95706 Scaling Up Nutrition in the Democratic Republic of Congo: What Will It Cost? A Policy Brief by Meera Shekar, Max Mattern, Luc Laviolette, Julia Dayton Eberwein, Wendy Karamba, and Jonathan Kweku Akuoku This policy brief presents cost estimates for implementing key nutrition interven- tions in the Democratic Republic of Congo (DRC) and compares the cost-effective- ness of several scale-up options.1 The goal of the analysis is to aid the Govern- ment of the DRC in setting priorities by identifying the most cost-effective packages of interventions and by leveraging additional resources from domestic budgets and development partners. Malnutrition in the DRC age (WHO 2012).3 Between 2001 and 2014, the prevalence of stunting among children Malnutrition, particularly in very young chil- under five in the DRC—about 43  percent— dren, leads to increased mortality rates, remained practically unchanged in the coun- increased illness, and longer-term effects on try, in spite of reductions in the prevalence of cognitive abilities. These result in irreversible underweight and wasting (Figure 1). Micro- losses to human capital that contribute to later nutrient deficiencies (hidden hunger) are also losses in economic productivity. Undernutri- prevalent, with particularly high vitamin A tion is responsible for about one-half of under- deficiency and anemia rates. five child mortality and one-fifth of maternal mortality in developing countries. Children A number of interventions are effective in reduc- who have been malnourished early in life are ing malnutrition and are consistently identified more likely to experience cognitive deficien- as being among the most cost-effective devel- cies and poor schooling outcomes. Longer opment actions, with huge potential to reduce term, stunting results in a loss of 10 to 17 per- poverty and boost prosperity. Investing in nutri- cent in wages earned over a lifetime. It is esti- tion can increase a country’s GDP by between mated that vitamin and mineral deficiencies in 3 and 11 percent annually (Horton and Steckel the DRC collectively add up to an estimated 2013).4 Cost-benefit analysis shows that nutri- loss of over $100 million in gross domestic tion interventions are highly effective (World product (GDP) every year (World Bank 2011).2 Bank 2010; Hoddinott et al. 2013).5 Invest- ments in early nutrition have the potential to Despite being home to only 1 percent of the boost wage rates by 5 to 50 percent and make world’s population, the DRC is one of the five children 33 percent more likely to escape pov- countries responsible for half of all deaths erty in the future, as well as to address gender globally among children under five years of inequities. 2 Figure 1  Stunting, Wasting, and Underweight in Children Under Five in the DRC, 20012014 50% 40% 30% 20% 10% 0% Stunting Wasting Underweight MICS 2001 DHS 2007 MICS 2010 DHS 2013–2014 Sources:  Multiple Indicators Cluster Survey (MICS) 2001, 2010; Demographic Health Survey (DHS) Program 2007, 20132014. See the full HNP Discussion Paper Scaling Up Nutrition in the Demographic Republic of Congo: What Will it Cost? for source information. Interventions to Reduce cost per life saved, cost per stunting case averted, and cost per life year adjusted for Malnutrition disability saved. We estimate the total costs This policy brief presents the cost of scaling- for scaling up all 10 interventions nation- up effective interventions in the DRC and wide, and also three more modest scale-up compares different scale-up scenarios to options: (1) focusing on only the regions with examine which scenario produces the best the highest burden of malnutrition, (2) scaling results for the lowest cost. The analysis con- up only a subset of interventions, and (3) scal- siders 10 nutrition-specific interventions that ing up a subset of interventions only in the have been shown to be effective in reducing regions with the highest burden of malnu- malnutrition (Box 1). The expected results trition. We also estimate the cost of scaling include lives saved, cases of stunting averted up six nutrition-sensitive interventions in the (for some scenarios), and life years adjusted agriculture and education sectors that have for disability saved as a result of the interven- shown some potentional for improving nutri- tions. Cost-effectiveness is measured as the tional outcomes. 3 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 7. Iron fortification of staple foods 8. Salt iodization Public provision of complementary food for the prevention of moderate acute malnutrition 9.  10. Community-based management of severe acute malnutrition in children Nutrition-sensitive interventions are delivered through sectors other than health and have the potential to improve nutrition indirectly: 1. Biofortification of cassava 2. Aflatoxin control in maize and groundnuts through biocontrol 3. Promotion of the wetting method for konzo control 4. School-based based deworming 5. School-based promotion of good hygiene 6. Water, sanitation, and hygiene infrastructure Nutrition-Specific on the investment of 13.6 percent. Most of the 10  interventions are very cost-effective, Interventions with the exception of the public provision of Implementing 10 nutrition-specific interven- complementary food for the prevention of tions in all regions of the DRC would cost moderate acute malnutrition, which is not $371 million annually and has the poten- cost-effective. tial to increase economic productivity by $591  million each year over the productive Given resource constraints, achieving immedi- lives of the beneficiaries (Figure 2), as well as ate full national coverage is probably not pos- to yield an impressive internal rate of return sible, so we consider various scale-up options. 