98241 Knowledge Brief Health, Nutrition and Population Global Practice SCALING UP NUTRITION FOR A MORE RESILIENT MALI: : NUTRITION DIAGNOSTICS AND COSTED PLAN FOR SCALING UP Meera Shekar, Max Mattern, Patrick Eozenou, Julia Dayton Eberwein, Jonathan Akuoku, Emanuela Di Gropello and Wendy Karamba June 2015 KEY MESSAGES KEY MESSAGES: • Despite recent improvements, malnutrition levels in Mali remain unacceptably high: 28 percent of children under five are malnourished (stunted). • Implementing 10 key nutrition-specific interventions nationwide would cost $64 million annually and produce tremendous health benefits. These interventions would be highly cost-effective and could increase economic productivity by $194 million each year over the productive lives of the beneficiaries. • Given resource constraints, eliminating the public provision complementary food for the prevention of moderate acute malnutrition (which is not cost-effective) would result in a very cost-effective scenario that would scale up 9 interventions nationwide, cost $24 million, and save almost 470,000 disability-adjusted life years and 11,000 lives. • An even lower-cost scenario would target only the four regions with the highest burden of stunting; it would require only $18 million and would save 320,000 disability-adjusted life years and 11,000 lives at a cost per life year saved of $57. Introduction Malnutrition in Mali This Knowledge Brief presents a profile of the nutrition Between 2001 and 2010 chronic malnutrition in Mali situation in Mali and cost estimates for implementing key declined dramatically, with an annual reduction rate in nutrition interventions. It then compares the cost- stunting of 4.4 percent per year. Between 2010 and 2012 effectiveness of several scale-up options. The goal of the there was an increase in stunting as a result of the 2011– analysis is to aid the Government of Mali in setting priorities 2012 crisis, although by 2013 stunting rates had begun to by identifying the most cost-effective packages of decline again (Figure 1). Children aged 0–12 months in interventions and to help leverage additional resources 2011–2012 were particularly affected by the crisis and will from domestic budgets and development partners. likely suffer life-long consequences. In 2013, the most recent year for which statistics are available, 28 percent of children under five were stunted, 17 percent were wasted, Page 1 HNPGP Knowledge Brief • and 9 percent were underweight. Despite recent on the regions with the highest burden of malnutrition, (2) improvements, these are still unacceptably high level of scaling up only a subset of interventions, and (3) scaling up malnutrition. In addition, micronutrient deficiencies (hidden a subset of interventions in the regions with the highest hunger) are also prevalent in Mali, with vitamin A deficiency burden of malnutrition. We also estimate the cost of scaling and anemia rates particularly high. up six nutrition-sensitive interventions in sectors other than health with potential for improving nutritional outcomes. Figure 1. Changes over Time in the Prevalence of Stunting, Wasting, and Underweight, Percent of Children Under Five, Box 1: Nutrition-Specific and Nutrition-Sensitive 2001–2013 Interventions Considered in the Analysis 43 Nutrition-specific interventions address the immediate 37 determinants of child nutrition: 29 28 27 29 28 1. Community nutrition programs for growth promotion 27 2. Vitamin A supplementation 19 20 20 17 3. Therapeutic zinc supplement with oral rehydration 15 13 salts 10 9 9 4. Micronutrient powders 9 5. Deworming 6. Iron-folic acid supplementation for pregnant women 7. Iron fortification of staple foods 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 8. Salt iodization 9. Public provision of complementary food for the Stunting Wasting Underweight prevention of moderate acute malnutrition 10. Community-based management of severe acute malnutrition in children Sources: Mali DHS for 2001, 2006; MICS/ELIM for 2010; SMART surveys for 2011–2013. Nutrition-sensitive interventions are delivered through sectors other than health and have the potential to improve nutrition indirectly: A number of interventions are effective in reducing malnutrition and are consistently identified as being among 1. Nutrition package delivered as part of a conditional the most cost-effective development actions, with a huge cash transfer program potential to reduce poverty and boost prosperity. Investing 2. Aflatoxin control in groundnuts 3. Nutrition education via agricultural extension in nutrition can increase a country’s GDP by between 3 and workers 11 percent annually (Horton and Steckel 2013). Cost- 4. School-based based deworming benefit analysis shows that nutrition interventions are 5. School-based promotion of good hygiene highly effective (World Bank 2010, Hoddinott et al. 2013). 