Knowledge Brief Health, Nutrition and Population Global Practice COSTED PLAN FOR SCALING UP NUTRITION IN NIGERIA Meera Shekar, Christine McDonald, Touyo Okorosobo, Ali Subandoro, Julia Dayton Eberwein, Max Mattern and Jonathan Akuoku and Wendy Karamba. June 2015 KEY MESSAGES KEY MESSAGES: • Nigeria is home to the third largest population of stunted children in the world with over 11.5 million children under five—38 percent—chronically undernourished (stunted). • Implementing 10 key nutrition-specific interventions in all regions of Nigeria would cost $837 million annually, produce tremendous health benefits (8.7 million disability-adjusted life years - over 183,000 lives saved and over 3 million cases of stunting averted) and is highly cost effective ($102 per disability-adjusted life year). • This package of 10 interventions could increase economic productivity by $2.6 billion each year over the productive lives of the beneficiaries and has an impressive internal rate of return of over 18 percent. • Given resource constraints, eliminating the public provision complementary food for the prevention of moderate acute malnutrition (which is not very cost-effective) would result in a very cost-effective scenario that would scale up 9 interventions nationwide, cost $511 million, and save 8.6 million disability-adjusted life years and over 160,000 lives. The cost per disability-adjusted life year is $56. • A much lower-cost scenario would scale up only selected interventions (see Box 2) to partial coverage levels in states where stunting prevalence exceeds 35 percent; it would require only $184 million and would save almost 2.3 million disability-adjusted life years and 59,000 lives at a cost per disability- adjusted life year saved of $82. Introduction the analysis is to aid the Government of Nigeria in setting priorities by identifying the most cost-effective packages of This Knowledge Brief presents the cost of scaling up key interventions and by leveraging additional resources from effective nutrition interventions in Nigeria and compares domestic budgets and development partners. This analysis different scale-up scenarios to determine which one is complemented by a fiscal space analysis of the Save produces the best results for the lowest cost. The goal of One Million Lives (SOML) program in Nigeria (Results for Development 2014). Page 1 HNPGP Knowledge Brief • Malnutrition in Nigeria Interventions to Reduce Malnutrition Nigeria is home to the third largest population of chronically The analysis considers 10 nutrition-specific interventions undernourished (stunted) children in the world. Figure 1 that have been shown to be effective in reducing shows the striking disparities between northern and malnutrition (Box 1). The expected results include lives southern regions, in which all states in North East and saved, cases of stunting averted, and disability-adjusted North West regions of the country have a stunting life years. 1 Cost-effectiveness is measured as the cost per prevalence above 40 percent, whereas the majority of life saved, the cost per case of stunting averted, and the states in the southern regions have a stunting prevalence cost per disability-adjusted life year saved. We estimate the below 25 percent (Nigeria MICS 2011). The prevalence of total costs for scaling up all 10 interventions nationwide, stunting in the North West region is 2.5 times that of the and also four more modest scale-up options: (1) focusing South East region. For example, in Lagos, only 8.9 percent on only the regions with the highest burden of malnutrition, of children under five are stunted, whereas in the State of (2) scaling up only a subset of interventions, (3) scaling up Katsina, the prevalence is 61.9 percent. Vitamin and a subset of interventions only in the regions with the highest mineral deficiencies (hidden hunger) are also pervasive, of burden of malnutrition, and (4) scaling up interventions to which anemia and vitamin A deficiencies are the most partial (rather than full) coverage rates. We also estimate prevalent. the cost of scaling up four nutrition-sensitive interventions in sectors other than health that have shown potential for improving nutritional outcomes. Figure 1: State-level prevalence of stunting, 2011 Box 1: Nutrition-Specific and Nutrition-Sensitive Interventions Considered in the Analysis Nutrition-specific interventions address the immediate determinants of child nutrition: 1. Community nutrition programs for growth promotion 2. Vitamin A supplementation 3. Therapeutic zinc supplement with oral rehydration salts 4. Micronutrient powders 5. Deworming 6. Iron-folic acid supplementation for pregnant women (-20,0] (-30,-20] 7. Iron fortification of staple foods (-40,-30] (-50,-40] 8. Salt iodization [-70,-50] 9. Public provision of complementary food for the prevention of moderate acute malnutrition Source: Nigeria MICS 2011. 