4 Figure 2  Costs and Benefits of scaling up 10 nutrition-specific interventions in DRC Box 2: Three Cost-Effective Scale-Up Options ANNUAL PUBLIC ESTIMATED If full coverage is not immediately feasible, INVESTMENT REQUIRED BENEFITS the three most cost-effective gradual scale- up scenarios are:  ost cost-effective: Scale up a subset 1. M 76,00 0 live of the most cost-efficient interventions s sav ed 5.4 m in nine high-burden provinces: illi years on life • $185 million required * sav ed 1 milli • 3.6 million life years saved* on ca stuntin ses $371 g ave of millio n r ted • 44,000 lives saved $591 millio econo n mic p gain in • cost per life year saved = $48 roduc tivity  owest cost: Scale up the same subset 2. L of the most cost-efficient interventions in the five highest-burden provinces: • $97 million required *Life years adjusted for disability (DALYs). • 1.8 million life years saved* • 22,000 lives saved • cost per life year saved = $50  reatest benefits, very cost-effective: 3. G Based on total resource requirements and the Scale up a subset of the most cost- cost-effectiveness of scaling up a subset of efficient interventions in all provinces: the most cost-effective interventions in the • $279 million required highest burden provinces,6 the three options • 5.3 million life years saved* presented here achieve the best outcomes for • 66,000 lives saved the lowest cost (Box 2). Because all three of these options have similar costs per life year • cost per life year saved = $49 saved, the choice between them will depend *Life years saved adjusted for disability (DALYs) largely on the resources available to fight undernutrition in the DRC. The costs of the interventions estimated here are likely to be slight overestimates, while the that already exists are lower because existing benefits are likely to be underestimated. In implementation arrangements can be used, many cases, actual program costs will be lower thus containing costs for staffing, operations, than estimated because they can be added and training. In effect, we do not account for to existing programs. Experience shows that all of the expected economies of scale. With the incremental costs of adding to a program respect to the benefits, our estimates are 5 Financing Improvements in Nutrition The identification of sources of financing is a crucial next step in planning for the scale- up of nutrition interventions in the DRC. A large gap currently exists between what is being invested in nutrition interventions and the most modest of the scale-up scenarios proposed here. The country’s development partners are the main source of financial sup- port for health and nutrition interventions. The government of DRC currently allocates likely to be underestimates of the true ben- only approximately 4 percent of its total bud- efits since, because of methodological limita- get to health, only a fraction of which is for tions, we are not able to estimate the benefits nutrition. Total donor financing for nutrition of some of the interventions we cost. interventions is also low, but it has gradu- ally increased from about $20 million annu- Nutrition-Sensitive ally in 2007 to $25 million in 2012 (Figure 3). Interventions More recently, the UK Department for Inter- national Development provided $7.3 million Evidence for the impact of nutrition-sensitive in support of nutrition interventions during interventions is less conclusive than evidence 2013–2015, and the World Bank is planning for nutrition-specific ones, and therefore our $16.4 million for key nutrition interventions estimates of costs and benefits are prelimi- for 2015–2020. USAID contributes about nary. The estimated annual costs are modest: $10 million a year to the treatment of severe $13 million for biofortication of yellow cas- acute malnutrition plus about $30 million a sava; $31 million for aflatoxin control; $5 mil- year for food assistance programs. ECHO, lion for promoting the wetting method for the Government of Belgium and the Gov- controlling konzo; $2 million for school-based ernment of Japan also support emergency deworming; $13 million for school-based pro- nutrition services and community based motion of good hygiene, and $1.04 billion for management of severe acute malnutrition. the water, sanitation, and hygiene interven- Nevertheless, given that the most modest of tion. We were not able to estimate the bene- the scenarios presented here would require fits of these interventions because of data and $97 million in annual investment, identifying methodological shortcomings. More robust additional sources of funding must be a pri- data on nutrition-sensitive interventions are ority. Furthermore, current aid for nutrition needed to inform future scale-up priorities. is heavily focused on addressing wasting, 6 Figure 3  Trends in donor funding for nutrition (20062012) $25.00 Current USD (millions) $20.00 $15.00 $10.00 $5.00 $– 2006 2007 2008 2009 2010 2011 2012 Basic Nutrition ODA $2.74 $1.93 $2.22 $5.10 $2.23 $4.75 $6.85 Humanitarian Nutrition Funding $17.93 $7.89 $15.78 $11.95 $16.79 $20.90 $17.89 Sources:  OECD. 2014. International Development Statistics (IDS) online databases. Accessed July 31, 2014. UNOCHA. 2014. Financial Tracking Services online database. Accessed July 31, 2014. despite levels being low relative to stunting, Endnotes and most current donor funding is support- 1. For the full report, see the 2015 HNP Discussion ing “supply side” interventions such as nutri- Paper Scaling Up Nutrition in the Democratic tion supplements and community-based Republic of Congo: What Will It Cost? treatment of severe acute malnutrition. 2. All dollar amounts are U.S. dollars unless otherwise Efforts to expand to demand-side interven- indicated. World Bank. 2011. Congo—Nutrition at tions, such as behavior change campaigns a glance. Nutrition at a glance. Washington DC: that change the choices households make World Bank. for good nutrition, are needed. 3. WHO (World Health Organization). 2012. “Child Health” Global Health Observatory data. Geneva: WHO. http://www.who.int/gho/child_health/en/ 4. Horton S. and R. Steckel. 2013. “Global Economic Conclusion Losses Attributable to Malnutrition 1900–2000 and Projections to 2050.” In The Economics of Human Overall, these findings point to a powerful set Challenges, ed. B. Lomborg, Cambridge, UK: of nutrition-specific interventions and a candi- Cambridge University Press. date list of nutrition-sensitive approaches that 5. World Bank. 2010. Scaling Up Nutrition. What Will represent a highly cost-effective approach to It Cost? Washington, DC: World Bank; Hoddinott, reducing the destructively high levels of child J., H. Alderman, J. R. Behrman, L. Haddad, and S. Horton. 2013. “The Economic Rationale for malnutrition in the DRC. Critical next steps are Investing in Stunting Reduction.” Maternal and for the Government of the DRC and its part- Child Nutrition 9 (Suppl. 2): 69–82. ners to develop a road map of key actions 6. The subset of interventions includes micronutrient to pursue and to identify milestones to be and deworming interventions; community nutrition reached in addressing undernutrition in the programs for growth promotion, and community- country. based treatment of severe acute malnutrition. 7