An Investment Framework for Nutrition Reaching the Global Targets for Stunting, Anemia, Breastfeeding, and Wasting Meera Shekar, Jakub Kakietek, Julia Dayton Eberwein, and Dylan Walters 175 159 million childr n stunt d in 2015 150 125 100 ~ 65 million f w r childr n stunt d in 2025 75 2015 2020 2025 An Investment Framework for Nutrition Reaching the Global Targets for Stunting, Anemia, Breastfeeding, and Wasting An Investment Framework for Nutrition Reaching the Global Targets for Stunting, Anemia, Breastfeeding, and Wasting Meera Shekar, Jakub Kakietek, Julia Dayton Eberwein, and Dylan Walters © 2016 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. 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Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. Cover illustration: Adapted from Nicole Hamam. Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii Foreword Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Abbreviations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xviii Glossary of Technical Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii Chapter 1 Reaching the Global Nutrition Targets: Stunting and Other Forms of Malnutrition. . . . . . . . . . . . . . . . . . . . . 1 Objectives of the Report  2 Why Invest in Nutrition?  3 Global Response  8 Analytical Framework  11 Measuring Progress  15 Building on Previous Estimates of Financing Needs to Scale Up Nutrition  16 Consultative Process: The Technical Advisory Group  18 The Scope of This Report  18 References 19 Chapter 2 Overview of Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Country Sample Selection  26 Evidence-Based Interventions and Delivery Platforms  30 Estimating Unit Costs Based on Program Experience  31 Assumptions about the Pace of Scale-Up  32 Estimating Total Financing Needs for Each Target  33 Estimating Impacts  34 Benefit-Cost Analyses  34 Data Sources  36 References 36 Chapter 3 Reaching the Global Target for Stunting . . . . . . . . . . . . . 41 Stunting Prevalence and Progress to Date  42 The Effects of Stunting  46 Interventions That Reduce Stunting  49 Analytic Approaches Specific to the Stunting Target  53 Contents v Results 60 Discussion 69 References 73 Chapter 4 Reaching the Global Target for Anemia . . . . . . . . . . . . . . 79 Anemia and Its Effects  80 Causes of Anemia  81 Interventions That Effectively Prevent Anemia  81 Analytic Approaches Specific to the Anemia Target  85 Results 95 Discussion 105 References 106 Chapter 5 Reaching the Global Target for Breastfeeding . . . . . . . 113 Optimal Breastfeeding and Its Benefits  114 The State of Breastfeeding Worldwide  115 Interventions That Effectively Promote Breastfeeding 116 Analytic Approaches Specific to the Breastfeeding Target 121 Results 126 Discussion 136 References 137 Chapter 6 Scaling Up the Treatment of Severe Wasting. . . . . . . . . 141 Wasting and Its Effects  142 The Treatment of Severe Acute Malnutrition among Children 145 Analytic Approaches Specific to the Wasting Target  146 Results 154 Discussion 159 References 164 Chapter 7 Financing Needs to Reach the Four Global Nutrition Targets: Stunting, Anemia, Breastfeeding, and Wasting. . . . . . . . . . . . . . . . . . . . . . . . 169 Method for Aggregating Financing Needs across All Four Targets  170 Total Financing Needs to Achieve All Four Targets  171 Expected Impacts: Method for Aggregating across Targets   175 A Priority Package of Interventions  178 Discussion 184 References 186 vi An Investment Framework for Nutrition Chapter 8 Financing the Global Nutrition Targets . . . . . . . . . . . . . 187 Current Levels of Spending on Nutrition  189 Financing the Scale-Up to Reach the Global Targets  202 Discussion 209 References 213 Chapter 9 Reaching the Global Targets for Stunting, Anemia, Breastfeeding, and Wasting: Investment Framework and Research Implications. . . . . . . . . . . . . . . . . . . . . . . . . 217 Rationale for Investing in Nutrition  219 Discussion 223 Limitations and Constraints  229 Policy Implications and Recommendations  233 References 237 Appendix A: Technical Advisory Group (TAG) Membership. . . . . 241 Appendix B: Baseline Intervention Coverage Rates by Target. . . . 243 Appendix C: Intervention Unit Costs and Data Sources for Unit Costs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253 Appendix D: Current Government Investments in Nutrition. . . . . 273 Appendix E: Current Official Development Assistance for Nutrition across Aid Categories. . . . . . . . . . . . . . . . . 279 List of Boxes Box 1.1 What Is Malnutrition? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Box 1.2 Gray Matter Infrastructure: Early Childhood Nutrition as a Determinant of Lifelong Cognitive Development. . . . 5 Box 1.3 Scaling Up World Bank Support to End Stunting: An Imperative for Developing Economies. . . . . . . . . . . . . 12 Box 9.1 Peru’s Success in Reducing Stunting. . . . . . . . . . . . . . . . . 224 Box 9.2 Senegal’s Nutrition Policy Development Process: A Work in Progress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226 Box 9.3 The Vietnam Experience: Investing in ­ Breastfeeding Promotion and Anemia Reduction. . . . . . . . . . . . . . . . . . . 228 Box 9.4 Achieving High Coverage of Nutrition-Specific Interventions: Lessons from Vitamin A Supplementation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234 Contents vii List of Figures Figure 1.1 Investments in Nutrition Build Human Capital and Boost Shared Prosperity. . . . . . . . . . . . . . . . . . . . . . . . . . 4 Figure 1.2 Key Global Responses on Nutrition . . . . . . . . . . . . . . . . . . . 9 Figure 1.3 A Framework for Achieving Optimum Nutrition. . . . . . . 14 Figure 2.1 Incremental Percentage of the Global Burden of Stunting and the Number of Additional Countries Included in the Analyses. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Figure 3.1 Global and Regional Trends of Child Stunting under Age Five, 1990–2014 . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Figure 3.2 Trends in Number of Children under Five Stunted by Region, 1990–2014. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Figure 3.3 Stunting Rates by Wealth Quintile, Selected Countries . . . 46 Figure 3.4 The Lives Saved Tool (LiST) and Underlying Model Used to Estimate Impact on Stunting . . . . . . . . . . . . . . . . . 58 Figure 3.5 Annual Financing Needs to Meet the Stunting Target by 2025 U.S.$, millions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Figure 3.6 Ten-Year Total Financing Needs to Meet the Stunting Target, by Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Figure 3.7 Estimated Total Financing Needs to Meet the Stunting Target, by Region US$, millions. . . . . . . . . . . . . . . . . . . . . . . 64 Figure 3.8 Ten-Year Total Financing Needs to Meet the Stunting Target, by Country Income Group. . . . . . . . . . . . . . . . . . . . 65 Figure 3.9 Costs and Impacts of a 10-Year Scale-Up of Interventions to Reach the Stunting Target. . . . . . . . . . . . . . . . . . . . . . . . . 66 Figure 4.1 Conceptual Model of Determinants of Anemia . . . . . . . . 82 Figure 4.2 Underlying Model Used to Estimate the Impact of Interventions on Anemia in Women. . . . . . . . . . . . . . . . 92 Figure 4.3 Annual Financing Needs to Meet the Anemia Target U.S. dollars, millions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Figure 4.4 Ten-Year Total Financing Needs to Meet the Anemia Target, by Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Figure 4.5 Ten-Year Total Financing Needs to Meet the Anemia Target, by Country Income Group . . . . . . . . . . . . . . . . . . . 99 Figure 4.6 Sensitivity Analysis for 10-Year Total Financing Needs to Meet the Anemia Target . . . . . . . . . . . . . . . . . . . . . . . . . 100 viii An Investment Framework for Nutrition Figure 4.7 Costs and Impacts of a 10-Year Scale-Up of Interventions to Meet the Anemia Target. . . . . . . . . . . 102 Figure 4.8 Sensitivity Analyses of the Impact of Interventions to Meet the Anemia Target . . . . . . . . . . . . . . . . . . . . . . . . . 104 Figure 5.1 Conceptual Framework for an Enabling Environment That Supports Breastfeeding. . . . . . . . . . . . . . . . . . . . . . . . 117 Figure 5.2 Annual Financing Needs to Meet the Breastfeeding Target U.S.$, millions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Figure 5.3 Ten-Year Total Financing Needs to Meet the Breastfeeding Target, by Region. . . . . . . . . . . . . . . . . . 129 Figure 5.4 Ten-Year Total Financing Needs to Meet the Breastfeeding Target, by Country Income Group. . . 129 Figure 5.5 Sensitivity Analyses for 10-Year Total Financing Needs to Meet the Breastfeeding Target US$, billions . . . . . . . . . 131 Figure 5.6 Projected Exclusive Breastfeeding Prevalence and Child Deaths Averted with Scale-Up of Interventions to Meet the Breastfeeding Target. . . . . . 132 Figure 5.7 Sensitivity Analyses of the Estimated Impact of Interventions on Exclusive Breastfeeding Rates . . . . . 134 Figure 6.1 Total Annual Financing Needs for the Treatment of Severe Acute Malnutrition under Constant and Declining Unit Cost Assumptions, 2016–25. . . . . . . . . . . 150 Figure 6.2 LiST Model of the Impact of the Treatment of Severe Acute Malnutrition on Mortality in Children under Five. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Figure 6.3 Ten-Year Total Financing Needs for the Treatment of Severe Acute Malnutrition, by Region . . . . . . . . . . . . . 154 Figure 6.4 Ten-Year Total Financing Needs for the Treatment of Severe Acute Malnutrition, by Country Income Group. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Figure 6.5 Total Annual Financing Needs to Scale Up the Treatment of Severe Acute Malnutrition, 2016–25 US$, millions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 Figure 7.1 Ten-Year Total Financing Needs to Meet All Four Targets, Breakdown by Target US$, billions. . . . . . . . . . . . 173 Figure 7.2 Ten-Year Total Financing Needs to Meet All Four Targets, by Region. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 Contents ix Figure 7.3 Ten-Year Total Financing Needs to Meet All Four Targets, by Country Income Group. . . . . . . . . . . . . . . . . . 174 Figure 8.1 Official Development Assistance for Basic Nutrition Disbursed between 2006 and 2013 US$, millions . . . . . . . 195 Figure 8.2 Current Financing for the Costed Package of Interventions by Governments and ODA in 2015, by Target US$, billions . . . . . . . . . . . . . . . . . . . . . . 198 Figure 8.3 Baseline ODA Financing for Nutrition by Region and Income Group. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 Figure 8.4 Business as Usual in Nutrition Financing: A $56 Billion Shortfall. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207 Figure 8.5 The Global-Solidarity Financing Scenario: The $70 Billion Required for Scale-Up Mobilized. . . . . . 208 Figure 9.1 Benefits of Investing in Global Nutrition Targets . . . . . . 221 Figure 9.2 Reductions in Prevalence of Stunting over Time, Selected Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222 List of Maps Map 3.1 Stunting Rates among Low- and Middle-Income Countries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 List of Tables Table 1.1 Six World Health Assembly Global Targets for Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Table 1.2 Studies That Estimate Global Financing Needs for Scaling Up Nutrition Interventions. . . . . . . . . . . . . . . . 17 Table 2.1 Number of Sample Countries, Percentage of Burden, and Multiplier Used to Extrapolate to All Low- and Middle-Income Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Table 2.2 Countries Included in the Estimates of the Four Targets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Table 2.3 Process for Estimating Unit Costs and Dealing with Missing Unit Cost Data. . . . . . . . . . . . . . . . . . . . . . . . . 31 Table 3.1 Interventions to Reach the Stunting Target. . . . . . . . . . . . . 54 Table 3.2 Minimum, Maximum, and Mean Unit Costs for Interventions to Meet the Stunting Target (Annual) U.S. dollars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 x An Investment Framework for Nutrition Table 3.3 Total Financing Needs to Meet the Stunting Target US$, millions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Table 3.4 Total Costs, Cost per Case of Stunting Averted, and Cost per Death Averted. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Table 3.5 Benefit-Cost Ratios of Scaling Up Interventions to Meet the Stunting Target, 3 and 5 Percent Discount Rates. . . . . 69 Table 3.6 Comparison across Three Studies of Unit Costs and Annual Financing Needs for Nutrition Interventions. . . . 70 Table 3.7 Population Covered and Unit Costs to Meet the Stunting Target in the Full Sample, Sub-Saharan Africa, and South Asia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Table 4.1 Recommended Iron and Folic Acid Dosages for Non-Pregnant and Pregnant Women . . . . . . . . . . . . . . 83 Table 4.2 Anemia Severity Thresholds in Women . . . . . . . . . . . . . . . 86 Table 4.3 Interventions to Reach the Anemia Target . . . . . . . . . . . . . 87 Table 4.4 Assumed Delivery Platforms for Iron and Folic Acid Supplementation for Women, by Secondary School Enrollment and Poverty Status. . . . . . . . . . . . . . . . . . . . . . . 89 Table 4.5 Minimum, Maximum, and Mean Unit Costs of Interventions to Meet the Anemia Target (Annual) U.S. dollars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Table 4.6 Ten-Year Total Financing Needs to Meet the Anemia Target . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Table 4.7 Total Cost, Cost per Case-Year of Anemia Averted, and Costs per Death Averted . . . . . . . . . . . . . . . . . . . . . . . 103 Table 4.8 Benefit-Cost Ratios of Scaling Up Interventions to Meet the Anemia Target, 3 and 5 Percent Discount Rates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Table 5.1 Interventions to Meet the Breastfeeding Target. . . . . . . . 120 Table 5.2 Minimum, Maximum, and Mean Unit Costs to Meet the Breastfeeding Target (Annual) U.S. dollars . . . . . . . . . . . . 127 Table 5.3 Total Financing Needs to Meet the Breastfeeding Target . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Table 5.4 Benefit-Cost Ratios of Scaling Up Interventions to Meet the Breastfeeding Target, 3 and 5 Percent Discount Rates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Contents xi Table 6.1 Differential Impact of Treatment of Severe Acute Malnutrition on Mortality by Underlying Prevalence of Disease Risk Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Table 6.2 Estimated Impact over 10 Years of the Treatment of Severe Acute Malnutrition . . . . . . . . . . . . . . . . . . . . . . . 157 Table 6.3 Benefit-Cost Ratios of Scaling Up Treatment of Severe Acute Malnutrition, 3 and 5 Percent Discount Rates . . . 158 Table 6.4 Benefit-Cost Ratios of Scaling Up Treatment of Severe Acute Malnutrition, by Number of Episodes per Year. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Table 6.5 Comparison of Cost Estimates of the Treatment of Severe Acute Malnutrition . . . . . . . . . . . . . . . . . . . . . . . 160 Table 6.6 Mortality Estimates for Severe Acute Malnutrition. . . . . 162 Table 7.1 Ten-Year Total Financing Needs to Meet All Four Targets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Table 7.2 Estimated Impacts of Meeting All Four Targets, 2025 Compared with 2015 Baseline. . . . . . . . . . . . . . . . . . . . . . . 