron and vitamin A deficiency, but this needs to be further investigated
when dietary intake data are available.
2. Possible Underlying Causes
There does not seem to be a problem in access to food by looking at the food supply data from FAO. Food
supply per capita dietary energy supply is reported as 2,270 kilocalories per person per day (October 2005)33,
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
11
which is above the daily average requirements of healthy adult individuals.11 Information on what the family
eats, especially young children and women, on a daily basis, is not available.
In terms of care for mothers and young children, low birth weight among newborns is not a significant
concern. (Low birth weight babies reveal the nutrition status of the mother.) Only 6% of new-borns are
estimated to weigh less than 2,500 grams at birth.34
In terms of breastfeeding and complementary feeding practices, here is where the analysis could be
highlighted as being one of the major concerns and possible causes of the high micronutrient malnutrition
among children under two. Almost all newborns are universally breastfed in Uzbekistan (99%). However, by
the age of 2 months old, exclusive breastfeeding with only breastmilk drastically decreases to 42% (Figure 10),
depriving the infant from receiving the vital nutrients, energy and protein which can be sufficiently obtained
from just providing pure breastmilk alone. There was a slight improvement of exclusive breastfeeding rates
from 2000 to 2002, however, where only 4.8% of children under 6 months of age were exclusively breastfed in
200035, while in 2002, this rate improved to 9%.
Box 5. Infant and Young Child Feeding Recommendations
The internationally recommended practice is to exclusively breastfeed babies up to 6 months of age, and continue
breastfeeding up to two years of age and beyond. To exclusive breastfeed means to give nothing but breastmilk to the
child until s/he is 6 months old. When complementary foods are being introduced after 6 months of age, on-demand
and frequent breastfeeding should be continued to ensure that infants receive all the benefits of breastfeeding.
Promotion of practice of exclusive breastfeeding alone contributes 58%-87% reduction of neonatal mortality (Lancet,
March 2005). WHO estimates that 1.5 million deaths a year could be prevented by effective breastfeeding protection
(1993).
Bottle feeding with nipples is discouraged at any age. The artificial nipple enables faster flow of milk to the child than
suckling and may discourage the baby to breastfeed.
Breastfeeding in general is a very common practice in Uzbekistan, as can be seen with the relatively long
median duration of breastfeeding which is practiced up to 20.4 months. Breastmilk is provided in addition of
other liquid or foods36. However, paediatricians and primary healthcare workers are said to frequently advise
the use of breastmilk substitutes (formula milk) or early introduction of other liquids and foods37 even for
children younger than 6 months old if women consult them on the slightest problems with breastfeeding38.
Figure 10
6-months Exclusive Breastfeeding by Age: Uzbekistan
120
Rate (%)
100
Exclusive
breastfeeding 6
months
99
80
60
42
40
14
20
9
3
2
A
89
67
45
23
<2
tb
irt
h
0
Months
11
The daily average requirements for healthy adult individuals are 2,000 Kcal/person/day, WHO, Geneva. Healthy Food and
Nutrition for Women and their Families (2001).
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
12
Table 5: Infant and Young Child Feeding Status by Age
Age in months
Exclusively
breastfed
At birth
<2
2-3
4-5
6-7
8-9
99.0
42.0
14.5
9.0
2.5
1.5
TOTAL <6 months
9.0
Source: UHES 2002
Supplement to Breastfeeding
Water-based
Plain water
liquids/juice
24.7
23.5
36.7
29.1
21.6
29.4
8.0
32.0
6.3
17.7
27.3
27.8
0
0
8.1
22.2
43.5
57.4
Percentage using a
bottle with a
nipple
-26.9
41.3
37.8
34.6
24.9
--
--
Complementary
Foods
The percentage of the usage of the bottle with a nipple is also elevated in Uzbekistan. 41.3% of mothers use
bottles with artificial nipples to feed their infants when the child is only 2-3 months old (Table 5). In August
2004, the Ministry of Health issued an Order (Pirkaz 378) in line with the International Code of Marketing
Breastmilk Substitutes to prohibit the free distribution and advertising of breastmilk substitutes in obstetric and
children's health care facilities (Box 6). However, monitoring the compliance of the Code does not seem to be
fully reinforced. As large-scale multi-national breastmilk substitutes industries are prevalent in the country,
surveillance of the Code compliance needs to be closely monitored.
Box 6. What is the Code?
(from IBFAN www.ibfan.org)
The Code is an international law that enforces:
 No advertising of breastmilk substitutes in the health care system or to the public.
 No free samples, subsidized supplies or gifts to be given to mothers, pregnant women, health workers or to health
facilities.
 No contact between the infant formula company marketing personnel and mothers.
 Materials for mothers to be non-promotional and to carry clear and full information and warnings on the negative
impact on using infant formula feeding.
 Materials for health workers to contain only scientific and factual information.
 No pictures of babies or other idealizing images on infant formula labels.
Complementary foods are introduced to children at 22.2% already at the age of 4-5 months. The data
available do not provide sufficient information as to evaluate the nutrient content of the complementary foods
provided to the young children. It is worthy to note that exclusive breastfeeding rates are very low, and there
is a high consumption of tea among women and children at an early stage in their life (See Box 7 on Tea
Drinking in Uzbekistan).
Box 7. Cultural characteristics of tea drinking in Uzbekistan
In Uzbekistan, tea is introduced to children at an early age: almost half of infants 0-3 months are given tea, and by
4-7 months 85% of infants are receiving tea. By age 8-11 month, the most common food/liquid item given to
children is tea (98%). (UDHS 1996). Uzbek children were often found to consume tea at meals (40% to 78%).
Parents served tea to over 40% of children under one, and about 40% of children aged 1 to 3 years old during
meals in Karakalpakstan (UNICEF, 2002).