10. Community-based management of severe acute malnutrition in children A number of interventions are effective in reducing Nutrition-sensitive interventions are delivered malnutrition and are consistently identified as being among through sectors other than health and have the the most cost-effective development actions, with huge potential to improve nutrition indirectly: potential to reduce poverty and boost prosperity. Investing 1. Biofortification of cassava in nutrition can increase a country’s GDP by between 3 and 2. Aflatoxin control in maize and groundnuts 11 percent annually (Horton and Steckel 2014. Cost- 3. School-based based deworming benefit analysis shows that nutrition interventions are 4. School-based promotion of good hygiene highly cost effective (World Bank 2010, Hoddinott et al. 2013). Investments in early nutrition boost wages by 5 to 50 percent and make children 33 percent more likely to Nutrition-Specific Intervention escape poverty in the future, as well as to address gender inequities (Hoddinott et al 2008, Hoddinott et al 2011). Implementing 10 nutrition-specific interventions in all regions of Nigeria would cost $837 million 2 annually, would Page 2 produce tremendous health benefits, and has the potential Box 2: Three Cost-Effective Scale-Up Options to increase economic productivity by $2.6 billion each year over the productive lives of the beneficiaries (Figure 2). It If full coverage is not immediately feasible, the three also would yield an impressive internal rate of return of 18 most cost-effective gradual scale-up scenarios are: percent. Most of the 10 interventions are highly cost- effective, with the exception of the public provision of 1. Most cost-effective: Scale up 9 interventions complementary food for the prevention of moderate acute (excluding the public provision of complementary food for moderate acute malnutrition) to full program malnutrition, which in Nigeria is only moderately cost- coverage: effective according to WHO-CHOICE criteria (WHO 2014). • $511 million public investment required Figure 2: Costs and Benefits of Scaling Up 10 • 8.6 million disability-adjusted life years saved Nutrition-Specific Interventions • 164,000 lives saved • cost per life year saved = $56 ANNUAL 2. Lower cost: Scale up critical interventions PUBLIC ESTIMATED INVESTMENT including community nutrition programs, micronutrient BENEFITS supplementation, deworming, and community-based REQUIRED management of severe acute malnutrition to full program coverage in states where stunting prevalence exceeds 25 percent: • $337 million public investment required • 4.7 million disability-adjusted life years saved • 96,000 lives saved • cost per life year saved = $66 3. Scaling up to partial program coverage levels is lowest cost scenario: scale up micronutrient and deworming interventions to partial coverage levels in all 36 states, and scale up community nutrition programs and community-based management of severe acute malnutrition to partial coverage levels in states where stunting prevalence exceeds 35 percent: • $184 million required Life years adjusted for disability. • 2.3 million disability-adjusted life years saved • 59,000 lives saved • cost per life year saved = $82 Resource constraints are likely to prevent immediate and full national scale-up, however, so we also explore more modest scale-up options and identify three scenarios that are the most cost-effective (Box 2). (Additional scenarios Nutrition-Sensitive Interventions are explored in the full report.) The scenario with the greatest impact per dollar spent is to scale up all We identify and cost four nutrition-sensitive interventions interventions except the pubic provision of complementary relevant to the Nigerian context (see also Box 1), for which food for the prevention of moderate acute malnutrition in all there is some evidence of positive impact on nutrition states. This option would be a highly cost-effective outcomes and some cost information. The estimated investment with a cost per disability-adjusted life year annual costs are modest: $25 million for biofortification of saved of $56 and a cost per life saved of $2,919. Yet this cassava, $65 million for aflatoxin control, $8 million for scenario is still extremely expensive and would require an school-based deworming, and $60 million for school-based annual public investment of $511 million. As