175 Table 7.3 Benefit-Cost Ratios of Scaling Up Interventions to Meet All Four Targets, 3 and 5 Percent Discount Rates U.S.$. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 Table 7.4 Cost per Outcome by Intervention. . . . . . . . . . . . . . . . . . . 180 Table 7.5 Potential Delivery Platforms for Scaling Up High-Impact Interventions . . . . . . . . . . . . . . . . . . . . . . . . . 181 Table 7.6 Total Financing Needs for Immediate Scale-Up of a Set of Priority Interventions US$, millions. . . . . . . . . 182 Table 7.7 Cost Effectiveness by Intervention Package. . . . . . . . . . . 183 Table 7.8 Benefits and Total Financing Needs by Intervention Package. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 Table 8.1 Financing Principles Used to Close the Resource Gap under the Global-Solidarity Scenario. . . . . . . . . . . . . . . . . 205 Table 9.1 Additional Financing Needs to Reach All Four Targets, Selected Years US$, millions. . . . . . . . . . . . . . . . . . . . . . . . . 227 xii An Investment Framework for Nutrition Foreword T he World Bank Group (WBG) is committed to the twin goals of eliminating extreme poverty and boosting shared prosper- ity. Although significant progress has been made, with global poverty rates having declined to less than 10 percent for the first time in history, childhood stunting—a leading measure of undernutrition and overall ­ well-being—remains a silent emergency of a magnitude as large as that of the AIDS epidemic: it affects 159 million children with negative consequences including illness, deaths, learning outcomes, poverty, and diminished productivity. The links between early child- hood nutrition and human capital have been well recognized for some time now. This report identifies a set of actions that, taken together, could allow the world to reach the global nutrition targets for stunt- ing, anemia in women, and exclusive breastfeeding for infants, as well as scale up the treatment of severe wasting. Doing so would bring many benefits to children’s nutrition in the immediate term, their long-term health and well-being, and their future productivity as vibrant adult members of society. Investing in this set of actions would require almost $70 billion over 10 years from domestic resources, offi- cial development assistance (ODA), and the private sector. Unlike many other development investments, investments in nutrition are durable, inalienable, and portable. Durable because investments made during the critical 1,000 day window of opportunity last a life- time without ever needing to be replenished. Inalienable and portable because they belong to that child no matter what and wherever she or he goes. Even more important are the findings in this report that these investments in nutrition are among the best in development, with a return of between $4 and $35 for every $1 invested. This report identifies ways to raise the needed financial resources to scale up actions to address the global targets. It will be vital to combine traditional financing—ranging from additional domestic government and ODA resources to reallocating existing government resources from less cost-effective investments to highly effective investments in nutrition—with innovative financing mechanisms such Foreword xiii as the Power of Nutrition and the Global Financing Facility in Support of Every Woman, Every Child. The time for action is now. Let us come together as an international community and drive down malnutrition. Childhood years are lim- ited, and each day that passes without action to address stunting and improve other nutrition outcomes diminishes the growth and prosper- ity of countries around the world. Timothy Grant Evans Senior Director, Health Nutrition and Population World Bank Group xiv An Investment Framework for Nutrition Acknowledgements T his report was led by Meera Shekar, with Jakub Kakietek, Julia Dayton Eberwein, and Dylan Walters. The overall work was a joint effort between the World Bank Group, Results for Devel- opment Institute, and 1,000 Days, with financial support from the Bill & Melinda Gates Foundation and the Children’s Investment Fund Foundation. The Results for Development Institute team that developed the financing scenarios for this work was led by Robert Hecht, with Shan Soe-Lin, Mary Rose D’Alimonte, Hilary Rogers, Stephanie Heung, and Daniel Arias. David de Ferranti provided technical guidance and Jack Clift provided support and peer review in the preparation of chapter 8. The 1,000 Days team was led by Lucy Sullivan with Danielle Porfido. Ellen Piwoz from the Bill & Melinda Gates Foundation and Augus- tin Flory from the Children’s Investment Fund Foundation provided valuable technical guidance. Jon Kweku Akuoku, Audrey Pereira, Rebecca Heidcamp, and Michelle Mehta (World Bank consultants); Thu Do (Results for Development Institute); and Robert Greener and Clara Picanyol (Oxford Policy Management) provided useful inputs to the analysis. Hope Steele edited the report. The authors are grateful to Keith Hansen, Vice-President of Human Development at the World Bank Group, and Tim Evans, Senior Direc- tor for the Health, Nutrition and Population Global Practice at the World Bank Group, for their guidance and support. Peer review comments were provided by Harold Alderman, Ellen Piwoz, Luc Laviolette, and Marelize Gorgens. In addition, very valu- able technical advice was provided by Sue Horton (University of Waterloo), Julia Kravasec (UNICEF), Monika Bloessner (WHO), and Neil Watkins and Nora Coghlan (Bill & Melinda Gates Foundation) on advocacy-related issues. Acknowledgements xv The team is deeply grateful to the members of the Technical Advisory Group for their contributions to this work (See appendix A for TAG members). Additional inputs from colleagues who attend the Febru- ary 22, 2016, full-day meeting are also greatly appreciated (also see appendix A for a list of meeting participants). Consultations with development partners, especially the International Coalition for Advocacy on Nutrition (ICAN), colleagues at DfiD and WHO, and others provided further guidance for the report. The authors are extremely grateful for the advice and inputs from all those who contributed their valuable time. xvi An Investment Framework for Nutrition Contributors World Bank Group Meera Shekar is Global Lead for Nutrition in the Health, Nutrition and Population Global Practice, World Bank, Washington, DC USA. Jakub Jan Kakietek is an Economist in the Health, Nutrition and Population Global Practice, World Bank, Washington, DC USA. Julia Dayton Eberwein is a Consultant in the Health, Nutrition and Population Global Practice, World Bank, Washington, DC USA. Dylan Walters is a Consultant in the Health, Nutrition and Population Global Practice, World Bank, Washington, DC USA. Anne Marie Provo is a Research Analyst in the Health, Nutrition and Population Global Practice, World Bank, Washington, DC USA. Michelle Mehta is a Consultant in the Health, Nutrition and Popula- tion Global Practice, World Bank, Washington, DC USA. Jon Kweku Akuoku is a Consultant in the Health, Nutrition and Population Global Practice, World Bank, Washington, DC USA. Audrey Pereira is a Consultant in the Health, Nutrition and Popula- tion Global Practice, World Bank, Washington, DC USA. Results for Development Institute David de Ferranti is the President and CEO of Results for Develop- ment Institute, Washington, DC USA. Mary D’Alimonte is a Program Officer for Results for Development Institute, Washington, DC USA. Hilary Rogers is a Program Officer for Results for Development Insti- tute, Washington, DC USA. 1,000 Days Lucy Sullivan is the Executive Director for 1,000 Days, Washington, DC USA. Contributors xvii Abbreviations AIDS acquired immune deficiency syndrome ART anti-retroviral therapy BCR benefit-cost ratio CRS Creditor Reporting System DALYs disability-adjusted life years DHS Demographic and Health Surveys FAO Food and Agriculture Organization of the United Nations FFI Food Fortification Initiative GAIN Global Alliance for Improved Nutrition GDP gross domestic product GFF Global Financing Facility HIV human immunodeficiency virus IQ intelligence quotient IU international units LiST Lives Saved Tool MICS Multiple Indicator Cluster Surveys MUAC mid-upper arm circumference ODA official development assistance OECD Organisation for Economic Co-operation and Development RSOC Rapid Survey of Children UNIMAP UNICEF Multiple Micronutrient Preparation WASH water, sanitation, and hygiene WHA World Health Assembly WHO World Health Organization WHZ weight-for-height z-scores WPP World Population Prospects All dollar amounts are U.S. dollars unless otherwise indicated. xviii An Investment Framework for Nutrition Glossary of Technical Terms A benefit-cost ratio summarizes the overall value of a project or pro- posal. It is the ratio of the benefits of a project or proposal, expressed in monetary terms, relative to its costs, also expressed in monetary terms. The benefit-cost ratio takes into account the amount of mon- etary gain realized by implementing a project versus the amount it costs to execute the project. The higher the ratio, the better the invest- ment. A general rule is that if the benefit from a project is greater than its cost, the project is a good investment. Capacity development for program delivery is a process that involves increasing in-country human capacity and systems to design, deliver, manage, and evaluate large-scale interventions (World Bank 2010). This includes developing skills by training public health per- sonnel and community volunteers to improve the delivery of services. These efforts typically accompany program implementation or, when possible, precede program implementation. In this analysis we allo- cate 9 percent of total programmatic costs to capacity development for program delivery. Cost-benefit analysis is an approach to economic analysis that weighs the cost of an intervention against its benefits. The approach involves assigning a monetary value to the benefits of an intervention and esti- mating the expected present value of the net benefits, known as the net present value. Net benefits are the difference between the cost and monetary value of benefits of the intervention. The net present value is defined mathematically as: T Ct Net present value =  (1 + r) – C t=1 t 0 where Ct is net cash inflows, C0 is the initial investment, the index t is the time period, and r is the discount rate. A positive net present value, when discounted at appropriate rates, indicates that the pres- ent value of cash inflows (benefits) exceeds the present value of cash outflows (cost of financing). Interventions with net present values that Glossary of Technical Terms xix are at least as high as alternative interventions provide greater ben- efits than interventions with net present values equal to or lower than alternatives. The results of cost-benefit analysis can also be expressed in terms of the benefit-cost ratio. Cost-effectiveness analysis is an approach to economic analysis that is intended to identify interventions that produce the desired results at the lowest cost. Cost-effectiveness analysis requires two components: the total cost of the intervention and an estimate of the intervention’s impact, such as the number of lives saved. The cost-effectiveness ratio can be defined as: Cost-effectiveness ratio = total cost of implementing the intervention impact of the intervention on a specific outcome The analysis involves comparing the cost-effectiveness ratios among alternative interventions with the same outcomes. The intervention with the lowest cost per benefit is considered to be the most cost-effec- tive intervention among the alternatives. A DALY is a disability-adjusted life year, which is equivalent to a year of healthy life lost due to a health condition. The DALY, devel- oped in 1993 by the World Bank, combines the years of life lost from a disease (YLL) and the years of life spent with disability from the disease (YLD). DALYs count the gains from both mortality (how many more years of life lost due to premature death are prevented) and morbidity (how many years or parts of years of life lost due to disabil- ity are prevented). An advantage of the DALY is that it is a metric that is recognized and understood by external audiences such as the World Health Organization (WHO) and the National Institutes of Health (NIH). It helps to gauge the contribution of individual diseases rela- tive to the overall burden of disease by geographic region or health area. Combined with cost data, DALYs allow for estimating and comparing the cost-effectiveness of scaling up nutrition interventions in different countries. A discount rate refers to a rate of interest used to determine the current value of future cash flows. The concept of the time value of money suggests that income earned in the present is worth more than the same amount of income earned in the future because of its earn- ing potential. A higher discount rate reflects higher losses to potential xx An Investment Framework for Nutrition benefits from alternative investments in capital. A higher discount rate may also reflect a greater risk premium of the intervention. The Lives Saved Tool (LiST) is an estimation tool that translates measured coverage changes into estimates of mortality reduction and cases of childhood stunting averted. LiST is used to project how increasing intervention coverage would impact child and maternal survival. It is part of an integrated set of tools that comprise the Spec- trum policy modeling system. Monitoring and evaluation (M&E), operations research, and techni- cal support for program delivery are all elements of cost-effective and efficient program implementation. Monitoring involves check- ing progress against plans through the systematic and routine col- lection of information from projects and programs in order to learn from experience to improve practices and activities in the future, to ensure internal and external accountability of the resources used and the results obtained, and to make informed decisions on the future of the intervention. Monitoring is a periodically recurring task. Evalua- tion is the assessing, as systematically and objectively as possible, of a completed project or intervention (or a phase of an ongoing project). Operations research aims to inform the program designers about ways to deliver interventions more effectively and efficiently. Techni- cal support entails ensuring that training, support, and maintenance for the physical elements of the intervention are available. In this cost- ing exercise we allocate 2 percent of total intervention costs for M&E, operations research, and technical support. Nutrition-sensitive interventions are those that have an indirect impact on nutrition and are delivered through sectors other than health such as the agriculture, education, and water, sanitation, and hygiene sectors. Examples include biofortification of food crops, conditional cash transfers, and water and sanitation infrastructure improvements. Nutrition-specific interventions are those that address the immediate determinants of child nutrition, such as adequate food and nutrition intake, feeding and caregiving practices, and treating