Tea inhibits iron absorption in the body due to the tannin present in both green and black tea. The high intake of
tea decreases the absorption of iron in the diet by 40%.
Pregnant women especially should be aware that tea inhibits iron absorption for the body and consequently to the
baby. Tea should be taken one or two hours after eating especially during pregnancy.
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
13
Lack of water, sanitation and hygiene could also be a determining factor for the causes of malnutrition. Only
29% of households in rural areas have piped water in their residences (54% overall; 85% in urban areas,)
whereas 23% utilizes the public tap as their water source. In the rural areas, the most common sources of water
is a public tap (33%), piped water (29.3%), and protected wells in their residence (11%).39 Pit toilets are the
most common sanitary facility, where up to 89% of rural households possess one, while 93% of urban
households have either a flush or pit toilet. Hand-washing before meals and after toilet usage and other
information on hygiene behavior are not available. Information on intestinal worm prevalence among children
under-five, school-aged children and pregnant and women of reproductive age would be useful to determine a
common cause of anemia among those groups.
In general, access to healthcare services is high, where 90% of children are born in maternities or hospitals.
85% of children are reported to have received all 8 recommended vaccinations in the first year of life40, and
DPT3 vaccination coverage is high with 94%.
3. Possible Basic Causes
Basic factors which underlie causes of malnutrition can be due to the lack of access to education, or lack of
resources to a country or community; and/or political, cultural, and social factors that affect utilization of those
resources12. Analysis on these issues will not be portrayed here due to the extensive work that will be required
to further investigate into each of these factors. As for education, Uzbekistan has high literacy rates (97% of
total population), and virtually all Uzbek adults have gone to school, with the median number of years of
schooling being nine41.
V. COST-BENEFIT CONSIDERATIONS FOR INVESTING IN NUTRITION
The cost analysis required in this section was conducted by Dr. Yoko Ibuka from Rutgers University. Some
sections of the study was extracted to facilitate the reading of the work. A more detailed report will be
available upon the finalization of the study.
1. Economic losses due to malnutrition
Possible economic losses due to malnutrition were calculated from the following six types of malnutrition and
micronutrient deficiencies, which are currently prevalent in Uzbekistan: stunting in children under fives,
underweight in children under fives, anemia in children under fives, anemia in women of reproductive age,
vitamin A deficiency, and iodine deficiency.
Table 7 shows the present values of productivity losses due to malnutrition and each micronutrient deficiency
with a 3% discount rate. All values except for (4) are shown in the present values after discounted by the
discount rate as well as survival rate. The ratio to GDP and per capita loss are also shown for each category in
the table. These values in the table should be interpreted with the greatest caution regarding the large
uncertainties involved in input data and model design. In the table, the total loss was also calculated by
summing up the losses due to each category between (1) and (6) for reference. However, notice that the total
should not be interpreted as the total economic losses in the economy, because the losses from (1) through (6)
are not mutually exclusive. For example, stunting and underweight in children are obviously related to the
micronutrient deficiencies.
The productivity loss ranges between 0.53% and 2.90% of GDP in 2002, totaling $53.11 million and $ 292.95
million respectively. The smallest burden is vitamin A deficiency, and the largest burden is iodine deficiency.
One reason why vitamin A deficiency yields the smallest burden is the low mortality rate under five in
Uzbekistan. The calculation of the economic loss due to vitamin A deficiency is based on the number of
12Based
on UNICEF’s Conceptual Framework on the causes of malnutrition (1990).
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
14
deaths under-five, and therefore low mortality rate is associated with small number of deaths due to vitamin A
deficiency.13 The loss per capita from vitamin A deficiency is $2.08, and $11.46 from iodine deficiency.
Iodine deficiency causes large productivity loss in the economy. The goiter rate in Uzbekistan is high14 and it
affects the productivity through intellectual impairment. Only the loss by goiter is estimated in our model, but
the loss would be larger if more moderate forms of iodine deficiency is also counted in the analysis.
Anemia among children under-fives is also a big burden in the country in terms of productivity losses in the
future. The prevalence rate in children is still seriously large15, and it would cause productivity losses in the
future through deterioration of cognition in childhood.
Underweight in children is another cause of large productivity losses. Underweight is associated with high
mortality in children, and the value shows the fact that the future productivity loss from the lost lives due to
malnutrition is not negligible, considering that the prevalence of underweight is considerably large, though
under-five mortality rate is not so.
Sensitivity analysis
Table 7 shows the results from the sensitivity analysis. The table contains both the result with 3% discount
rate and 10% discount rate for comparison. The present value of productivity losses with 10% discount rate is
much smaller than those with 3 % in each case, and it ranges from 0.10 % to 0.44 % as ratio to GDP, and per
capita losses are between $0.39 and $1.75. The total loss is also shown. The total loss is now 2.22% of GDP,
which is less than one third of the result with 3% discount rate.
3. Economic losses if no investments are made in nutrition
If no investments were made to improve the nutritional situation of the population in Uzbekistan, economic
losses would be much higher if the nutrition status did improve for the next six years. Due to the decease in
the prevalence rate, the economic loss due to stunting would be 1.11 % of GDP without the improvement, and
2.02% in children anemia. The total loss from the four categories shows more than 4% reduction in relation to
the GDP (Figure 11).
Figure 11: Comparison of economic losses of 2002 to those simulated with 1996 prevalence rate
Source: Ibuka calculation, May 2006
12.00
10.56
10.00
8.00
(%)
6.39
6.00
4.83
4.00
2.00
2.59
1.11
0.73
1.12
2.90
2.02
1.64
Simulation with 1996 data
Total of (1),
(2), (3) and (6)
(6) Iodine
deficiency
(3) Anemia
under fives
(2)
Underweight
under fives
(1) Stunting
under fives
0.00
2002
13
Under-five mortality rate is 69 per 1,000 live births and infant mortality rate is 57 per 1,000 live births in 2003.