6. Reaching the Millennium Development Goals Investments in early nutrition could boost wage rates by 5 (MDGs) for improved access to water and sanitation to 50 percent and make children 33 percent more likely to escape poverty in the future, as well as to address gender inequities (Hoddinott et al. 2008, Hoddinott et al. 2013). Nutrition-Specific Interventions Interventions to Reduce Malnutrition Implementing 10 nutrition-specific interventions in all regions of Mali would cost $64 million annually with the This Knowledge Brief presents the cost of scaling up potential to increase economic productivity by $194 million effective interventions in Mali and compares different each year over the productive lives of the beneficiaries scale-up scenarios to determine which one produces the (Figure 2);2 it also would yield a positive net present value best results for the lowest cost. The analysis considers 10 and an impressive internal rate of return on the investment nutrition-specific interventions that have been shown to be of 18 percent. Most of the 10 interventions are cost- effective in reducing malnutrition (Box 1). The expected effective, with the exception of the public provision of results include lives saved, cases of stunting averted, and complementary food for the prevention of moderate acute disability-adjusted life years that would be saved as a result malnutrition, which is not cost-effective according to WHO- of the interventions.1 Cost-effectiveness is measured as CHOICE criteria (WHO 2014). the cost per life saved, cost per stunting case averted, and cost per disability-adjusted life year saved. We estimate the Given resource constraints, achieving immediate national total costs for scaling up all 10 interventions nationwide, coverage may not be possible, so we consider various and also three more modest scale-up options: (1) focusing scale-up options and identify two scenarios that are the most cost-effective (Box 2). The costs of the interventions Page 2 HNPGP Knowledge Brief estimated here are likely to be slight overestimates, while Nutrition-Sensitive Interventions the benefits are likely to be underestimated. In many cases, We identify and cost six nutrition-sensitive interventions Figure 2: Costs and Benefits of Scaling UP 10 relevant to the Mali’s context, for which there is some Nutrition-Specific Interventions in Mali evidence of positive impact on nutrition outcomes and for which there is some cost information (the interventions are listed in Box 1). The estimated annual costs are relatively ANNUAL PUBLIC modest: $49.4 million for the nutrition package in the INVESTMENT ESTIMATED REQUIRED BENEFITS conditional cash transfer program; $1.3 million for aflatoxin control in groundnuts via improved granaries; $19.0 million for nutrition education delivered via agricultural extension workers; $0.3 million for school-based deworming; and $6.2 million for school-based promotion of good hygiene. Although the costs for reaching the Millennium Development Goals for improved access to water and sanitation are unavailable, the World Health Organization reports that the benefits of meeting these targets outweigh their costs two to one (Hutton 2012). Estimates from other sources suggest that aflatoxin control via improved granaries would cost $272 per disability- adjusted life year saved and school-based deworming $4.55 per life year saved. These results must be considered preliminary approximations, as there are significant limitations in the available data and in the methodological approaches. More robust data on nutrition- * Disability-adjusted life years sensitive interventions are needed to inform future scale- up priorities. actual program costs will be lower than estimated because Financing Improvements in Nutrition they can be added to existing programs. Our estimates may underestimate the true benefits since, because of Despite the resumption of bilateral development assistance methodological limitations, we are not able to estimate the and the mobilization of resources for the response to the benefits of some of the interventions we cost. crisis of 2011–2012, additional financing for nutrition