disease. Exam- ples include promotion of good infant and young child nutrition, micronutrient supplementation, and deworming. ODA refers to official development assistance and similar kinds of aid. This comprises aid from bilateral assistance agencies (and the Glossary of Technical Terms xxi high-income countries to which they belong), multilateral organiza- tions (such as the development banks), and a wide variety of chari- table institutions (including large international nongovernmental organizations). Sensitivity analysis is a technique that evaluates the robustness of findings when key variables change. It helps to identify the variables with the greatest and least influence on the outcomes of the interven- tion, and it may involve adjusting the values of a variable to observe the impact of the variable on the outcome. Stunting is an anthropometric measure of low height-for-age. It is an indicator of chronic undernutrition and is the result of prolonged food deprivation and/or disease or illness. It is measured in terms of Z-score (or standard deviation score); a child is considered stunted with a height-for-age Z-score of −2 or lower. Underweight is an anthropometric measure of low weight-for-age. It is used as a composite indicator to reflect both acute and chronic undernutrition, although it cannot distinguish between them. It is measured in terms of Z-score (or standard deviation score); a child is considered underweight with a weight-for-age Z-score of −2 or lower. Wasting is an anthropometric indicator of low weight-for-height. It is an indicator of acute undernutrition and the result of more recent food deprivation or illness. It is measured in terms of Z-score (or standard deviation score). A child with a weight-for-height Z-score of −2 or lower is considered wasted. xxii An Investment Framework for Nutrition Executive Summary I n 2015, 159 million children under the age of five were chronically malnourished or stunted, underscoring a massive global health and economic development challenge (UNICEF, WHO, and World Bank 2015). In 2012—in an effort to rally the international community around improving nutrition—the 176 members of the World Health Assembly endorsed the first-ever global nutrition targets, focusing on six areas: stunting, anemia, low birthweight, childhood overweight, breastfeeding, and wasting. These targets aim to boost investments in cost-effective interventions, spearhead better implementation prac- tices, and catalyze progress toward decreasing malnutrition. Some of the targets (stunting and wasting) are further enshrined within the United Nations’ Sustainable Development Goal 2 (SDG 2), which com- mits to ending malnutrition in all its forms by the year 2030. Nutrition Targets: Investment Case and Constraints Ending malnutrition is critical for economic and human development. Childhood stunting, an overarching measure of long-term malnutri- tion, has life-long consequences not just for health, but also for human capital and economic development, prosperity, and equity. Being stunted in early childhood reduces schooling attainment, decreases adult wages, and makes children less likely to escape poverty as adults (Fink et al. 2016; Hoddinott et al. 2008; Hoddinott et al. 2011; Martorell et al. 2010). Conversely, reductions in stunting are estimated to potentially increase overall economic productivity, as measured by GDP per capita, by 4 to 11 percent in Africa and Asia (Horton and Steckel 2013). Thus nutrition interventions are consistently identified as one of the most cost-effective development actions (Horton and Hoddinott 2014). Furthermore, investments in early nutrition yield permanent and inalienable benefits. Although the investment case for nutrition is strong, efforts to reach the nutrition SDG targets are constrained by a range of factors Executive Summary xxiii Figure ES.1:  World Health Assembly Global Targets for Nutrition 2025 Target REDUCE THE NUMBER of stunt d STUNTING childr n und r fiv b 40% REDUCE THE NUMBER of wom n of ANEMIA r productiv with n mi b 50% INCREASE THE RATE of xclusiv EXCLUSIVE br stf din in th first six months BREASTFEEDING up to t l st 50% REDUCE AND MAINTAIN childhood w stin WASTING ( cut m lnutrition) to l ss th n 5% Source: WHO 2014 including insufficient financing, complexity in terms of implemen- tation (that is, how to bridge disciplines and sectoral borders), and determining the methods and costs (both financial and human resources) involved in monitoring SDG targets. In relation to nutri- tion’s contribution to this whole-of-society approach to develop- ment, these challenges are exacerbated because of the major gaps in knowledge regarding the costs and resources required for scaling up these interventions. Two earlier studies have estimated the total costs of scaling up nutrition interventions (Bhutta et al. 2013; Horton et al. 2010). However, those studies estimate the cost of a comprehensive package of evidence-based interventions affecting child undernutri- tion at large but do not focus on achieving specific outcomes (see chapter 1 in the full report for a discussion of these studies). Fur- thermore, neither of these studies provides estimates of the costs of reaching the global nutrition targets, including the SDG targets. In addition, no previous study has systematically linked the costs with the potential for impact and the interventions’ returns on invest- ment, nor assessed the financing shortfall between what is required and what is currently being spent at the global level. Finally, no prior study has presented a comprehensive global analysis of domestic financing from governments and official development assistance (ODA). This report aims to close these knowledge gaps by providing xxiv An Investment Framework for Nutrition Figure ES.2:  Benefits of Investing in Global Nutrition Targets STUNTING ANEMIA 65 million c s s of stuntin pr v nt d 265 million c s s of n mi in wom n pr v nt d 2.8 million child d ths v rt d 800,000 child d ths v rt d BREASTFEEDING WASTING 105 million mor b bi s 91 million childr n tr t d xclusiv l br stf d for s v r w stin 520,000 child d ths v rt d mor th n 860,000 child d ths v rt d BENEFITS OF INVESTING IN ALL FOUR TARGETS 65 million c s s of stuntin pr v nt d At l st 3.7 million child d ths v rt d a more comprehensive estimate of costs as well as financing needs, linking them both to expected impacts, and laying out a potential financing framework. An in-depth understanding of current nutrition investments, future needs and their impacts, and ways to mobilize the required funds is included to move the agenda from a political com- mitment to a policy imperative. Estimated Financing Needs These analyses estimate financing needs for the targets for stunting, anemia in women, exclusive breastfeeding for infants, and wast- ing among young children. The analyses are not able to estimate the financing needs to achieve the wasting target, mainly because of a lack of sufficient evidence on interventions to prevent wasting. Instead, the analyses estimate costs for the scale-up of the treatment of severe wasting. Two of the global nutrition targets—those for low birth- weight and for child overweight—are not included in these analyses because there are insufficient data either on the prevalence of the condition (low birthweight) or consensus on effective interventions to reach the goal (child overweight). The expected effects of the proposed interventions on the prevalence of stunting among children, anemia in women, and rates of exclusive breastfeeding for infants are estimated, along with their impacts on Executive Summary xxv mortality. Benefit-cost analyses are conducted for each intervention, translating the results into benefits in relation to stunting and anemia cases prevented, increased numbers of children breastfed, cases of wasting treated, lives saved, and potential earnings gained over adult working life. Issues of technical and allocative efficiency as they relate to the implementation of scaling-up efforts are also addressed. This report finds that an additional investment of $70 billion over 10 years is needed to achieve the global targets for stunting, anemia in women, exclusive breastfeeding and the scaling up of the treatment of severe wasting. The expected impact of this increased investment is enormous: 65 million cases of stunting and 265 million cases of ane- mia in women would be prevented in 2025 as compared with the 2015 baseline. In addition, at least 91 million more children under five years of age would be treated for severe wasting and 105 million additional babies would be exclusively breastfed during the first six months of life over 10 years. Altogether, investing in interventions to reach these targets would also result in at least 3.7 million child deaths averted. In an environment of constrained resources, if the world could not afford the $70 billion needed to achieve the targets but instead could invest in only a subset of interventions, it would have to set priori- ties. In this context, this report recommends that investments should kick-off with scaling up interventions with the highest returns (that is, those that maximize allocative efficiency) and those that are scal- able now (that is, those that maximize technical efficiency), with the strong caveat that scaling up only this priority set of interventions would not achieve the global targets. Financing this more limited set of actions will require an additional investment of $23 billion over the next 10 years. When combined with other health and poverty reduc- tion efforts, this priority investment approach could still yield signifi- cant returns: an estimated 2.2 million lives would be saved and there would be 50 million fewer cases of stunting in 2025 than in 2015. In terms of financing sources—as with other areas that the SDGs aim to address—a mix of domestic on-budget allocations from country governments combined with ODA, and newly emerging innovative financing mechanisms coupled with household contributions, could finance the remaining gap. This underscores again the extent to which a whole-of-society effort is needed for financing the achievement of the nutrition targets in the context of the broader sustainable devel- opment goals; this mix of financing is also in line with other SDG challenges. xxvi An Investment Framework for Nutrition Box ES.1: A Big Bang for the Buck: The Benefits of Investing in Nutrition With many competing development objectives, the main chal- lenge for policy makers is to decide which actions should be prioritized. One way to do this is to compare benefit-cost ratios across interventions and programs. Even though methodolo- gies differ across studies (see Alderman, Behrman, and Puett 2016 for detailed discussion of these differences), there is a strong body of evidence that shows very high economic returns to investing in nutrition (Alderman, Behrman and Puett 2016; Copenhagen Consensus Center 2015; Hoddinott et al. 2013). The analyses in this report support that conclusion and report benefit-cost ratios well above 1, the breakeven point, under a range of assumptions (see the figure in this box). The benefits of investments to increase rates of exclusive breastfeeding are par- ticularly high: $35 in returns for every dollar invested. Not only are investments in nutrition one of the best value-for-money development actions, they also lay the groundwork for the suc- cess of investments in other sectors. Figure ES.B1: The Dramatic Benefits of Investing in Nutrition 40 35 R turn for v r $1 inv st d, in doll rs 30 20 12 11 10 4 0 wom n An mi in W stin Exclusiv Stuntin stf din br These analyses also confirm the high returns on investment that come from investing in nutrition among children and women. Not only do investments in nutrition make one of the best value-for-money development actions, they also lay the groundwork for the success of investments in other sectors. Achieving the targets is within reach if partners work together to immediately step up in investments in nutrition. Indeed, some coun- tries (Peru, Senegal, and others) have shown that rapid scale-up of nutrition interventions can be achieved and lead to swift declines in stunting rates (see chapter 9 for a discussion of country achievements in reducing malnutrition). Key Recommendations 1. The world needs $70 billion over 10 years to invest in high- impact nutrition-specific interventions in order to reach the global targets for stunting, anemia in women, and exclusive breastfeed- ing for infants and to scale up the treatment of severe wasting among young children. Although $7 billion a year may seem to be a large investment, it pales in comparison to the $500 billion per year (nearly $1.5 billion/ day) that is currently spent on agriculture subsidies (Potter 2014) and the $543 billion per year (over $1.5 billion/day) spent on fossil fuel subsidies (International Energy Agency 2014), or $19 billion per year on HIV-AIDS (UNAIDS 2016). The nutrition-specific investments presented in this report are expected to have large benefits: 65 million cases of stunting and 265 million cases of anemia in women would be prevented in 2025 as compared with the 2015 baseline. In addition, at least 91 million more children would be treated for severe wasting and 105 million additional babies would be exclusively breastfed during the first six months of life over 10 years. Altogether, achieving these targets would avert at least 3.7 million child deaths. And, every dollar invested in this package of interventions would yield between $4 and $35 in economic returns. This is in line with previous studies suggesting returns of $18 (Hoddinott et al. 2013). 2. Recent experience from several countries suggests that meeting these targets is feasible, although some of the targets—especially xxviii An Investment Framework for Nutrition those for reducing stunting in children and anemia in women—are ambitious and will require concerted efforts in financing, scale- up, and sustained commitment. On the other hand, the target for exclusive breastfeeding has scope to be much more ambitious. 