The estimate of total goiter rate varies among resources. The lower bound (24%) is used for our estimation so that
overestimation could be avoided.
15
49.2 % for any anemia, and 23% for severe and moderate anemia (UHES2002).
14
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
15
Table 6: Economic losses due to malnutrition (Level, per capita and ratio to GDP)
(1)
(2)
(3)
(4)
Anemia in
women of
reproductive
ages
(5)
Vitamin A
deficiency
under
fives
Stunting
under
fives
Underweight
under fives
Anemia
under fives
Estimated productivity loss (million $)
73.71
113.55
Loss per capita ($)
2.88
4.44
165.33
104.41
6.47
4.08
Loss / GDP (%)
Source: Y. Ibuka calculation, May 2006
0.73
1.12
1.64
1.03
(6)
Iodine
deficiency
Total of (1)
to (6)
53.11
292.95
803.06
2.08
11.46
31.41
0.53
2.90
7.95
Table 7: Sensitivity analysis (Discount rate 3% and 10%)
(1)
(2)
(3)
(5)
(6)
Stunting
under fives
Underweight
under fives
Anemia
under fives
Vitamin A
deficiency
under fives
Iodine
deficiency
Total of
(1) to (6)
3%
73.71
113.55
165.33
53.11
292.95
715.02
10%
12.83
21.29
31.00
9.96
44.72
224.23
3%
2.88
4.44
6.47
2.08
11.46
27.97
10%
3%
0.50
0.73
0.83
1.12
1.21
1.64
0.39
0.53
1.75
2.90
8.77
7.08
10%
0.13
0.21
0.31
0.10
0.44
2.22
Discount rate
Estimated productivity loss
(million $)
Loss per capita ($)
Loss / GDP (%)
Source: Y. Ibuka calculation, May 2006
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
16
4. Economic gains from investing in nutrition
Table 8 shows the economic gains from investing in nutrition interventions. In each intervention, the gains
from three coverage levels are presented. The gains depend on (1) maximum attainable benefit, (2) coverage of
program, and the (3) effectiveness (which consists of compliance and efficacy) of the activities. Maximum
attainable benefit is an increasing function of current malnutrition-prevalent rate and the size of population
where micronutrient deficiency is prevalent. Therefore, a larger gain is obtained when: 1) the current
prevalence rate of the malnutrition is larger (i.e. the current burden of the malnutrition is heavier), 2) the
intervention has larger coverage, and 3) the intervention is more strictly enforced, and 4) the efficacy of each
intervention is higher.
The maximum attainable benefit ((1) in table 6) is high in salt iodization ($293 million), iron supplementation
of pregnant women and/or women of reproductive age ($ 270 million), and breastfeeding promotion ($ 222
million). As goiter rate in Uzbekistan is high, and it places huge economic burden on the country. Therefore,
the potential benefit from the reduction in iodine deficiency prevalence would also be large. As for flour
fortification with iron, the total economic loss (or the maximum attainable benefit) is large. Breastfeeding
promotion would potentially yield a large benefit because of the current inadequate and incomplete
breastfeeding practices, particularly among children under six month of age16.
The gains from the
interventions range from $38 million to $ 86 million when the program coverage is 95%. In the case of 50%
coverage, the values reduce by almost half in each case.
5. Cost-benefit analysis
Table 9 shows the benefit per cost in US dollars for the different nutrition interventions. Since both benefits
and costs are constant with respect to the size of programs, cost-benefit ratios are constant across the coverage
levels of programs.
Fortification for iron is the most cost-effective among five interventions shown here. The cost-benefit ratio is
119, and it outperforms iron supplementation. The reason is the unit cost for supplementation is more than 10
times as high as for fortification. Vitamin A supplementation is relatively cost-effective because the unit cost is
less than iron supplementation, and the total cost for vitamin A supplementation is the lowest among the five
interventions. Salt-iodization is less cost-effective than flour fortification with iron because of the higher unit
cost, although the gains from salt iodization are almost the same in both fortification interventions.
Table 9: Cost-benefit ratio
Benefit / Cost
Breastfeeding promotion
36
Vitamin A supplementation
73
Iron supplementation
8
Flour fortification with iron
119
Salt iodization
35
Source: Y. Ibuka’s calculations, May 2006
6. Long-term effects of not investing in nutrition
(To be reported late May 2006)
16
Kamatsuchi, Uzbekistan Nutritional Analysis (2006)
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
17
Table 8: Economic gains from interventions
Maximum
attainable benefit
(million $)
Coverage (%)
Effectiveness (%)
Gains from intervention
(million $)
(1)
(2)
(3)
(4)=(1)*(2)*(3)
95%
222.04
95
24
50.62
80%
222.04
80
24
42.63
50%
222.04
50
24
26.64
95%
53.11
95
75
37.84
80%
53.11
80
75
31.87
50%
53.11
50
75
19.92
95%
104.41
95
67
66.46
80%
104.41
80
67
55.96
50%
104.41
50
67
34.98
95%
269.74
95
33.5
85.84
80%
269.74
80
33.5
72.29
50%
269.74
50
33.5
45.18
95%
292.95
95
30
83.49
80%
292.95
80
30
70.31
292.95
50
30
43.94
Program
coverage
Breastfeeding promotion
Vitamin A supplementation
Iron supplementation of
pregnant women and/or
women of reproductive age
Flour fortification with iron
Salt iodization
50%
Source: Ibuka’s calculations, May 2006
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
18
VI. NUTRITION ACTIVITIES IN UZBEKISTAN
Some key interventions in nutrition will be highlighted in following. See Table 12 in the Annex for a listing of
the current nutrition activities ongoing in Uzbekistan. The percentage coverage of the on-going interventions
are summarized in Table 13. Some spaces are kept blank in the table due to the lack of information. The
program coverage was obtained by the number served for vitamin A supplementation and iron and folic
supplementation. The value for the program coverage in flour fortification with iron shows the possible
attainable coverage, given the project budget.