in Mali will be needed to scale up even the most modest scenarios Box 2: Two Cost-Effective Scale-Up Options presented here. At the central government level, there is currently no dedicated budget line item for nutrition. Thus If full coverage is not immediately feasible, the two resources will need to be mobilized from national budgets, most cost-effective gradual scale-up scenarios are: with additional support from donors. Within the national budgets, it will be important to prioritize health sector funds 1. Most cost-effective: Scale up 9 interventions for nutrition-specific interventions. It will also be important (excluding the public provision of complementary food) nationwide: for other sectors—such as water and sanitation and social protection—to engage in the cost-effective nutrition- • $24 million required sensitive interventions the report has identified. • 470,000 disability-adjusted life years saved* • 11,000 lives saved Conclusion • cost per life year saved = $51 Overall, these findings point to a powerful set of nutrition- 2. Lowest cost: Scale up 9 interventions (excluding specific interventions and a candidate list of nutrition- the public provision of complementary food) in the sensitive approaches that represent a highly cost-effective four highest-burden regions of Mali: approach to reducing the destructively high levels of child • $18 million required malnutrition in Mali. They also show ways to improve • 320,000 disability-adjusted life years saved* allocative efficiency in Mali’s nutrition programming. Having • 11,000 lives saved seen the impact of the recent food crisis on the children, it • cost per life year saved = $57 is critical to realize that an investment in nutrition is also an Page 3 HNPGP Knowledge Brief • investment in resilience. A critical next step is for the Cost-Effectiveness by Region. Geneva: WHO-CHOICE Government of Mali and its partners to develop a set of key (Choosing Interventions that are Cost-Effective) Program. http://www.who.int/choice/costs/CER_levels/en/ actions to address undernutrition in the country. World Bank. 2010. Scaling Up Nutrition. What Will It Cost? Washington, DC: World Bank. Notes 1 A disability-adjusted life year (also known as a DALY) is equivalent to a year of healthy life lost due to a health condition. This HNP Knowledge Note highlights the key findings from: M. Shekar, M. Mattern, P. Eozenou, J. Dayton Eberwein, J.K. Akuoku, E. Di 2 All dollar amounts are U.S. dollars Gropello and W. Karamba. 2015. “Scaling Up Nutrition For a More Resilient Mali: Nutrition Diagnostics and Costed Plan for Scaling Up.” Health, Nutrition and Population (HNP) Discussion Paper. Washington, DC: The World Bank Group Sources DHS (Demographic and Health Survey) Program. 2001. Mali DHS 2001: Final Report. Bethesda, MD: Measure DHS. ———. 2006. Mali DHS 2006: Final Report. Bethesda, MD: Measure DHS. Hoddinott, J., H. Alderman, J. R. Behrman, L. Haddad, and S. Horton. 2013. “The Economic Rationale for Investing in Stunting Reduction.” Maternal and Child Nutrition 9 (Suppl. 2): 69–82. Hoddinott et al. 2008. “Effects of a Nutrition Intervention During Early Childhood on Economic Productivity in Guatemalan Adults.” Lancet. 371:411–16. Hoddinott, J., J. Maluccio, J. R. Behrman, R. Martorell, P. Melgar, A. R. Quisumbing, M. Ramirez-Zea, A. D. Stein, and K. M. Yount. 2011. “The Consequences of Early Childhood Growth Failure over the Life Course.” Discussion Paper 1073. International Food Policy Research Institute, Washington, DC. Horton, S. and R. Steckel. 2013. “Global Economic Losses Attributable to Malnutrition 1900–2000 and Projections to 2050.” In The Economics of Human Challenges, ed. B. Lomborg. Cambridge, U.K.: Cambridge University Press. Hutton, G. 2012. Global Costs and Benefits of Drinking-Water Supply and Sanitation Interventions to Reach the MDG Target and Universal Coverage. Geneva, Switzerland: World Health Organization MICS/ELIM (Multiple Indicators Cluster Survey). 2010. Multiple Indicator Cluster Survey (MICS) 2010: Mali. Bamako, Mali: United Nations Children Fund (UNICEF). SMART. 2011 and 2012. Enquête Nutritionnelle Anthropométrique et de Mortalité Rétrospective, Mali 2012. Bamako, Mali: Government of Mali. ———. 2013. Enquête Nutritionnelle Anthropométrique et de Mortalité Rétrospective, Mali 2012. Bamako, Mali: Government of Mali. WHO (World Health Organization). 2014. Cost-Effectiveness and Strategic Planning: Threshold Values for Intervention 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