3. Some areas of future research need to be prioritized. These include: Research on scalable strategies for delivering high-impact inter- ventions is necessary, including how to address bottlenecks to scaling up, for example through results-based budgeting approaches or other ways of incentivizing results. Such research will not only facilitate faster scale-up, but it would also have the potential to increase the technical efficiency and delivery costs for these interventions, thereby reducing the global financing needs. Another critical area for future research is the assessment of allocative efficiency—that is, identifying the optimum funding allocation among different interventions or an allocation that maximizes the impact under a specific budget constraint. The present analyses show cost per outcome, allowing for only limited comparisons of cost-effectiveness among different interventions for the same targets. Research to improve the technical efficiency of nutrition spending is also urgently needed. This includes identifying new strategies for addressing complex nutritional problems such as stunting and anemia, as well as technologies to help take these solutions to scale more rapidly and at lower cost. Because of the multifactorial nature of anemia, research is under way to clearly determine what fraction of the problem can be addressed by nutrition interven- tions; the estimates presented in this report may need to be revised accordingly once results become available. Additionally, some micronutrient deficiencies are not included here (i.e., iodine defi- ciencies), because these were not included in the global targets, even though they have significant impacts on morbidity, mortality, and economic productivity. Strengthening the quality of surveillance data, unit cost data for interventions in different country contexts, and building stronger data collection systems for estimating current investments in nutrition (from both domestic governments and ODA) are also crucial. Further research is needed on the costs of interventions Executive Summary xxix xxx Figure ES.3: An Affordable Package of Nutrition-Specific Interventions to Meet Four Nutrition Targets Improvin nutrition Iron nd folic cid for pr n nt moth rs suppl m nt tion for ~$10 p r child nnu ll non-pr n nt wom n $70B ov r 10 rs in ddition to curr nt sp ndin Improvin child nutrition, Improvin f din Continu d improv m nts in includin micronutri nt pr ctic s, includin und rl in f ctors: suppl m nt tion br stf din W t r nd Wom n's Food v il bilit s nit tion duc tion, nd div rsit Pro-br stf din soci l polici s St pl food h lth nd & N tion l br stf din fortific tion mpow rm nt promotion c mp i ns An Investment Framework for Nutrition such as maternity protection to support women in the workforce so they can exclusively breastfeed infants for the first six months. In addition, significant resources will be required to build a living database of current investments, including closely monitoring spending and ensuring accountability, and to undertake national- level public expenditure reviews. A dedicated effort to understanding which interventions prevent wasting is urgently needed. It is also essential to learn more about cost-effective strategies for managing moderate acute malnutri- tion, and whether or not these can contribute toward the preven- tion of wasting. More evidence is needed on the costs and impacts of nutrition- sensitive interventions—that is, interventions that improve nutrition through agriculture, social protection, and water and sanitation sectors, among others. It is evident that stunting, as well as anemia, are multifactorial and can be improved through increasing quality, diversity, and affordability of foods, increasing the control of income by women farmers, and also by reducing exposure to fecal pathogens by improved water, sanitation, and hygiene practices. However, the attributable fraction of the burden that can be addressed by these interventions is unknown. The last five years have seen a proliferation of studies to improve clarity on these issues, as well as on the use of social programs as a platform for reaching the most vulnerable. Future work in this area should take into account such new evidence as studies are published. Call to Action As the world stands at the cusp of the new SDGs, with global pov- erty rates having declined to less than 10 percent for the first time in history (World Bank 2016), there is an unprecedented opportunity to save children’s lives, build future human capital and gray-matter infrastructure, and provide equal opportunity for all children to drive faster economic growth. These investments in the critical 1,000 day window of early childhood are inalienable and portable and will pay lifelong dividends—not only for the children directly affected but also for us all in the form of more robust societies—that will drive future economies. Executive Summary xxxi References Alderman, H, J. R. Behrman, and C. Puett. 2016. Big Numbers about Small Children: Estimating the Economic Benefits of Addressing Undernutrition. World Bank Research Observer 31 (2) forthcoming 2016. Bhutta, Z. A, J. K. Das, A. Rizvi, M. F. Gaffey, N. Walker, S. Horton, P. Webb, A. Lartey, and R. E. Black. 2013. “Evidence-Based Interventions for Improvement of Maternal and Child Nutrition: What Can Be Done and at What Cost?” The Lancet 382 (9890): 452–77. Copenhagen Consensus Center. 2015. Smart Development Goals: The Post-2015 Consensus. http://www.copenhagenconsensus.com/sites/default/files/ outcomedocument_col.pdf Fink, G., E. Peet, G. Danaei, K. Andrews, D. C. McCoy, C. R. Sudfeld, M. C. Smith Fawzi, M. Ezzati, and W. W. Fawzi. 2016. “Schooling and Wage Income Losses Due to Early-Childhood Growth Faltering in Developing Countries: National, Regional, and Global Estimates.” The American Journal of Clinical Nutrition 104 (1): 104–12. 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, J., J. A. Maluccio, J. R. Behman, R. Flores, and R. 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Washington, DC: World Bank. http://www.world bank.org/en/publication/global-monitoring-report Executive Summary xxxiii Chapter 1 Reaching the Global Nutrition Targets: Stunting and Other Forms of Malnutrition Meera Shekar, Julia Dayton Eberwein, Anne Marie Provo, Michelle Mehta, and Lucy Sullivan Key Messages • In 2015, 159 million children globally were stunted in their physical and cognitive development, yielding poor learning outcomes and, eventually, premature death and disabil- ity with significant long-term economic consequences for future work forces in already constrained economies. • Low- and middle-income countries, mainly in Sub-Saharan Africa and South Asia, bear most of the burden of poor nutrition outcomes; stunting prevalence rates exceed 30 percent in these two regions, albeit some middle-income countries in other regions, such as China, Guatemala, Indo- nesia, and Mexico, also carry high burdens. • These losses are largely preventable with adequate invest- ments in proven interventions targeting the critical first 1,000 days of a child’s life, from the beginning of a woman’s pregnancy to her child’s second birthday. • Stunting and other forms of malnutrition can be a life sen- tence, but these must not be accepted as the “new normal.” Although political commitment is growing rapidly for investing in the 1,000-day window of opportunity, more is needed to move this agenda from a pet cause to a common Chapter 1  Reaching the Global Nutrition Targets 1 cause and from a political imperative to an economic imperative. • To galvanize action on these issues, in 2012 the World Health Assembly set the first-ever global targets for nutri- tion. These focus on six areas: stunting, anemia, exclusive breastfeeding, wasting, low birthweight, and overweight; the first four of these are the focus of this report. • This report adds to previous work in three ways: by provid- ing a more comprehensive estimate of financing needs, by linking financing needs to impacts, and by laying out a potential financing framework for four of the six global nutrition targets. • Given the right investments in “gray-matter infrastructure” at the right time, every child can achieve her or his full potential. The payoffs from these investments are durable, portable, and inalienable. An in-depth understanding of current nutrition investments, future needs, their impacts, and ways to mobilize the required financing is essential. Objectives of the Report This report aims to close remaining knowledge gaps related to the financing needs, impacts, and financing of nutrition interventions by: • estimating investments needed to achieve the global targets for reducing stunting in children under five, reducing anemia in women, increasing the prevalence of exclusive breastfeeding among infants; and mitigating the impacts of wasting among young children by estimating the financing needs to scale up treatment of severe wasting; • linking financing needs with potential for impact for the first time; and • proposing a financing framework for mobilizing the needed resources. 2 An Investment Framework for Nutrition Why Invest in Nutrition? With so many competing priorities, policy makers naturally ask why they should invest in nutrition. Current estimates suggest that all forms of malnutrition (undernutrition, micronutrient deficiencies, and overweight) cost the global economy an estimated $3.5 trillion per year, or $500 per individual, creating a major impediment for country governments in their efforts to reduce poverty and create thriving and productive communities (Global Panel 2016). Unlike investments in physical infrastructure, investments intended to reduce malnutrition (box 1.1) generate benefits that are durable, inalienable, and por- table. These investments also fuel progress on all of the 17 develop- ment goals enshrined in the Sustainable Development Goals (SDGs), including education and alleviating poverty. Why is this so? Ensuring optimum nutrition—particularly early in life—can permanently alter an individual’s development trajectory and maximize her or his pro- ductive potential. Globally, over 2 billion individuals are malnourished (IFPRI 2016). They include 159 million children who are stunted (low height-for- age), which affects not only their physical but also their cognitive development (UNICEF, WHO, and World Bank 2015). Each year, undernutrition accounts for about 45 percent of all child deaths worldwide (Black et al. 2013). Undernourished children who sur- vive often suffer serious cognitive delays (Grantham-McGregor et al. 2007), yielding poor learning outcomes and schooling deficits. Ulti- mately, the consequences of undernutrition are premature death and Box 1.1: What Is Malnutrition? The term malnutrition encompasses both undernutrition and overnutrition. Undernutrition is commonly measured by inade- quate height-for-age (stunting), by inadequate weight-for-height (wasting), or by deficiencies in micronutrients such as vitamin A, iodine, zinc, and iron. Overnutrition is often measured as exces- sive weight-for-height (overweight and obesity) using growth reference standards for children and body mass index measure- ments (weight-for-height squared, or kg/m2) for adults. Chapter 1  Reaching the Global Nutrition Targets 3 Figure 1.1: Investments in Nutrition Build Human Capital and Boost Shared Prosperity SCHOOLING EARNINGS POVERTY ECONOMY E rl nutrition E rl nutrition Childr n who R duction in pro r ms c n pro r ms c n sc p stuntin stuntin c n incr s school r is dult r 33% mor incr s GDP compl tion b w s b 5–50% lik l to sc p b 4–11% on r pov rt s dults in Asi nd Afric Data Sources: Hoddinott et al. 2011; Hoddinott et al. 2008, Horton and Steckel 2013, and Martorell et al. 2010. d ­ isability—along with the loss of creative and intellectual energy (Lye 2016). These outcomes are compounded by billions in economic losses due to excess health care spending and lower productivity. Thus investments in nutrition provide an opportunity not only to improve nutrition indicators, but also to contribute to achievement of other goals, such as increasing school completion, raising adult wages, help- ing children escape poverty, and increasing national gross domestic product (figure 1.1). Fortunately, these losses are largely preventable if adequate invest- ments in proven interventions are made, particularly those that focus on ensuring optimum nutrition in the critical 1,000 day window between the start of a woman’s pregnancy and her child’s second birthday (Black et al. 2008, 2013; World Bank 2006). Not only do these investments improve the nutritional status of a population for a life- time (see box 1.2), but they can also stimulate gains in the efficiency of health and education spending and trigger productivity gains that further accelerate economic growth. Stunting and other forms of malnutrition can be a life sentence; they must not be accepted as the “new normal.” Although political com- mitment is growing rapidly for investing in the 1,000-day window of opportunity, more is needed to move this agenda from a pet cause to a common cause, and from a political imperative to an economic impera- tive. Given the right investments in “gray-matter infrastructure” at the right time, every child can achieve her or his full potential. And the payoffs from these investments are durable, portable, and inalienable. 4 An Investment Framework for Nutrition Box 1.2: Gray Matter Infrastructure: Early Childhood Nutrition as a Determinant of Lifelong Cognitive Development “Just as a weak foundation compromises the quality and strength of a house, adverse experiences early in life can impair brain architecture, with negative effects lasting into adulthood” (Huebner et al. 2016). “Neural connections are made at a significant speed in a child’s early years, and the quality of these connections is affected by the child’s environment, including nutrition, interaction with caregivers and exposure to adversity, or toxic stress” (Huebner et al. 2016). Stunting (low height-for-age) is the leading population measure of chronic undernutrition and has been included as a key indicator under the SDGs (Target 2.2).1 Moreover, stunting is a remarkable proxy for exposure to a host of early life behavioral and environmental insults that limit children’s overall potential. Childhood stunting has life- long consequences not just for health but also for cognitive function, human capital, poverty, and equity; these early deficits reverberate across generations (Victora et al. 2010). Importantly, malnutrition often exists in an inter-generational cycle, and malnourished mothers are more than twice as likely to have stunted children as well-nourished mothers (Ozaltin, Hill, and Subramanian 2010).2 Widespread evidence from a range of settings and using diverse empirical approaches indi- cates that malnutrition leads to reductions in schooling and in learn- ing per year of school, ultimately resulting in lower earnings. Being stunted in early childhood is associated with a delayed start at school (Daniels and Adair 2004), reduced schooling attainment (Fink et al. 2016; Martorell et al. 2010), and substantially decreased adult wages 1 Stunting is defined among children under five years of age as being of a height that is more than two standard deviations below the median height for a child of the same age and sex (height-for-age Z-score <–2) according to the WHO Growth Standard (WHO 2009). The term malnourished mothers uses maternal short stature (<145 cm) as an indicator of maternal 2 malnutrition. Chapter 1  Reaching the Global Nutrition Targets 5 when measured at both the individual (Hoddinott et al. 2008) and country level (Fink et al. 2016). One study found that young children who were stunted were 33 percent less likely to escape poverty as adults (Hoddinott et al. 2011). These consequences add up to overall GDP losses of 4 to 11 percent in Africa and Asia (Horton and Steckel 2013) (figure 1.1). Thus the direct nutrition interventions that can miti- gate the burden of stunting are consistently identified as being among the most cost-effective development and global health actions (Horton and Hoddinott 2014). Wasting (low weight-for-height) occurs when children lose weight rapidly, generally from low caloric intakes and/or repeated infec- tions.3 Wasting is an indicator of acute undernutrition. It can result from ongoing food insecurity in resource-poor settings involving insufficient diets in terms of quantity, quality, and diversity; subop- timal breastfeeding; and recurrent episodes of illness—for example, diarrhea (WHO 2014b). At the same time, children living through humanitarian crises, such as famine and complex emergencies, are particularly vulnerable to acute malnutrition. Wasting and infection can create a vicious cycle, whereby acute malnutrition leads to lower immune function, which increases susceptibility to infections and subsequently results in decreased appetite, nutrient malabsorption, elevated metabolic requirements, and undernutrition (WHO 2014b). Consequently, wasted children have roughly twice the risk of mor- tality as stunted children (WHO 2014b), and severely wasted chil- dren have an 11-fold increase in mortality risk when compared with healthy children (McDonald et al. 2013). More details are provided in chapter 6. Micronutrient deficiencies (sometimes referred to as “hidden hun- ger”) affect nearly 2 billion people worldwide. Deficiencies of iodine, iron, vitamin A, zinc, and folic acid are those most commonly identi- fied in populations and have significant impacts on health and human capital. • Iodine deficiency is one of the main preventable causes of cogni- tive impairment among children. Maternal iodine deficiency, in particular, has grave consequences for fetal development and 3 Wasting is defined for children under five years of age as being of a weight that is more than two standard deviations below the median weight for a child of the same height and sex (weight-for- height Z-score <−2) according to the WHO Growth Standard (WHO 2009). 