a) Iron-folate supplementation – Anemia reduction and prevention for women and children
Uzbekistan initiated weekly iron-folate supplementation for pregnant women, children 1-2 years old, and girls
aged 12-14 since 2002 in three oblasts, which now expanded to 6 oblasts with the financial support from
UNICEF and JICA. With the World Bank-supported Health II project, the Government of Uzbekistan intends
to expand its coverage to the remaining 4 oblasts by the end of 2007. Though weekly supplementation (rather
than a daily supplementation) is still not recommended as a public health measure, Uzbekistan follows the
Central Asian agreed-upon protocol of weekly supplementation determined by the Kazakh Academy in
Almaty: weekly doses of 60 mg of iron and 400 μg of folic acid (in a combined tablet) for all women of
reproductive age; 120 mg of iron and 800 μg of folic acid per week (2 pills) for pregnant women. It was
originally recommended that 30 mg of iron and 200 μg of folic acid to be given to children 1-2 years of age
every week in syrup form; but as there are no more syrups available, 1 tablet of 60 mg of iron and 400 μg of
folic acid are provided to them on a weekly basis. WHO recommends daily supplementation—not weekly--for
three months for pregnant and all women for iron deficiency prevention (See Table 10).
Iron tablets are available to pregnant women free of charge in the antenatal care visits. The World Bankfunded Health I project has provided hematocrit machines, of high quality, to measure anemia. However,
HemoCues may be easier to use at the SVP levels rather than the highly technical and specialized machines. It
was noted that if the trained doctors or laboratory technicians transfer or leave the facility, the other SVP level
staff may not have the capacity to use the highly technical machines. More microcuvettes, which are used with
the anemia measuring HemoCues machines, appear to be high in demand42.
Several other small scale anemia control activities have been implemented by other institutions in previous
years, such as ZdravPlus (by USAID), but most international NGOs have closed down in the last few months
in the country. Documentation of these initiatives was not available to make further assessments of these
initiatives.
Table 10. Dosage schedules for Iron Supplementation to Prevent Iron Deficiency Anemia
Age groups
Indications for
supplementation
Children from
6 to 23 months
of age
Where the diet does not
include foods fortified
with iron or where anemia
prevalence is above 40%
Where anemia prevalence
is above 40%
Children from
24 to 59
months of age
School-aged
children
(above 60
months)
Women of
childbearing
age
Anemia
rate in
Uzbekistan
60%
43.5%
Where anemia prevalence
is above 40%
Not known
Where anemia prevalence
is above 40%
> 60%
Internationally
Recommended Dosage
schedule43
Iron: 2 mg/kg
body weight/day from 6 to
23 months of age
Iron: 2 mg/kg body
weight/day up to 30 mg for 3
months
Iron: 30 mg/day
Folic acid: 250 μg/day for 3
months
Iron: 60 mg/day
Folic acid: 400 μg/day for 3
months
Actual Target
Group Dosage
Given in
Uzbekistan
Children 12-24
months: Iron: 60 mg.
Folic acid: 400
μg/week/3 months
None
Only girls 12-14
years: Iron: 60 mg.
Folic acid: 400
μg/week/3 months
Iron: 60 mg. Folic
acid: 400 μg/week/3
months
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
Coverage
2002-2004:
Ferghana
2003-2005:
Karakalpak
Rep, Khorezm,
Andijan
2004-2006:
Namangan
2005-2007:
Djizzak,
Syrdarya,
Kashkadarya,
Surkhandarya
2005: Health
19
Pregnant
women
Universal supplementation
> 60%
Lactating
women
Where anemia prevalence
is above 40%
> 60%
Iron: 60 mg/day
Folic acid: 400 μg/day as
soon as gestation starts, no
later than 3rd month and
continue until rest of
pregnancy.
Iron: 60 mg/day
Folic acid: 400 μg/day for 3
months post-partum
Iron: 60 mg. Folic
acid: 400 μg/week/3
months
II: Navoi,
Tashkent,
Samarkand,
Bukhara
None
b) Flour fortification – Anemia reduction and prevention among women and general population
Flour fortification was initiated at 14 government managed mills, fortifying grade 1 flour17, with iron and other
micronutrients, using a premix (KAP 1) developed by the Kazakh Academy in Almaty. The funds and
technical support are provided by the World Bank-managed GAIN grant. Fortified flour logo is stamped on the
packages to designated fortified flour. The initiative is supported by various partners, such as the World Bank,
GSAIN, UNICEF, ADB, under the coordination of the Government of Uzbekistan. UNICEF implements the
communication activities under a Grant Agreement signed with the Bank to promote the consumption of
fortified flour to the public. The Uzbek flour fortification initiative is advancing well in comparison to the rest
of the countries in the Central Asia region according to experts attending the regional flour fortification
meeting. According to the wheat flour market study conducted in 2005, the maximum coverage where the
fortified flour can reach 30% of the general population44.
c) Vitamin A Supplementation – Vitamin A deficiency control and prevention
Vitamin A supplementation for children 6-59 months is being conducted through Healthy Child Weeks, with
vitamin A capsules support from UNICEF through the Micronutrient Initiative/CIDA. Nationwide vitamin A
supplementation was carried out in February and August 2005. Coverage of supplementation of children aged
6-59 months was 94.3–96.8 %. These events use social mobilization activities (through TV, radio, health
system) to advertise that children need to be brought to the health facilities to obtain vitamin A.