illustrated in promotion of good hygiene. However, these must be the box, the analysis finds several cost-effective alternative considered preliminary estimates, as there are significant scenarios, so the choice of scenario will depend both on limitations in the available data and in the methodological budgetary considerations and on political considerations approaches, especially in contextualizing global unit costs regarding targeting services to states with the highest to the Nigerian situation. In addition, we were not able to burden of malnutrition. The costs of the interventions estimate the benefits of these interventions because of estimated here are likely to be slight overestimates, while data and methodological shortcomings, although we do the benefits are likely to be underestimated. Page 3 HNPGP Knowledge Brief • report benefits estimated by other reports. More robust Hoddinott, J., J. Maluccio, J. R. Behrman, R. Martorell, P. Melgar, data on nutrition-sensitive interventions are needed to A. R. Quisumbing, M. Ramirez-Zea, A. D. Stein, and K. M. Yount. inform future scale-up priorities. 2011. “The Consequences of Early Childhood Growth Failure over the Life Course.” Discussion Paper 1073. International Food Policy Research Institute, Washington, DC. Financing Improvements in Nutrition Hoddinott, J., H. Alderman, J. R. Behrman, L. Haddad, and S. The costs discussed thus far relate only to the scale-up Horton. 2013. “The Economic Rationale for Investing in Stunting from current coverage and do not take into account the Reduction.” Maternal and Child Nutrition 9 (Suppl. 2): 69–82 financing necessary to maintain existing coverage levels, which Results for Development (R4D) estimates to be Horton S. and R. Steckel. 2013. “Global Economic Losses approximately $49 million annually (Results for Attributable to Malnutrition 1900–2000 and Projections to 2050.” Development 2014). The R4D analysis also identifies In The Economics of Human Challenges, ed. B. Lomborg. several sources of planned investments for nutrition Cambridge, UK: Cambridge University Press. estimated at about $175 million over the next four years. This analysis suggests a planned increase in funding for Nigeria Multiple Indicators Cluster Survey (MICS). 2011. National Bureau of Statistics (NBS). Abuja: Federal Government nutrition of approximately $126 million over four years. Our of Nigeria. analysis predicts financing needs over five years of between $769 million and $987 million depending on the Results for Development (R4D). 2014. Saving One Million Lives: scenario, resulting in an estimated financing gap of Fiscal Space Analysis. Washington, DC: Results for between $543 and $861 million over five years. Therefore Development. any scale up of nutrition interventions will not only require World Bank. 2010. Scaling Up Nutrition. What Will It Cost? additional financing but also the prioritization of Washington, DC: World Bank; interventions based on need, cost-effectiveness, and allocative efficiencies. World Health Organization. 2014. Cost-Effectiveness and Strategic Planning: Threshold Values for Intervention Cost- Effectiveness by Region. Geneva: WHO-CHOICE (Choosing Conclusion Interventions that are Cost-Effective) Program. http://www.who.int/choice/costs/CER_levels/en/ These results will be useful to decision makers as they plan future efforts to scale up interventions to address Notes malnutrition in Nigeria and develop nutrition financing plans 1A life year adjusted for disability (also known as a DALY) is that bring together the health, education, and agriculture sectors. The health sector must include the costs of plans equivalent to a year of healthy life lost due to a health condition. for financing universal health coverage and SOML within its nutrition pillar. Several opportunities exist for 2 All dollar amounts in US dollars. incorporating these highly cost-effective interventions into the World Bank’s current and planned investments in health, and education. This HNP Knowledge Note highlights the key findings from: Meera Sources Shekar, with Christine McDonald, Tuoyo Okorosobo, Ali Subandoro, Max Mattern, Julia Dayton Eberwein, Jonathan Kweku Akuoku and Hoddinott, J, Maluccio, JA, Behrman, JR, Flores, R, and Martorell, Wendy Karamba. 2014. “Costed Plan for Scaling Up Nutrition: Nigeria.” R. 2008. Effect of a nutrition intervention during early childhood Health, Nutrition and Population (HNP) Discussion Paper. Washington, on economic productivity in Guatemalan adults. Lancet. 371: DC: The World Bank Group. 411–416 The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, go to: www.worldbank.org/health. Page 4