6 An Investment Framework for Nutrition child intelligence quotient (IQ). Children born to mothers who were iodine deficient during pregnancy experience, on average, a loss of 12.5 to 13.5 IQ points (Bleichrodt and Born 1994; Qian et al. 2005). Iodine-deficient children lose 13 IQ points on aver- age, making them less educable (World Bank 2006). • Iron deficiency is one of the most common direct epidemiologi- cal causes of anemia globally, albeit isolated infections (espe- cially helminthic infections) and repeated infections as a conse- quence of poor hygiene also have a key role to play in anemia, as do other factors. Given the multifactorial nature of anemia, research is underway to clarify what fraction of the problem can be addressed by nutrition interventions. Although anemia can affect anyone, children and women of reproductive age in low- and middle-income countries are at the greatest risk.4 Anemia is a major contributor to maternal and perinatal mortality as well as low birthweight among children. The morbidity associated with anemia in working-age adults can lead to lower work productiv- ity as a result of both impaired cognitive functioning and risk of infection. Furthermore, iron deficiency anemia has been associ- ated with developmental deficits and delayed brain maturation in children under age three (Walker et al. 2011). Supplementation for pregnant women with iron and folate has been linked with improvements in cognition of the offspring at seven to nine years (Christian et al. 2010). More details are provided in chapter 4. • Vitamin A deficiency in childhood is a leading risk factor for morbidity, including preventable pediatric blindness, and mortality in low-income countries. Vitamin A deficiency results from insufficient dietary consumption of vitamin A–rich foods (including animal flesh foods, liver, and green leafy vegetables) and is often exacerbated by illness (WHO 2010). Vitamin A deficiency increases the severity of measles and diarrheal and malaria infections in childhood. Conversely, vitamin A supple- mentation for children is linked to a 23 percent reduction in child mortality (Beaton et al. 1993). • Zinc plays a pivotal role in immune function and growth. Zinc deficiency is associated with increased incidence, severity, and 4 The current World Health Organization thresholds for mild, moderate, and severe anemia are 110–119, 80–109, and <80 grams of hemoglobin per liter for non-pregnant women and 100–109, 70–99 and <70 grams for pregnant women (WHO 2011). Chapter 1  Reaching the Global Nutrition Targets 7 duration of diarrhea and, as recent evidence demonstrates, has a negative effect on child growth (Imdad and Bhutta 2011). • Folic acid deficiency in mothers before or during pregnancy can lead to serious neural tube defects in their infants, resulting in cognitive and developmental delays. Folic acid supplementation reduces the risk of neural tube defects by over 70 percent (Bhutta et al. 2013). However, delivery mechanisms for supplementation have proven challenging, particularly for non-pregnant women of reproductive age. Exclusive breastfeeding (defined as the practice of giving an infant only breastmilk for the first six months of life, with no other food, other liquids, or even water) has many widely known benefits. How- ever, in reality, social, societal, and environmental factors make this practice challenging for millions of mothers globally. Near full scale- up of exclusive breastfeeding practices could prevent 823,000 annual deaths in children under five years (Victora et al. 2016). Non-breastfed children are nearly three to four times more likely to die of illnesses in the first six months, and there is overwhelming evidence of the positive effects of breastfeeding in preventing pneumonia and diar- rhea in young children (Victora et al. 2016). Recent evidence shows that breastfeeding is also associated with higher IQs (Horta, Loret de Mola, and Vitora 2015) and, in the longer term, with enhanced labor market and economic outcomes (Lutter 2016; Rollins et al. 2016). The existence of pro-breastfeeding policies and supportive environments to protect breastfeeding as the best source of nutrition for infants is far from universal, making promotion of exclusive breastfeeding an even greater challenge. More details are provided in chapter 5. Global Response Over time, malnutrition rates have not declined fast enough, mainly because of the lack of global action and investment in evidence-based solutions. However, global consensus regarding the essential role of nutrition in achieving sustainable development is growing (fig- ure 1.2). Supported by a solid and growing evidence base regarding what works to address malnutrition, key actors have gradually come to recognize the importance of investing in nutrition. In 2000, ending hunger in all its forms was included in the Millennium Development Goals. A seminal 2006 World Bank report, Repositioning Nutrition as Central to Development, further galvanized world leaders to recognize 8 An Investment Framework for Nutrition Figure 1.2: Key Global Responses on Nutrition World H lth Ass mbl ndors s Compr h nsiv Impl m nt tion Pl n on M t rn l, Inf nt, Th World B nk in nd Youn Child p rtn rship with Nutrition nd s t Rom th Bill & M lind of Glob l Nutrition D cl r tion on G t s Found tion, T r ts Nutrition nd USAID, nd th Fr m work for ov rnm nts of Nutrition for Action Sust in bl Mill nnium J p n nd C n d Growth summit r ffirms d v lopm nts D v lopm nt Go ls: K institution l D v lopm nt l unch th r is s $4 billion lob l Go l 2, T r t 2.2 Go ls includ “Sc lin Up for nutrition- commitm nt includ s r ductions ndin hun r in Nutrition” (SUN) sp cific to r ducin in stuntin , w stin , ll its forms mov m nt inv stm nts m lnutrition nd ov rw i ht Chapter 1  Reaching the Global Nutrition Targets 2000 2006 2008 2010 2012 2013 2014 2015 R positionin 1st L nc t S ri s on 2nd L nc t S ri s on Nutrition s C ntr l M t rn l nd Child M t rn l nd Child for D v lopm nt: A Und rnutrition: First Nutrition: Upd t of s min l r port lob l summ r of vid nc on ff ctiv lv ni in world vid nc on ff ctiv int rv ntions t r tin public tions l d rs to r co ni int rv ntions m t rn l nd child nutrition s critic l t r tin m t rn l m lnutrition; lso includ s K l m nt of th lob l nd child m lnutrition ov rw i ht nd ob sit d v lopm nt nd 9 nutrition as a critical element of the global development agenda. The 2008 Lancet Series on Maternal and Child Undernutrition builds on an earlier estimate of the impact of nutrition interventions on child mor- tality (Jones et al. 2003) and provides answers to what interventions could have the maximum impact. This was followed by Scaling-Up Nutrition: What Will It Cost?, which was the first-ever effort to estimate the financing needs of scaling up key nutrition interventions (Horton et al. 2010), and then another Lancet Series on Maternal and Child Nutrition in 2013 (Bhutta et al. 2013). Armed with improved knowledge and increased global commitment, the Scaling Up Nutrition (SUN) movement was launched jointly at the World Bank in 2010 with the Bill & Melinda Gates Foundation, USAID, and the governments of Japan and Canada. The political commitment raised by the SUN movement led to greater demand for investments in nutrition and a greater response from development partners and governments. In this same year, the 1,000 Days movement began, advocating for action and investment in nutrition for women and chil- dren in the critical days from conception until a child is two years old. As of 2016, the SUN network includes 57 client countries supported by over 100 partners from bilateral agencies, academia, and businesses as well as over 3,000 civil society organizations worldwide.5 The 2013 Nutrition for Growth event organized by the U.K. Depart- ment for International Development (DfID), the Children’s Invest- ment Fund Foundation (CIFF), and the Government of Brazil was another landmark. The event yielded commitments of over $4 billion, albeit only a small number of stakeholders report have reached or are on-course to reaching this commitment (IFPRI 2016). Building on this momentum, the International Coalition for Advocacy on Nutrition (ICAN) was formed to unite civil society organizations working to end malnutrition in all of its forms and advocate for the prioritization of investments and policies that save and improve lives through better nutrition. In April 2016, the United Nations General Assembly proclaimed a Decade of Action on Nutrition (2016–2025) to provide a unique oppor- tunity for all stakeholders to strengthen joint efforts toward ending all forms of malnutrition. Convened by the WHO and the Food and Agriculture Organization of the United Nations (FAO), the Decade of Action on Nutrition offers an opportunity for accountability for 5 For more information on the SUN movement, see http://scalingupnutrition.org/ 10 An Investment Framework for Nutrition country-driven, SMART commitments to advance the global nutri- tion agenda within the SDGs and framed by the Rome Declaration on Nutrition.6 A Nutrition for Growth media moment highlighting prog- ress since 2013 was held on the margins of the Rio Summer Olympics in August 2016 and a future pledging moment is anticipated in 2017. In August 2016, as part of the sixth Tokyo International Conference on African Development (TICAD-VI) in Nairobi, the Japan International Cooperation Agency (JICA) launched a new Initiative on Food and Nutrition Security in Africa (IFNA), with a plan to scale up nutrition- specific and nutrition-sensitive actions in 10 countries in Africa. The World Bank has been integrally engaged in many of these mile- stones, and momentum continues to build within the organization (box 1.3), which is catalyzing further action at national and global levels. In April 2016 and coinciding with the World Bank’s Spring Meetings, global nutrition leaders gathered in Washington DC to discuss the main findings from the analyses in this report on costing and financing and their implications for domestic and overseas aid. Another key landmark of the World Bank’s commitment to investing in nutrition is expected to be a summit on human capital with heads of state and ministers of finance during the 2016 Annual Meetings of the International Monetary Fund and the World Bank Group. The process of translating evidence into action and political and financial commitments through advocacy has taken time, but the current impe- tus is significant. Analytical Framework The analyses presented here are informed by the conceptual frame- work for nutrition (see figure 1.3), which illustrates the benefits during the life course as a result of nutrition-specific and nutrition- sensitive interventions, as well as the benefits of an enabling environ- ment. Nutrition-specific interventions are primarily delivered within the health sector and address the immediate determinants of child nutrition, such as breastfeeding, adequate food and nutrient intake, feeding and caregiving practices, and disease prevention and man- agement. Nutrition-sensitive interventions are delivered through other sectors—for example, agriculture, water and sanitation, education, or social protection—and address the underlying or basic influencers on childhood nutrition outcomes. The synergy between nutrition-specific 6 SMART: specific, measureable, achievable, relevant, and time-bound. Chapter 1  Reaching the Global Nutrition Targets 11 Box 1.3: Scaling Up World Bank Support to End Stunting: An Imperative for Developing Economies Over the last decade, the World Bank has been a major contribu- tor to the dialogue on scaling up actions to prevent stunting. More recently, this effort has been spearheaded by President Jim Yong Kim, as illustrated in these remarks: Economies are increasingly more dependent on digital and higher- level competencies and skills, and our investments in “grey matter infrastructure” are perhaps the most important ones we can make. In too many low- and middle-income countries, children are dis- advantaged before they even set foot in school because they did not have adequate early nutrition and stimulation, or were exposed to toxic environments. Childhood stunting rates of 45 percent—and as high as 70 percent in some countries—are a stain on our collective conscience. This is a turnaround from the early- to mid-2000s, when sup- port for the nutrition agenda had waned significantly both at the country level and among development partners. In 2002–04, the World Bank’s support for nutrition was at a low, with minimal staffing, very little analysis of what works, low institutional and senior management commitment, and minimal investments. This changed dramatically with the publication of the seminal report Repositioning Nutrition as Central to Development (World Bank 2006), which brought attention to the issue—not just within the World Bank, but also among key partners and governments. Within the institution, this new attention led to a rapid and significant scale-up of staffing for nutrition financed through a special contingency fund in 2007–08. The follow-on 2010 World Bank publication Scaling Up Nutrition: What Will It Cost? provided the world with the first estimates of global nutrition costs, and the SUNa movement launched in 2010 rallied partners around the cause. Simultaneously, the World Bank’s commitment to investing in the early years (early life nutrition, early learning and stimula- tion, and nurturing care and protection from stress to support these agendas) is growing exponentially, in scope, scale, and 12 An Investment Framework for Nutrition Box 1.3: Scaling Up World Bank Support to End Stunting: An Imperative for Developing Economies (cont.) coverage, led by the World Bank Group’s twin goals of reducing poverty and boosting shared