One time dosing of women shortly after birth is effective in raising vitamin A levels in breastmilk, and
improving the vitamin A status of the infant for at least 6 months. Supplementation of women after delivery
should be encouraged.
d) Salt Iodization - Iodine deficiency control and prevention
Asian Development Bank has provided technical assistance grants to Uzbekistan for universal salt iodization
with an initial contribution to purchase equipment for most large scale salt producers in the country. In 1998,
only 8% of salt was iodized at the retail level; then in 2001, though 50% of salt was iodized, only 6.5% has
adequate levels of iodine. Local governments in Karakalpakstan, Samarkand, Surkhandarya and Fergana
oblasts have issued decrees prohibiting the sale of un-iodized salt. Though the promotion of consumption of
iodized salt is still being carried out by the Institute of Health, it is essential to obtain adequate iodized salt
production in the country before further dissemination activities continue. Current household coverage for
consumption of adequately iodized salt is 19%45.
In Uzbekistan, universal salt iodization legislation is yet to be adopted. All countries in Central Asia, except
Uzbekistan (Azerbaijan, Kyrgyz Republic, Kazakhstan, Mongolia, Tajikistan) have adopted a Universal Salt
Iodization Law.
17
Superior grade flour is the highest grade of flour in the country. Grade 1 is below superior grade in quality.
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
20
e) Breastfeeding Promotion – Overall malnutrition prevention for infants
More attention has been given to the promotion of exclusive breastfeeding at the rural health care (SVPs), but
this does not seem to be enough judging by the low rates of exclusive breastfeeding of children under 6 months
old. Though the MOH approved the national policy on breastfeeding practice and key experts were trained on
lactation management since 1999, breastfeeding policies are still not clear throughout the country, even within
the Ministry of Health. Exclusive breastfeeding practices are only focused on the first 1 or 2 months of life,
and upon questioning in the field and with the Health Ministry staff themselves, it was evident that they were
not fully aware of the recommended duration of breastfeeding nor the importance of continuing breastfeeding
up to 2 years of the child’s life.
Medical students at 16 major medical schools are currently being trained on lactation management. To date,
32 health institutions have been certified as “Baby Friendly.”46 Rather than merely focusing on hospitals,
health institutions should be targeted to be baby friendly. Greater emphasis will be placed on pre-service
training on lactation management at medical schools, rather than training pediatricians as there are too many to
train (over 12,000) in the country. The current coverage of the activities fall less than 10% of the entire
health facilities.
f)
Integrated Messages at the Community Level
Currently, mid-level health workers go door-to-door to provide iron-folate tablets to pregnant women and
young children and provide key health messages. Whether this practice is continued or the effectivity of this
approach can not be verified as there are no assessment to enable us to make a judgment. The usage of midlevel health worker provide an excellent opportunity for overall heath and nutrition counseling, but motivation
of these workers and overburdening them with multiple tasks may pose a problem in sustainability.
A local women-based NGO is promoting key family practices under the Family Empowerment Program
initiated in May 2003, though the coverage is still small (6 districts in 3 oblasts). The main strategy is to
promote integrated, key family practices in rural communities, mobilizing the communities through the service
providers, parents and community educators (community workers to educate the community on key family
practices, who are paid by the government). Integrated education and training materials for care practices for
children 0-6 are developed based on the UN agency supported Facts for Life47. The materials will be now
catered for children 0-3 and 3-6 years old with targeted messages, including promotion of breastfeeding,
immunization, childhood illnesses prevention, water and sanitation and early learning.
WHO has supported the training of healthy dietary intakes at the national level (rational nutrition). The
intended objective was to change the overall dietary behaviors of the population. Central level ministry staff
were trained, but this has not yet expanded to the periphery.
g) Growth monitoring Promotion (GMP)
Growth monitoring promotion will be further expanded by the Government in 2005. Weights of children
under one year old are noted in the health books which are kept at the SVPs, and are not taken home by the
parents. There were no signs that children older than 1 year old were regularly weighed. Given the low rates
of underweight in the country, more emphasis should be placed on providing key nutritional counseling on
anemia prevention, and promotion of exclusive breastfeeding practices within the GMP sessions, in addition to
monitoring the growth of children.
VII. INSTITUTIONAL ARRANGEMENTS FOR NUTRITION IN UZBEKISTAN
Nutrition activities are dealt by different departments within the Ministry of Health (Annex. Figure 12). The
Sanitary Epidemiological Surveillance Department in the Ministry of Health sets standards for micronutrient
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
21
fortification in food fortification (salt and flour) and gives recommendations on dietary allowance to the
general population. The Institute of Hygiene and Nutrition deals with food safety issues of fortified products.
The Department of Hematology and Blood Transfusion oversees iron supplementation and flour fortification
issues. Department of Pediatrics deals with breastfeeding, while the Medical Academy oversees vitamin A
supplementation. Institute of Health deals with the communication aspects of nutrition activities. Different
departments manage the donor-driven projects in a seemingly isolated matter, neither without much
coordination nor between the different departments. Most of the nutrition activities exist in certain districts
only and do not cover a large scale to make a national impact.
Common indicators for baseline and impact assessment for the nutrition interventions are not yet defined nor
understood within the Ministry of Health. There seems to be a better understanding of the overall objectives
of reaching reduction of malnutrition goals as a non-income goal set forth among the Millennium Decade
Goals.
VIII.
RECOMMENDATIONS AND CONCLUSIONS
To accelerate progress towards the MDG goals, using different combinations of available and known-to-beeffective methods should be deployed, not as stand-alone efforts, but as part of a comprehensive plan with a
common vision of reducing undernutrition and micronutrient deficiencies across the country. As noted by the
World Bank Office in Tashkent, the Ministry of Health could benefit from a national nutrition framework and
a master plan of action to lay out the framework of where the country needs to head towards in regards to
focusing on malnutrition reduction and focus on priority interventions. Existing and future investments should
be targeted to specific target populations within an overall national plan.
