By Andrew Green

Earlier this year, as many as 100 children died in Indonesia’s remote Papua province. They were suffering from malnutrition when they became infected during a measles outbreak. Their immune systems were too weak to fight off the disease.

“Measles is not dangerous, it’s a mild disease,” the province’s military spokesperson Muhammad Aidi told the media in the midst of the response. “But because those children are malnourished, they can’t cope in that condition.”

Indonesia’s government has made significant attempts to fight hunger in recent years, committing new financial resources to the effort, improving infrastructure to ease the flow of food to remote areas and taking a vocal role in regional efforts to end all forms of malnutrition. But the measles outbreak underscored the scale of the challenge Indonesia and other middle-income countries (MICs) face when it comes to grappling with malnutrition – particularly within the poorest communities.

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Around eight of every 10 malnourished children in the world reside in MICs, according to new research released this week by RESULTS, a nonprofit advocacy organization. And poor children, who have not benefited from their country’s developmental gains as it moves into middle-income status, are disproportionately affected.

With global funding for nutrition already limited and donors increasingly withdrawing their support from MICs, the governments of those countries are often left to bear the full burden of implementing malnutrition programs. But comprehensively addressing hunger, particularly in poor communities, requires a significant commitment from governments that have myriad competing priorities.

The result is that malnutrition remains rampant – and might even worsen – in countries making the transition from low- to middle-income status.

RESULTS analyzed the malnutrition situation in 89 middle-income countries between June and December 2017. The researchers excluded 20 countries the World Bank classified as being in a “fragile situation,” primarily because of ongoing or recently concluded conflicts.

Read More: 124 Million People Were at the Brink of Starvation in 2017, New Report Finds

The researchers concluded that “economic growth in these countries has not acted as a guarantee for equitable improvements in nutrition, health and the lives of their populations.”

Nearly half of the hungry people in the world – roughly 363 million people in 2014 – live in just five MICs: China, India, Brazil, Indonesia and Brazil, according to the International Food Policy Research Institute. Globally, RESULTS concluded there are 1.8 million child deaths annually in the 89 MICs they considered that are linked to malnutrition.

“Unless we address malnutrition in these countries, we are sure to miss the [Sustainable Development Goals], because this is where the true burden of malnutrition really is,” Anushree Shiroor, a senior policy advocacy officer with RESULTS and the author of the recent report, told News Deeply. The goals include ending hunger and achieving food security by 2030.

In the report, Shiroor outlined a number of factors that contribute to the high rates of malnutrition in MICs – and particularly lower-middle-income countries (LMICs) – and recommendations for how to begin to address the problem.

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The report identifies two steps the countries, themselves, can take: Asserting greater ownership of the issue, which translates into political leadership and sustainable domestic financing, and creating a robust policy framework. In the review, RESULTS found that 58 percent of the LMICs had a valid nutrition policy or a development policy that prioritized nutrition. That number dropped to 39 percent among upper-middle-income countries.

Within the MICs, though, experts said country ownership was not enough to tackle the problem. In Indonesia, for instance, Dr. Diah Utari, an expert in nutrition at the University of Indonesia, said the government has been proactive about addressing malnutrition.

During the crisis in the Papua province, for instance, “the central government immediately sends aid in the form of food, health workers,” Utari told News Deeply. She also pointed to a bigger health budget and to the role Indonesian officials played in pushing the Association of Southeast Asian Nations’ commitment last year to rapidly expand its efforts to reduce malnutrition.

Even a committed government will struggle to address all of the factors that contribute to malnutrition, she said. In Indonesia and many MICs, malnutrition is particularly linked to the educational status of mothers. Utari also highlighted the need to improve infrastructure, so rural communities have better access to a variety of food, as well as to health services. Failing to address these issues means not just that malnutrition will continue, but that it will disproportionately affect the poorest communities.

The domestic resources to tackle such systemic problems are often unavailable, though, and there are increasingly few other places to look for funds.

RESULTS found that donor funding for “basic nutrition” – already less than one percent of total overseas development assistance (ODA) – actually decreased in recent years, both in absolute terms and as a percentage of ODA. And much of that funding is no longer available to countries as they transition to middle-income status, anyway, despite the entrenched, persistent inequalities that governments either can’t or won’t address.

There is also an opportunity, she said, to look for alternative solutions, including financing approaches that might spur and multiply domestic investments and innovations like improved crop systems.

One of the first goals, though, is to ensure the global community understands this is something that needs to be addressed. “We need to get attention to the fact that malnutrition in middle-income countries is a huge problem,” she said.

“The examples of countries beginning to mobilize and momentum around malnutrition is increasing,” Shiroor said. “But that does not mean donors can just step away from their role on addressing nutrition in these countries.” Instead, she called for them to establish a clear, reasonable transition process that was realistic about domestic capabilities.

This article originally appeared on Malnutrition Deeply. You can find the original here.