prosperity. Investments in reducing stunting as well as early childhood stimulation and learning are now center stage on the corporate agenda, not just in the health sector, but across several sectors, including education, water and sanitation, social protection, and agriculture. In addition to Inter- national Development Association (IDA) and International Bank for Reconstruction and Development (IBRD) resources, new resources are also becoming available to support this agenda at both global and national levels—from partners such as the Bill & Melinda Gates Foundation, the Children’s Investment Fund Foundation, the Dangote Foundation, Tata Trusts, the Power of Nutrition,b and the Global Financing Facility in support of Every Woman Every Child.c These and many other partners, including civil society organizations, are rallying around to catalyze and reinforce the achievement of results in support of the Sustainable Development Goals. Notes a. For more information on the SUN movement, see http:// www.scalingupnutrition.org b. For more information on the Power of Nutrition, see http:// www.powerofnutrition.org/ c. For more information on the Global Financing Facility in sup- port of Every Woman Every Child, see http://www .worldbank.org/en/topic/health/brief/global-financing- facility-in-support-of-every-woman-every-child interventions and interventions in other sectors is critical to break- ing the cycle of malnutrition and sustaining the gains from direct nutrition-specific interventions (World Bank 2013). This report focuses on costing, financing, and estimating the impact of nutrition-specific interventions with sufficient evidence of benefit for reaching the World Health Assembly global nutrition targets for stunting, anemia, and breastfeeding, and interventions for treating wasting. Chapter 1  Reaching the Global Nutrition Targets 13 Figure 1.3: A Framework for Achieving Optimum Nutrition 14 B n fits durin th lif cours Adult st tur Morbidit nd Co nitiv , motor, School p rform nc Work c p cit mort lit in childhood socio motion l d v lopm nt nd l rnin c p cit Ob sit nd NCDs nd productivit Nutrition sp cific Optimum f t l nd child nutrition nd d v lopm nt Nutrition s nsitiv int rv ntions nd pro r mm s nd ppro ch s pro r mm s • A ricultur nd • Adol sc nt h lth food s curit Br stf din , F din nd Low burd n of nd pr conc ption • Soci l s f t n ts nutri nt-rich foods, c r ivin pr ctic s, inf ctious dis s s nutrition • E rl child d v lopm nt nd tin routin p r ntin , stimul tion • M t rn l di t r • M t rn l m nt l h lth suppl m nt tion • Wom n's mpow rm nt • Micronutri nt suppl m nt tion or Food s curit , F din nd c r ivin Acc ss to nd us of • Child prot ction fortific tion includin v il bilit , r sourc s (m t rn l, h lth s rvic s, • Cl ssroom duc tion • Br stf din nd conomic cc ss, hous hold, nd s f nd h i nic • W t r nd s nit tion compl m nt r nd us of food communit l v ls) nvironm nt • H lth nd f mil f din pl nnin s rvic s • Di t r suppl m nt tion Buildin n n blin for childr n Knowl d nd vid nc nvironm nt • Di t r Politics nd ov rn nc • Ri orous v lu tions div rsific tion L d rship, c p cit , nd fin nci l r sourc s • Advoc c str t i s • F din b h viours Soci l, conomic, politic l, nd nvironm nt l cont xt (n tion l nd lob l) • Hori ont l nd v rtic l nd stimul tion coordin tion • Tr tm nt of s v r • Account bilit , inc ntiv s cut m lnutrition r ul tion, l isl tion • Dis s pr v ntion • L d rship pro r mm s nd m n m nt • C p cit inv stm nts • Nutrition int rv ntions in • Dom stic r sourc m r nci s mobilis tion An Investment Framework for Nutrition Source: Black et al. 2013, p. 16, © Elsevier. Reproduced with permission from Elsevier; further permission required for reuse. Measuring Progress Lessons from the Millennium Development Goal era demonstrate that clear, ambitious targets can ignite countries to action. In 2012— in an effort to rally the international community around improving nutrition—the 176 members of the World Health Assembly endorsed ­ a Comprehensive Implementation Plan on Maternal, Infant, and Young Child Nutrition (WHO 2014a). The plan includes the first-ever global nutrition targets, focusing on six areas: stunting, exclusive breastfeed- ing, wasting, anemia, low birthweight, and overweight (table 1.1). The World Health Assembly targets aim to boost investment in cost-effective interventions and catalyze progress toward decreasing malnutrition and micronutrient deficiencies. Although targets are set at the global level, member states were urged to develop national targets to facilitate a harmonized approach to measure progress toward the goals, provide accountability for actions, and develop or modify policies to achieve the goals. To help countries set targets and monitor their progress, the WHO has developed a tracking tool that allows users to explore scenarios that take into account different rates of progress (WHO 2015).7 To sustain momentum, world leaders enshrined some of the World Health Assembly targets within the sec- ond SDG, committing to end malnutrition in all its forms by the year 2030. Indicators related to stunting, wasting, and child overweight are included in the SDG framework under Target 2.2 (IAEG-SDG 2016). Although many of these indicators are improving over time, a 7 The tracker is available online at http://www.who.int/nutrition/trackingtool/en/ Table 1.1: Six World Health Assembly Global Targets for Nutrition Nutrition target 2025 global target 1. Stunting 40% reduction in the number of children under five who are stunted 2. Anemia in women 50% reduction of anemia in women of reproductive age 3. Low birthweighta 30% reduction of low birth weight 4. Overweighta No increase in childhood overweight Increase the rate of exclusive breastfeeding in the first six months up 5. Exclusive breastfeeding to at least 50% 6. Wasting Reduce and maintain childhood wasting to less than 5% Source: WHO 2012. Note: a. It was not possible to estimate financing needs to reach the low birthweight and overweight targets because of insufficient evidence on the interventions that will reduce these conditions. Chapter 1  Reaching the Global Nutrition Targets 15 continuation of current trends would not allow the world to achieve the targets. For example, based on current global trends, approxi- mately 127 million children under five will be stunted by 2025; the World Health Assembly goal is to decrease this number to no more than 100 million by 2025 (WHO 2014c). Building on Previous Estimates of Financing Needs to Scale Up Nutrition A broad package of reproductive, maternal, newborn, and child health interventions were costed by Stenberg et al. (2014), which included some related nutrition interventions. However, that analysis did not establish links with the World Health Assembly targets—nor did it include the full package of nutrition interventions. Two previous stud- ies have estimated the global cost of scaling up nutrition interventions (Bhutta et al. 2013; Horton et al. 2010). The 2010 World Bank report Scaling Up Nutrition was the first systematic attempt to estimate the resources needed to scale up nutrition interventions on a global level. It focuses on estimating the financing needs (not impact) of scaling up 13 proven interventions, based in part on the findings of the 2008 Lancet Series on Maternal and Child Undernutrition (Bhutta et al. 2008). Financing needs were estimated using the program experience approach, and the report estimates the additional financing needs to scale up the set of interventions to be $10.3 billion per year. In the 2013 Lancet Series on Maternal and Child Nutrition, Bhutta et al. revisited the evidence of intervention effectiveness and estimated the financ- ing needs of a global scale-up of interventions to address all forms of malnutrition to be about $9.6 billion per year. Similar to Scaling Up Nutrition, this estimate assumed a one-year scale up but, unlike Scaling Up Nutrition, it based financing needs on an ingredients-based approach grounded on the WHO OneHealth Tool (Bhutta et al. 2013). In addition to these global studies, several country-level costing and financing studies have contributed to the knowledge base, especially in gaining a better understanding of unit costs for nutrition interven- tions and in developing the methods to estimate financing needs, impacts, and benefits (IFPRI 2016; Shekar et al. 2014; Shekar, Dayton Eberwein, and Kakietek 2016; Shekar, Mattern, Eozenou et al. 2015; Shekar, Mattern, Laviolette et al. 2015). Those studies estimated the costs of a comprehensive package of evidence-based interventions affecting different aspects of child 16 An Investment Framework for Nutrition undernutrition but did not provide estimates of the financing needs required to reach the global targets. No previous or planned study has systematically linked global financing needs with potential for impact, or assessed the shortfall between what is required and what is currently being spent to address the World Health Assembly global targets. Finally, no prior study has presented a comprehensive global analysis of donor and national government investments, or what financing scenarios may be needed to close these gaps. The current report adds to the previous work in three unique ways: by providing a more comprehensive estimate of financing needs, by link- ing financing needs to impacts, and by laying out a potential financing framework (table 1.2). An in-depth understanding of current nutrition investments, future needs and their impact, and ways to mobilize the required funds is needed to move the agenda from political commit- ment to policy imperative. It should be noted that the estimates from these analyses are lower than the previous two because it includes a smaller set of interventions than previous estimates (that is, it Table 1.2: Studies That Estimate Global Financing Needs for Scaling Up Nutrition Interventions Lancet Series on Maternal Scaling Up Nutrition Investing in Nutrition and Child Nutrition (Horton et al. 2010) (this analysis) (Bhutta et al. 2013) • Focus is on estimating • Focus is on estimating • Focus is on financing needs financing needs, not impacts financing needs and some and impacts of four out of • Includes interventions impact estimations for six Global Nutrition Targets to address all forms of stunting (stunting, anemia, exclusive undernutrition • Includes interventions breastfeeding, wasting) and to address all forms of financing estimates • Assumes going from current coverage to 90% in 1 year malnutrition • More realistic scale-up: • Assumes going from current increasing current coverage • Program experience to 90% over 10 years financing needs coverage to 90% in 1 year • Ingredients-based financing • Declines in stunting over • Additional cost to scale-up time are modeled rather than estimated to be $10.3 billion/ needs assumed year • Additional cost to scale-up estimated to be $9.6 billion/ • Program experience year financing needs • Additional costs to scale-up estimated to be $49.5 billion over 10 years for stunting alone and $69.9 billion for all four targets • Several financing options included Chapter 1  Reaching the Global Nutrition Targets 17 excludes oral rehydration solution with therapeutic zinc and calcium supplements). This report also uses updated unit costs, which may be lower than the ones used in the previous analyses. Consultative Process: The Technical Advisory Group These analyses were guided by the expert advice of a Technical Advisory Group (TAG). This group comprised nutrition experts from around the world, representing country ministries of health, other implementing agencies, academia, and the donor community (see appendix A for a list of the TAG members). The TAG met on four occa- sions to provide feedback on issues such as the selection of interven- tions, methodology, and data sources, and for validating assumptions made in the models. Their contribution culminated in a one-day in- person meeting to review the final methods and interpret the results (see appendix A for a list of participants). The Scope of This Report Two of the global nutrition targets—those for low birthweight and for child overweight—are not included in the analyses because there are insufficient data, either on the prevalence of the condition (low birth- weight) or consensus on effective interventions to reach the goal (child overweight) is lacking. Financing needs are estimated for scaling up interventions to treat severe wasting, but it was not possible to esti- mate the financing needs of achieving the wasting target because of a lack of evidence about which interventions are effective in preventing wasting. For the remaining three targets, the analyses focus on cost- ing a package of primarily preventive nutrition-specific interventions, which have proven to be efficacious in averting stunting and anemia, enhancing breastfeeding, and reducing child mortality. Further, the analyses were limited to low- and middle-income coun- tries because this is where the undernutrition problem is concentrated. In addition, high-income countries can finance their own efforts, and the financing needs and targeting strategies in these countries are likely to be different from those in low- and middle-income countries. 18 An Investment Framework for Nutrition The remainder of this report is structured as follows: Chapter 2 describes the analytical framework for the costs, impacts, and benefit- cost analyses. Chapters 3, 4, 5, and 6 present the financing needs and impacts for reaching targets for stunting, anemia in women, and breastfeeding for infants, and for treating wasting, respectively. Chap- ter 7 reports on the total financing needs and benefits of scaling up to meet all targets, taking into account the fact that some interventions overlap across targets. Chapter 8 presents scenarios for scaling up financing to reach the targets by 2025. Chapter 9 discusses the findings and sets forth policy and programmatic action items for the future, including areas for future research. 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Victora. 2016. “Why Invest, and What It Will Take to Improve Breastfeeding Practices?” The Lancet 387 (10017): 491–504. Shekar, M., J. Dayton Eberwein, and J. Kakietek. 2016. “The Costs of Stunting in South Asia and the Benefits of Public Investments in Nutrition.” Maternal and Child Nutrition 12 (Supl 1): 186–95. Shekar, M., M. Mattern, P. Eozenou, J. Dayton Eberwein, J. K. Akuoku, E. Di Gropello and W. Karamba. 2015. “Scaling Up Nutrition for a More Resilient Mali: Nutrition Diagnostics and Costed Plan for Scaling Up.” Health, Nutri- tion and Population (HNP) Discussion Paper. Washington, DC: The World Bank Group. Shekar, M., M. Mattern, L. Laviolette, J. Dayton Eberwein, W. Karamba, and J. K. Akuoku. 2015. “Scaling Up Nutrition in the DRC: What Will It Cost?” Health, Nutrition and Population (HNP) Discussion Paper. Washington, DC: The World Bank Group. Shekar, M., C. McDonald, A. Subandoro, J. Dayton Eberwein, M. Mattern and J. K. Akuoku. 2014. “Costed Plan for Scaling Up Nutrition: Nigeria.” Health, Nutrition and Population (HNP) Discussion Paper. Washington, DC: The World Bank Group. Stenberg, K., H. Axelson, P. Sheehan, I. Anderson, A. M. Gülmezoglu, et al. 2014. “Advancing Social and Economic Development by Investing in Wom- en’s and Children’s Health: A New Global Investment Framework.” The Lancet 383 (9925): 1333–54. UNICEF, WHO, and World Bank (United Nations Children’s Fund, World Health Organization, and World Bank). 