It was formally agreed in a nutrition round-table meeting held in Tashkent, Uzbekistan on February 17, 2005,
that a national nutrition framework is needed, and that all the actors and departments involved in nutrition
interventions work together to form a Nutrition Task Team. This would consist of all the departments working
on nutrition within the MOH, as well as the donors and technical agencies such as the World Bank, UNICEF,
WHO, Asian Development Bank, CDC and USAID and others.
It was noted in the same meeting that a nutrition coordinator at the central government will soon be appointed
to serve as the focal point for all nutrition interventions for the country. This would facilitate better
communication and coordination between the different departments, as well as with the donors and agencies
which all have different agendas of work.
For Uzbekistan, some of the following specific points should be noted as priority recommendations, in
addition to some of the generic key notes which need to be considered to deal with overall malnutrition
strategies (Box 8):
1. There is an urgency to tackle high rates of malnutrition, namely anemia, vitamin A and iodine
deficiency, especially among children under 2 years old with focus for all children under-five and
pregnant women.
2. Promotion of exclusive breastfeeding needs to be taken up nationwide to provide a “good start in life”
for all children. This needs to be prioritized and speed up the process to save the current infants from
entering the malnutrition cycle.
3. Focus should be on nation-wide coverage interventions and go to scale with successful initiatives.
4. Compile a systematic master plan to combat malnutrition, especially micronutrient malnutrition, with
the various departments within the Ministry of Health and other sectors.
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
22
5. Ccommunity level workers must be key partners in communicating and monitoring the behavior
change interventions, since sustainable behavior change cannot rely just on health system
communication alone.
Box 8. Key facts to know regarding malnutrition strategies
 Major damages caused by malnutrition take place in the womb and during the first two years of life.
 Any damage caused to the child during this time is irreversible.
 Malnutrition results in lower intelligence and reduced physical capacity; which results in the
reduction in productivity, therefore slowing down economic growth.
 Malnutrition passes from generation to generation from mothers to the child.
 To break this cycle, the focus must be on preventing and treating malnutrition among pregnant
women and children aged 0 to 2 years, though the overall programmatic target population could
cover children under five.
 Evidence suggests that the origins of obesity and non-communicable diseases, such as cardiovascular
heart disease and diabetes may also lie in early childhood.
Uzbekistan has an advantage over many developing countries in that the majority of its adult population is
literate and able to read and understand educational messages about nutrition. Another advantage is that there
is high utilization of the health services. It is possible to deliver essential nutrition messages and interventions
to the majority of the population of women during pregnancy and immediately after delivery and children,
particularly in their first year of life through the health system, as well as through the community networks and
through written and visual media coverage.
The key is to address malnutrition successfully is to focus on short, medium and long-route framework (Table
11). Short route interventions have an immediate effect and they should aim to reach the largest coverage as
possible in the shortest amount of time. The short routes include nationwide promotion and/or campaign of
one or two key behavior messages, Child Health Weeks conducted annually or biannually, with distribution of
key micronutrients, such as iron, vitamin A and possibility deworming tablets (if worm prevalence among
women and children are verified). The set-backs of these nationwide approaches are mainly of sustainability,
and the short, one time contact with the nutrition intervention and the target population. These shorter routes
should be combined with medium route approaches, such as with food fortification, routine coverage with iron
and vitamin A supplementation, in combination with periodic targeted message communication to the target
groups. Longer routes are also required, usually to set policies and standards, and to enforce compliance to the
various decrees.
Uniting the development assistance agencies and the various divisions within the Ministry of Health and other
Ministries around a common nutrition agenda to drive its own investment agenda is essential. Accelerating the
move from nutrition activities to a more coordinated program approach would offer an opportunity to scale up
nutrition. Reorienting some of the large-scale investments in the country to improve the implementation
quality addressing malnutrition prevention towards younger children and pregnant women or would-be
mothers are recommended as effective program approaches.
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
23
Table 11 Nutrition Approaches – Short, Medium and Long Route Options for Uzbekistan
Necessary for all
Underweight /
Stunting
Iodine
Deficiency
Short route
Medium route
6 months exclusive
breastfeeding; and BF up to
2 years
Promotion of exclusive
breastfeeding; BF up to
2 years
Promotion of
exclusive
breastfeeding
Appropriate complementary
feeding after 6 months
Targeted messages on
complementary feeding
Targeted
messages on
complementary
feeding
Growth
monitoring
Salt iodization;
Passing of the salt
iodization law
6 months exclusive
breastfeeding; and BF up to
2 years
Salt iodization
Long route
Nutrition education:
change of dietary
habits; Enforcement
of compliance to The
Code of Breastmilk
substitutes
Trade and agricultural
policy reform;
Research
Growth monitoring
Enforcement of flour
fortification law
Appropriate complementary
feeding after 6 months
Vitamin A
Deficiency
6 months exclusive
breastfeeding; and BF up to
2 years
Vitamin A
supplementation: Child
Health
Weeks/Campaign
Vitamin A
supplementation:
routine
6 months exclusive
breastfeeding; and BF up to
2 years
Iron-folate
supplementation
(pregnant women)
Flour fortification;
Passing of flour
fortification law.
Appropriate complementary
feeding after 6 months
Iron for children;
Iron-folate
supplementation
(women)
Appropriate complementary
feeding after 6 months
Iron Deficiency
Overweight /
Obesity
6 months exclusive breastfeeding promotion & BF up
to 2 years
Appropriate complementary
feeding after 6 months
Deworming (after
worm prevalence is
assessed)
Targeted messages
Exclusive breastfeeding promotion &
BF up to 2 years
Targeted
messages
Targeted
messages
Nutrition
education
Nutrition education
on dietary intake;
Agricultural reform;
trade policy reform;
research
Nutrition education
on dietary intake;
agriculture;
Enforcement of flour
fortification law
Nutrition education
on healthy eating
habits and exercising;
Adjusting pricing
policies for processed
foods, etc.