2015. Joint Child Malnutrition Estimates. Global Database on Child Growth and Malnutrition. http://www.who.int/ nutgrowthdb/estimates2014/en/ (accessed October 2015). Victora, C., R. Bahl, A. Barros, G. V. A. França, S. Horton, J. Krasevec, S. Murch, M. J. Sankar, N. Walker, and N. C. Rollins. 2016. “Breastfeeding in the 21st Century: Epidemiology, Mechanisms and Lifelong Effect.” The Lancet 387 (10017): 475–90. Victora, C. G., M. de Onis, P. C. Hallal, M. Blössner, and R. 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Repositioning Nutrition as Central to Development: A Strategy for Large-Scale Action. Washington, DC: World Bank. ———. 2013. Improving Nutrition through Multisectoral Approaches. Washington, DC: World Bank. Chapter 1  Reaching the Global Nutrition Targets 23 © R. M. Nunes Chapter 2 Overview of Methods Jakub Kakietek, Julia Dayton Eberwein, Dylan Walters, and Meera Shekar Key Messages • The total 10-year costs for scaling up key interventions are estimated for reaching the targets to reduce stunting among children and anemia in women, increase exclusive breast- feeding rates for infants, and mitigate the impact of wasting among children. • For each of these four targets, the analyses cover the highest-burden countries; the results are extrapolated to all low- and middle-income countries. • Data and methods derived from country-level costing are used to inform the analyses and determine the set of evidence-based interventions needed to meet each target. • The impact of the additional investments on the prevalence of stunting, anemia in women, and rates of exclusive breast- feeding is estimated, along with the additional impacts on child mortality. • Cost-benefit analyses are performed for each target indi- vidually, translating the results into benefits in terms of potential earnings gained over adult working life. Chapter 2  Overview of Methods 25 T his chapter describes the general methodological approach used in estimating the costs and impacts of achieving the four World Health Assembly targets: stunting, anemia in women, and exclusive breastfeeding for infants, and mitigating the impact of wasting among young children. The methods for estimating benefit- cost ratios are also described. Target-specific methodological consid- erations are discussed in chapters 3 through 6. The methods used to estimate current and future financing scenarios are described sepa- rately in chapter 8. Country Sample Selection Although the nutritional status of women and children is a public health concern in many high-income countries, this report focuses on estimating the costs and impacts of achieving the World Health Assembly targets in low- and middle-income countries only, because this is where the burden is greatest. Concentrating on low- and ­ middle-income countries allows for greater confidence in the esti- mates because information on cost, coverage, and service delivery modality in high-income countries are either not comparable or not readily accessible. Furthermore, the estimates generated here are intended to inform policy makers in low- and middle-income country governments that are considering investing in nutrition as well as offi- cial development assistance partners and philanthropic foundations that are developing investment strategies. A sample of high-burden low- and middle-income countries is identi- fied for each of the four targets. Figure 2.1 shows the proportion of the burden of stunting captured by a given number of countries. The figure indicates that 37 countries account for 85 percent of the global burden of stunting. Based on this assessment, a decision was made to systematically cut off the number of countries in the sample to a man- ageable number for the purpose of these analyses. Thus 37 countries are included for stunting, 26 for anemia, 27 for breastfeeding, and 24 for wasting (table 2.1). This approach allows global estimates to be developed more efficiently given the level of effort required to obtain, often scant, information on cost estimations and impacts. Each sample includes the 20 countries with the highest burden of a given aspect of malnutrition (that is, the highest number of stunted children, of women of reproductive age suffering from anemia, of 26 An Investment Framework for Nutrition Figure 2.1: Incremental Percentage of the Global Burden of Stunting and the Number of Additional Countries Included in the Analyses 100 90 80 70 60 P rc nt 50 40 Numb r of countri s includ d in th s mpl 30 20 10 0 1 11 21 31 41 51 61 71 81 91 101 111 121 Numb r of countri s includ d in th n l s s Data Source: IFPRI 2014. Table 2.1: Number of Sample Countries, Percentage of Burden, and Multiplier Used to Extrapolate to All Low- and Middle-Income Countries Percentage of the Number of Multiplier used to extrapolate the cost global burden Target countries in to estimate financing needs for all captured in the the sample low- and middle-income countries sample Stunting 37 84.0 1.19 Anemia 26 82.2 1.22 Breastfeeding 27 78.1 1.28 Wasting 24 82.9 1.21 children under six months of age who were not exclusively breast- fed, and of children under five years of age suffering from wasting). In addition, all countries with malnutrition burdens above a specific prevalence threshold are added to the respective sample of coun- tries (see table 2.2 for threshold levels). This strategy for selecting the sample ensures that both large and small countries with high burdens of stunting are represented. Table 2.1 lists the number of countries in each sample, the percentage of burden captured in the sample, and the multiplier used to extrapo- late the sample cost to all low- and middle-income countries. Natu- rally there is overlap in country selection across target interventions. Chapter 2  Overview of Methods 27 Table 2.2: Countries Included in the Estimates of the Four Targetsa Global nutrition target (number of 20 countries with Additional countries with countries in the highest absolute burden highest/lowest prevalenceb sample) Bangladesh, China, Democratic Benin, Burundi, Cambodia, Republic of Congo, Egypt, Ethiopia, Central African Republic, Eritrea, Stunting India, Indonesia, Kenya, Madagascar, Guatemala, Lao PDR, Liberia, (37 countries) Mexico, Mozambique, Myanmar, Nigeria, Malawi, Nepal, Niger, Papua New Pakistan, Philippines, Sudan, Tanzania, Guinea, Rwanda, Sierra Leone, Uganda, Vietnam, Yemen Somalia, Timor-Leste, Zambia Bangladesh, Brazil, China, Democratic Republic of Congo, Egypt, Ethiopia, India, Indonesia, Islamic Republic Anemia in women Republic of Congo, Gabon, Ghana, of Iran, Mexico, Myanmar, Nigeria, (26 countries) Mali, Senegal, Togo Pakistan, Philippines, South Africa, Tanzania, Thailand, Turkey, Uzbekistan, Vietnam Algeria, Bangladesh, Brazil, China, Côte d’Ivoire, Democratic Republic of Congo, Exclusive Chad, Djibouti, Dominican Egypt, Ethiopia, Iraq, India, Indonesia, breastfeeding Republic, Gabon, Somalia, Mexico, Myanmar, Nigeria, Pakistan, (27 countries) Suriname, Tunisia Philippines, Tanzania, Turkey, Vietnam, Yemen Afghanistan, Bangladesh, China, Democratic Republic of Congo, Egypt, Wasting (24 Ethiopia, India, Indonesia, Iraq, Mali, Chad, Djibouti, Eritrea, Timor- countries) Myanmar, Niger, Nigeria, Pakistan, Leste Philippines, South Sudan, Sri Lanka, Sudan, Vietnam, Yemen Note: a. The prevalence rates in this table are based on the most recent survey available on the date of access (February 1, 2015) from UNICEF, WHO, and World Bank 2014. b. For the stunting target, sample countries have a greater than 40 percent prevalence of stunting. For anemia in women, sample countries have a greater than 50 percent preva- lence of anemia. For breastfeeding, sample countries have a less than 10 percent rate of exclusive breastfeeding. For wasting, sample countries have a greater than 15 percent prevalence of wasting. Twelve countries are included in all four samples, 3 are included in three samples, and 12 are included in two. For the stunting target, estimates of financing needs are based on a sample of 37 countries. This includes 20 countries with the high- est absolute burden (the highest number of stunted children) and an additional 17 countries with the highest stunting prevalence (a prevalence exceeding 40 percent, which is the WHO threshold for a “very high” stunting prevalence). These countries account for 84.3 percent of the global stunting burden. The sample for the anemia 28 An Investment Framework for Nutrition target consists of 26 countries (20 countries with the highest abso- lute burden and 6 countries with anemia prevalence higher than 50 percent) and accounts for 82.8 percent of the burden of anemia in women of reproductive age. The breastfeeding target sample consists of 27 countries (20 with the highest absolute burden and 7 countries with exclusive breastfeeding prevalence lower than 10 percent), which together account for 78.1 percent of the burden of non-exclusively breastfed children (0 to 5 months). The wasting target sample consists of 24 countries (20 countries with the highest absolute burden and 4 countries with wasting prevalence higher than 15 percent), together accounting for 82.9 percent of the burden of wasted children. The list of countries included in each sample for each target is shown in table 2.2. Financing needs and impacts are estimated and modeled for each country. For each target, the results from the sample are then extrapo- lated to all low- and middle-income countries. It is assumed that the financing needs for countries outside the sample are proportional to their burden of malnutrition. For example, for the stunting target, the countries in the sample account for 84 percent of the burden of stunt- ing in all low- and middle-income countries. Therefore it is assumed that they also account for 84 percent of the total costs. Consequently, the total cost is calculated for low- and middle-income countries by multiplying the sample cost by 1/0.84 or 1.19. This is clearly a simpli- fication but it is consistent with the approach used in previous global nutrition costing studies (see Horton et al. 2010). Financing needs are analyzed along two dimensions. The first is geo- graphic. All low- and middle-income countries are grouped accord- ing to World Bank regions: Sub-Saharan Africa, Europe and Central Asia, East Asia and Pacific, Latin America and the Caribbean, Middle East and North Africa, and South Asia.1 This geographic classification serves as a proxy for unobserved factors that may potentially affect the cost of delivering nutrition interventions (for example, develop- ment, infrastructure, and structural constraints). A classification based on geography is intuitive and has been used in the past in studies assessing the cost of implementation of nutrition interventions (Bhutta et al. 2008; Bhutta et al. 2013; Horton et al. 2010). Country income com- prises the second dimension for analyzing financing needs because wealth has been shown to be one of the key predictors of the cost 1 For a list of countries in each region, see https://datahelpdesk.worldbank.org/knowledgebase/ articles/906519 Chapter 2  Overview of Methods 29 of health service provision (Edejer et al. 2003). Variation in country wealth is examined using the World Bank country income groups: low-income, lower-middle-income, and upper-middle-income.2 Evidence-Based Interventions and Delivery Platforms Two key principles guided the selection of interventions: (1) a strong evidence base must exist for effectiveness in reducing stunting in chil- dren under five years of age, reducing anemia in women of reproduc- tive age, increasing exclusive breastfeeding, and reducing wasting;3 and (2) the interventions must be relevant for a substantial portion of low- and middle-income countries or, as is the case with intermittent presumptive treatment of malaria in pregnancy, applicable across a specific region as a result of a high prevalence of malaria. High-impact interventions are identified based on the 2013 Lancet Series on Maternal and Child Nutrition and the 2016 Lancet Series on Breastfeeding. For stunting, wasting, and anemia, literature reviews were conducted to identify any additional evidence reviews and meta-analyses published after the publication of the Lancet series. The literature reviews do not identify any additional interventions that should be included in the study. This report focuses on nutrition-specific interventions primarily because the evidence base for the impact of nutrition-sensitive inter- ventions on stunting, anemia, breastfeeding, and wasting remains limited (Ruel et al. 2013), and therefore it is not feasible to cost these interventions, nor to fully assess their impact on the global targets. For some targets, the analyses incorporate the potential impact of ­ nutrition-sensitive interventions for which there is evidence, but does not cost those since it is not possible to apportion a part of the cost to the nutrition outcomes specifically. For example, in the case of the water, sanitation and hygiene (WASH) interventions, even though the costs are known (Hutton 2015), because they include large infrastruc- ture costs it is not possible to determine what portion of these costs 2 For a list of countries included in each World Bank income group, see https://datahelpdesk .worldbank.org/knowledgebase/articles/906519 3 To effectively reach targets for stunting, anemia, and breastfeeding, selected interventions are all preventive. However, with the limited research on preventing wasting, only treatment interventions are selected for mitigating wasting. 