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
24
Breastfeeding
Promotion
ANNEXES: Table 12 Activities for Malnutrition Control and Prevention in Uzbekistan
Activity
Coverage / Years of Activity
- Issuance of the Code;
- Lactation Management &
BF training
2004: National level
- Drafting of the Code of Marketing
Breastmilk Substitutes legislation
- Introduction of Lactation management
into pre-service curricula
2005: 6 maternities + 13 policlinics
certified as Baby Friendly Health
Institutions, 32 total
2006: 70% of maternities/policlinics
targeted in 6 oblasts
2002-2004: Ferghana
2003-2005: Karakalpak Rep, Khorezm,
Andijan
2004-2006: Namangan
2005-2007: Djizzak, Syrdarya,
Kashkadarya, Surkhandarya
2005 - : Health II: Navoi, Tashkent,
Samarkand, Bukhara
2005-2010: Ferghana, Khorezm, Djizzak,
Karakalpakstan, Andijan, Namangan,
Jizzakh, Syrdarya, Kashkadarya, Tashkent
city
Baby Friendly Health
Institutions Initiative
Executing Govt Body in
Min. of Health
Dept Pediatrics
Supporting
Agencies/Donors
UNICEF
UNICEF
UNICEF: training,
communication
materials; JICA (ironfolate) (2002-2005);
World Bank Health II,
ZdravPlus (40 rayons
for 2005-2008)
Entire population.
-Purchase of lab equipment
- Establishment of standards
(under revision)
- Public awareness raising
- Children 6-11 months
(100,000 IU)
- Children 12-59 mos;
- Women post-partum
(200,000 IU)
Dept Mother & Child Health),
Dept Hematology & Blood
Transfusion; Endocrinology
Dept; Medical Academy;
Institute of Health.
Medical Academy
GAIN (World Bank;
UNICEFCommunication),
ADB (initial set up)
Food Fortification of wheat
flour with iron & folic acid
(KAP1)
Vitamin A Supplementation:
- Protocol development
- Training of medical
personnel nationwide
- Communication
2003-present: Nationwide; twice a year
Salt iodization:
- Elaboration of legislation
– Development of standards
– Communication. – Supply
purchase
Ferghana, Khorezm, Djizzak,
Karakalpakstan oblasts, Tashkent city
Entire population
Sanitary Epidemiological
Surveillance; Institute of
Hygiene and Nutrition
ADB, UNICEF. ADB
waiting the
endorsement of
legislation to release
funds in 2006.
- Promotion of Healthy
Nutrition: training
2006: National level MOH staff
Surkhandarya, Kashkadarya
oblasts (HOPE) with focus on
anemia prevention. WHO
focus on national level.
Institute of Health
WHO; Project HOPE
(2003-2005)
- Development of integrated
monitoring & evaluation for
iron and folic acid
deficiency
Foreseen in 2006
Integrat
ed
Monitor
ing
System
Promot
ion of
Ration
al
Nutriti
on
(Dietar
y
Intake)
Iron Deficiency Anemia
Dept. of Hematology & Blood
Transfusion. Dept Mother &
Child Health Devt
Vitamin A
Deficiency
- Children 12-24 months
- Girls 12-14 years
- Women 15-40 yrs
- Pregnant women
- Anemic children
Iodine
Deficiency
Iron-folate supplementation
Target Group / Element
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
UNICEF / CIDA (Vit
A capsules)
CDC
25
Table 13: On-going programs and their coverage in Uzbekistan
Years
Breastfeeding promotion
Vitamin A
supplementation
Target population
Number
served
Coverage of the
program in the
entire period
(%)
Children 6-59%
months of age, mothers
at their first 6-8 weeks
after childbirth
All oblasts of
Uzbekistan
100
2000-2009
2003-2005
2003-2008
4,315,403
466,503 in the Republic of Karakalpakstan (20032005)
415,875 in Khorezm (2003-2005)
45
661,923 in Andijan (2003-2005)
Women of fertile age,
girls 12- 14 years old
and infant 6-24 months
of age
Iron and folic acid
supplementation
378,661 in Namangan (2004-2006)
837,528 in Fergana (2005-2007)
296,163 in Djizzak (2005-2007)
60,961 in Syrdarya (2005-2007)
671,171 in Kashkadarya (2006-2008)
526, 618 in Surhandarya (2006-2008)
2003-2005
All population of target
groups
2005-2009
Women of fertile age
(15-49), children under
59 months
2003-2005
All population of target
groups
Flour fortification with
iron
Salt iodization
74
Source: M.Kamatsuchi, Field-derived information from Uzbekistan. Table made by Y. Ibuka.
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
26
Annexes
Figure 12. Institutional Arrangements for Nutrition, Uzbekistan
The Cabinet of Ministers
World Bank / GAIN
Ministry of Health
Expert Commission
NA TIONA L
UNICEF
Department of
Hematology
ADB
Women’s
Committee of
Uzbekistan,
IFSAU,
Mahkhallya
Kamolot
Foundation
WHO
CDC/CAR
Joint Projects
Implementation Bureau
(JPIB)
Department of
Endocrinology
Center of State Sanitary
Epidemiological
Surveillance (RCSSEI)
Nutrition Coordinator
Institute of Food Hygiene
& Nutrition
Medical Academy
Institute of Health
- Rayon Khokimiats of CRH
- Rayon departments of popular
schooling,
- Working groups,
- Rayon level Coordinators
Provincial (oblast)
branches of the Health
Institute and others;
Oblast dispensaries
RAYON
(DISTRICT)
Women’s Committee,
Makhallya Fund,
Kamolot Foundation, etc
- Oblast Health departments
- JPIB Health-2
- “Women and Child Health
development”
- Oblast departments of popular
schooling & working groups
OBLAST
(PROVINCE)
Branches and oblast
departments of
Uzbekistan Women’s
Committee, IFSAU,
Mahkhallya Kamolot
Funds, etc.
District Health Centers
(rayons)
Makhalla Committees
Makhallaya/community
Primary Healthcare Facilities
leaders
(SVPs)
- Religious leaders
- Women Committee
leaders
M. Kamatsuchi,
Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
27
COMMUNITY
-
Figure 13. Conceptual Framework of the Causes of Malnutrition
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
28
The first draft has been revised or commented by:
Dr. Meera Shekar, Senior Nutrition Specialist, HDNHE
Dr. James Garrett, Senior Economist, HDNHE
The Cost-analysis Section Outline has been reviewed by:
Dr. John Langenbrunner, Senior Economist (Health), ECSHD
Dr. Andriy Storozhuk, Senior Economist, ECSHD
1
IMF (April 2005). Data available at: www.imf.org/external
Macro International, Uzbekistan Demographic Health Survey 1996. UDHS 1996 only measured children’s underweight
prevalence among children aged three (18.8%) and not among children under-five as done in the 2002 Uzbekistan Health &
Education Survey.
3 The World Bank, Repositioning Nutrition as Central to Development: A Strategy for Large-scale Action, Washington DC, 2006.
4 Macro International, Uzbekistan Health & Education Survey (UHES) 2002. 21% is the stunting level of children under 5 years
of age.
5 World Bank, Repositioning Nutrition (2006).
6 JR Behrman, H. Alderman and J. Hoddinott, “Copenhagen consensus-challenges and opportunities: Hunger and Malnutrition.”
Copenhagen Consensus Challenge Papers (May 7, 2004).
7 Key partners include: World Bank, UNICEF, ADB, WHO, JICA, CDC
8 Macro International, Uzbekistan Health & Education Survey (DHES) 2002. 21% is the stunting level of children under 5 years
of age.
9 World Bank, Socio-Economic Differences in Health, Nutrition and Population, 2 nd Ed. (2003).
10 Lisa C. Smith, Marie T. Ruel, and Aida Ndiaye (March 2004) ‘Why is child malnutrition lower in urban then rural areas? An
assessment from 36 countries’, International Food Policy Research Institute, FCND Discussion Paper No. 176.
11 DHS Kazakhstan (1999). Children <3 years old.
12 DHS Kyrgyz Republic (1997). Children <3 years old.
13 DHS Tajikistan (2002). Children 6 months – 5 years.
14 DHS Turkmenistan (2000). Children <3 years.
15 UHES (2002). Data of children under 3 derived from dataset of children under 5.
16 UDHS (1996)
17Cem Mete and Stefania Cnobloch, working paper. World Bank (Feb 2006).
18 UHES 2002.
19 UHES 2002, p. 144.
20 WHO/UNICEF/UNU, Iron Deficiency Anemia--Assessment, Prevention, and Control. A guide for programme managers,
WHO, Geneva, 2001.
21 DHS Kazakhstan (1999).
22 DHS Turkmenistan 1997. Data of children < 3 years.
23 DHS Tajikistan 2003
24 UN General Assembly, May 2002.
25 Shrimpton, Roger, Cesar G. Victora, Mercedes de Onis, Rosangela Costa Lima, Monika Blossner, and Graeme Clugston. “The
Worldwide Timing of Growth Faltering: Implications for Nutritional Interventions.” Pediatrics 107: e75 (2001).
26 UNICEF website statistics.
27 National survey conducted in 1997-98.
28 Self-reported data on illness are found to be highly susceptible to respondent error. Various cultural, gender, and community
factors can affect the accuracy of such data. Faulty respondent recall could result in underreporting of illnesses—a problem most
apt to occur in the case of the spontaneously reported illnesses. Additionally, a respondent may have been unaware of an illness
that presented only mild symptoms—again resulting in underreporting of the illnesses. There is also the possibility that in
communities that have the reputation of being unhealthy, such as the Aral Sea Environmental Disaster Area, respondents may
attribute minor symptoms to chronic illness and over report illness. Thus, self-reported illness data must be interpreted cautiously
and reported rates should not be considered as prevalence estimates for specific illnesses. (Mete, Cnobloch (2006)
29 Institute of Endocrinology, Uzbekistan, 1999-2000.
30 UNICEF, Multiple Indicator Cluster Survey (MICS) Uzbekistan (2000).
31 UHES 2002.
32 UHES 2002.
33 FAO. ESSA, Food and Agricultural Indicators <fao.org/countryprofiles> (October 2005)
34 UNICEF, MICS2, Uzbekistan.
35 UNICEF MICS2 2000 Uzbekistan.
2
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
29
36
UHES 2002.
UNICEF, Baby-Friendly Institutions Proposal, August 2005
38 UNICEF, Proposal (2005).
39 UHES 2002.
40 UNICEF, Uzbekistan MICS2 (2000).
41 UHES 2002
42 Interview with Deputy Minister of Health in Karalpakstan, February 2005.
43 WHO/UNICEF/UNU, Iron Deficiency Anemia (2001)
44 Anna Crole-Rees, Analysis of the wheat, flour and bread sub-sectors : Perspectives for universal flour fortification in
Uzbekistan (March 2006).
45 UNICEF CEE/CIS website, <www.unicef.org>
46 UNICEF Proposal, August 2005.
47 UNICEF, Facts for Life, New York (2002)
37
M. Kamatsuchi, Macroeconomic Growth Barriers in Uzbekistan: Nutritional Focus, May 2006
30