30 An Investment Framework for Nutrition apply to their impact on stunting reduction. With the exception of the treatment of severe wasting, the analyses focus primarily on preven- tive interventions. Chapters 3 through 6 provide additional method- ological details for each target. Estimating Unit Costs Based on Program Experience The unit costs are estimated using the program experience approach where data were collected on the actual financing needs of programs, as in Horton et al. (2010) (table 2.3).4 Unit cost data were obtained from peer-reviewed publications, gray literature, and costed national nutrition plans as well as primary data collected by the World Bank as part of a series of country-level costing studies from Sub-Saharan Africa (Shekar et al. 2014; Shekar, Dayton Eberwein, and Kakietek 2016; Shekar, Mattern, Eozenou, et al. 2015; Shekar, Mattern, Lavio- lette, et al. 2015). If no unit cost data are available for a given interven- tion in a given country, the mean unit cost for other countries in that region is used. If there are no unit cost data for any country in a given region, the unit costs are approximated by using the average from other regions and applying regional adjustment factors from Horton et al. (2010), if appropriate. Table 2.3: Process for Estimating Unit Costs and Dealing with Missing Unit Cost Data Step Description • Select most recent unit costs Step 1: Within country • If a range is reported, the average of the reported range is used • Extrapolate unit cost data for countries where the data are Step 2: Within region missing based on other countries in the same region for which data are available • If data are missing for all countries in a region, extrapolate a regional unit cost estimate based on application of regional unit Step 3: Across regions cost multiplier • Use the estimate as the approximate unit cost for all countries in that region 4 The other main method for estimating unit costs is the ingredients approach, which constructs the cost of an ideal service delivery model based on the cost of required inputs. See Bhutta et al. 2013. Chapter 2  Overview of Methods 31 Assumptions about the Pace of Scale-Up The analyses assume program coverage of each intervention increases at a constant rate over five years from current coverage rates in 2016 to 100 percent coverage rates in 2021, followed by a subsequent five- year maintenance phase with steady 100 percent program coverage between 2021 and 2025. This scale-up scenario is used to allow for the full accrual of the benefits of the interventions affecting stunt- ing, which are delivered during the first five years of a child’s life. In particular, full program coverage needs to be maintained for five years in order for the cohort of newborns to five-year-olds to fully accrue its benefits. Furthermore, the Lives Saved Tool (LiST)—the tool used to model the impact of the interventions—is a cohort model in which the likelihood of stunting depends on interventions, risk fac- tors, and whether or not the child was stunted in the previous year. Because LiST is a cohort model, in a given year, a child benefits from all interventions received in this year (direct impact of interventions) as well as interventions received in all previous years (indirect impact of interventions through reduced risk of stunting in previous years). Therefore, once all interventions are scaled up to maximum coverage, it will take five years for the cohort of newborns to accrue full benefits of the interventions. This same pace of scale-up is used for the anemia and exclusive breastfeeding targets for two primary reasons. First, some of the interventions included in the stunting target are also included in the package of interventions needed to reach other targets (for example, counseling for mothers and caregivers on good infant and young child nutrition and hygiene practices for the exclusive breastfeeding target and antenatal micronutrient supplementation and intermittent presumptive treatment of malaria in pregnancy in malaria-endemic regions for the anemia target). Second, using the same assumptions about scale-up allows for easier aggregation and calculation of financ- ing needs for a comprehensive intervention package (see chapter 7). However, because there is no overlap of interventions between stunt- ing and the treatment of wasting, a linear scale-up from 2016 through 2025 is assumed for the treatment of severe wasting, as discussed in chapter 6. To account for potential increases in marginal costs as program cover- age approaches 100 percent (for example, more financing is required 32 An Investment Framework for Nutrition to access the hardest-to-reach groups), the approach adopted in Horton et al. (2010) is followed: the costs of 100 percent coverage are calculated, although the impact assessments assume that only 90 per- cent of the beneficiaries are reached for all interventions. Estimating Total Financing Needs for Each Target For each intervention in each country in each sample, the additional financing needs to scale up program coverage from the current level to 100 percent are estimated: FNy = UC p ICy p Popy where: FNy is the annual financing need for a given intervention in year y, UC is the unit cost, ICy is the incremental coverage assumed for year y, and Popy is the target population in year y. The total financing needs per intervention over the 10-year period is the sum of the annual financing needs. Total financing needs per country is the sum of the 10-year financing needs of all interven- tions for a given target. The total financing needs for the sample for each target are calculated by summing the country-level total 10-year financing needs. To take into account the program costs, an additional 9 percent of the estimate was added for capacity development, 2 per- cent for monitoring and evaluation, and 1 percent for policy develop- ment on top of the total direct financing needs. This assumption about the size of program costs follows the methodology used in Horton et al. (2010). However, making this blanket assumption is recognized as a limitation and an area where better data are needed. To determine total financing needs, a multiplier equal to the inverse of the percentage of the target’s burden contained in each target’s coun- try sample was applied to extrapolate the sample estimates to cover all low- and middle-income countries (see table 2.1). Chapter 2  Overview of Methods 33 Estimating Impacts The impact analyses are based on LiST (LiST 2015) estimations. LiST is an epidemiological model for maternal and child health that allows users to estimate the impact of expanding the coverage of maternal and child health and nutrition interventions on mortality, morbidity, and the nutritional status of children under age five. LiST is used to model the impact of the interventions on stunting prevalence and on mortality in children under age five. LiST does not include interven- tions targeting non-pregnant women of reproductive age. It also does not model the impact of any of the interventions on that target group. Therefore a separate model was developed (using Microsoft Excel) to estimate the impact of anemia prevention interventions on the preva- lence of anemia in women. LiST is used to model mortality impacts for each intervention in each country in the samples. The country-specific results are then combined to obtain a population-weighted reduction in overall prevalence. The same relative prevalence change in low- and middle-income coun- tries is assumed for all countries to which the results are extrapolated. The global reductions in prevalence of stunting and anemia, and the increase in exclusive breastfeeding rates, are estimated by applying these relative reductions in the sample to the 2015 baselines in all low- and middle-income countries (data from UNICEF, WHO, and World Bank 2015). For mortality reductions, the same multipliers that are used to extrapolate the financing needs are also used to estimate reductions in mortality for all low- and middle-income countries (see table 2.1). Benefit-Cost Analyses A benefit-cost analysis is an economic evaluation tool commonly used by policy makers, industry, and researchers to assess the monetary value of benefits of interventions relative to their costs. The benefit- cost ratios are computed in these analyses for all four targets. For each target, maternal and child mortality averted are translated into expected earnings gains over adult working lives, up to age 65 or average country life expectancy at birth (whichever is lower). Similarly, the impact results (number of cases of stunting averted and additional children exclusively breastfed) are also translated into benefits in terms of expected earnings gained over adult working life 34 An Investment Framework for Nutrition via improvements in cognitive development. Estimations of expected increases in income as a result of the prevention of stunting are based on Hoddinott et al. (2013) and those as a result of increases in income are from Rollins et al. (2016). Reductions in anemia in women, are translated into earnings gained via increased productivity within the years the intervention was received, based on methods employed in Horton and Ross (2003). Specific assumptions about these benefits are explained in chapters 3 through 6. Beneficiary earnings projections are based on GDP per capita; labor share of income; and, for anemia, the percent share of all work that is manual labor. In an effort to keep the estimates conservative, a 3 per- cent per year GDP growth rate is assumed for all low- and middle- income countries, even though the average annual GDP growth rate for the countries in this sample has been approximately 5 percent over the past decade (World Bank 2016).5 It is assumed that a maximum of 90 percent of earnings gains could be realized (Hoddinott et al. 2013) and that labor wages are responsible for 52 percent of gross national income (Lübker 2007). Discounting is needed in this analysis since there may be up to a 65 year gap between incurring costs and yielding some of the ben- efits of investments in nutrition. However, the appropriate discount rate to use continues to be a topic of debate. Guidelines from WHO- CHOICE (Edejer et al. 2003) and, more recently, the Bill & Melinda Gates Foundation’s Methods in Economic Evaluation Project (BMGF 2014) both advise that the base-case scenarios in economic evaluations of health interventions assume a 3 percent discount rate for both costs and benefits. Three percent is argued to reflect the cost of public sector borrowing of capital at market rates (Hoddinott 2016; Wethli 2014). Recent work on economic evaluations pertaining to reducing the impact of climate change over the next hundred or more years have proposed social discount rates as low as 1.4 percent would be appro- priate (Stern 2008) or time-varying discount rates that decline after many years and affect future generations (Arrow et al. 2012; Hoddi- nott 2016; Sunstein and Weisbach 2008). For the analyses in this report, benefit-cost ratios are presented for a base-case scenario using a 3 percent discount rate on costs and benefits, as per the existing guide- lines, as well as a 5 percent discount rate in the sensitivity analyses to parallel recent seminal nutrition economic analyses (Hoddinott 2016; Horton and Hoddinott 2014; Rajkumar, Gaukler, and Tilahun 2012). 5 Authors’ calculations, based on data from World Bank 2016. Chapter 2  Overview of Methods 35 Results from these analyses are presented in multiple formats— median benefit-cost ratios among all countries in the sample, the pooled benefit-cost ratios of all countries, and the subgroup of pooled benefit-cost ratios for each region and income group—to allow the reader to interpret the results as appropriate for different contexts. More accurate estimates can be developed through country-level studies and ex-post benefit-cost analyses of programs within specific country contexts. Data Sources Data on the baseline prevalence of stunting, anemia, exclusive breast- feeding, and wasting are from the latest update of the World Health Assembly Global Nutrition Tracker dataset (September 2015). Baseline intervention coverage data are from Demographic and Health Sur- veys (DHS) or from Multiple Indicator Cluster Surveys (MICS). The World Population Prospects 2015 (UN DESA 2015) is used to obtain population data, including the projected 2015 population baseline and projected population growth from 2016 through 2025. Data on GDP and population living under the poverty line are from the World Development Indicators database. Other sources specific to one target are declared in the target-specific chapters that follow. References Arrow, K., M. Cropper, C. Gollier, B. Groom, G. M. Heal, R. G. Newell, W. D. Nordhaus, R. S. Pindyck, W. A. Pizer, P. R. Portney, T. Sterner, R. S. J. Tol, and M. L. Weitzman. 2012. “How Should Benefits and Costs Be Discounted in an Intergenerational Context? The Views of an Expert Panel.” RFF Discussion Paper 12-53, Resources for the Future, Washington, DC. Bhutta, Z. A., T. Ahmed, R. E. Black, S. Cousens, K. Dewey, E. Glugliani, B. A. Haider, B. Kirkwood, S. S. Morris, H. P. S. Sachdeve, and M. Shekar. 2008. “What Works? Interventions for Maternal and Child Undernutrition and Survival.” The Lancet 371 (9610): 417–40. Bhutta, Z. A., J. K. Das, A. Rizvi, M. F. Gaffey, N. Walker, S. Horton, P. Webb, A. Lartey, and R. E. Black. 2013. “Evidence-Based Interventions for Improve- ment of Maternal and Child Nutrition: What Can Be Done and at What Cost?” The Lancet 382 (9890): 452–77. BMGF (Bill & Melinda Gates Foundation). 2014. Methods for Economic Evalua- tion Project (MEEP) Final Report. NICE International. https://www.nice.org 36 An Investment Framework for Nutrition .uk/Media/Default/About/what-we-do/NICE-International/projects/ MEEP-report.pdf Edejer, T., R. Baltussen, T. Adam, R. Hutubessy, A. Acharya, D. B. Evans, and C. J. L. Murray, eds. 2003. Making Choices in Health: WHO Guide to Cost-­ Effectiveness Analysis. Geneva: WHO. Hoddinott, J. 2016. “The Economics of Reducing Malnutrition in Sub-Saharan Africa.” Global Panel on Agriculture and Food Systems for Nutrition Working Paper. http://glopan.org/sites/default/files/Global_Panel_Working_Paper .pdf 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. Horton, S. and J. Hoddinott. 2014. “Benefits and Costs of the Food Nutrition Targets for the Post-2105 Agenda.” Copenhagen Consensus Center Working Paper, Copenhagen, Denmark. http://www.copenhagenconsensus.com/ sites/default/files/food_security_and_nutrition_perspective_-_horton_ hoddinott_0.pdf Horton, S. and J. Ross. 2003. “The Economics of Iron Deficiency.” Food Policy 28 (1): 51–75. Horton, S., M. Shekar, C. McDonald, A. Mahal, and J. K. Brooks. 2010. Scaling Up Nutrition: What Will It Cost? Directions in Development Series. Washing- ton, DC: The World Bank. Hutton, G. 2015. “Benefits and Costs of the Water and Sanitation Targets for the Post-2015 Development Agenda.” Copenhagen Consensus Center Work- ing Paper. http://www.copenhagenconsensus.com/sites/default/files/ water_sanitation_assessment_-_hutton.pdf IFPRI (International Food Policy Research Institute). 2014. Global Nutrition Report 2014. Washington, DC: IFPRI. LiST (Lives Saved Tool). 2015. Baltimore, MD: Johns Hopkins Bloomberg School of Public Health. http://livessavedtool.org/ (accessed December 31, 2015). Lübker, M. 2007. “Labour Shares.” Policy Brief, Policy Integration Depart- ment, International Labour Office, Geneva. Rajkumar, A. S., C. Gaukler, and J. Tilahun. 2012. Malnutrition in Ethiopia. An Evidence-Based Approach for Sustained Results. Africa Human Development Series. Washington, DC: World Bank. Rollins, N. C., N. Bhandari, N. Hajeebhoy, S. Horton, C. K. Lutter, J. C. Mar- tines, E. G. Piwoz, L. M. RIchter, and C. G. Victora. 2016. “Why Invest, and Chapter 2  Overview of Methods 37 What It Will Take to Improve Breastfeeding Practices?” The Lancet 387 (10017): 491–504. Ruel, M., H. Aldernal, the Maternal and Child Nutrition Study Group. 2013. “Nutrition-Sensitive Interventions and Programmes: How Can They Help Accelerate Progress in Improving Maternal and Child Nutrition?” The Lancet 382 (9890): 66–81. Shekar, M., J. Dayton Eberwein, and J. Kakietek. 2016. “The Costs of Stunting in South Asia and the Benefits of Public Investments in Nutrition.” Maternal and Child Nutrition 12 (Supl 1): 186–95. Shekar, M., M. Mattern, P. Eozenou, J. Dayton Eberwein, J. K. Akuoku, E. Di Gropello and W. Karamba. 2015. “Scaling Up Nutrition for a More Resilient Mali: Nutrition Diagnostics and Costed Plan for Scaling Up.” Health, Nutri- tion and Population (HNP) Discussion Paper. Washington, DC: World Bank. Shekar, M., M. Mattern, L. Laviolette, J. Dayton Eberwein, W. Karamba, and J. K. Akuoku. 2015. “Scaling Up Nutrition in the DRC: What Will It Cost?” Health, Nutrition and Population (HNP) Discussion Paper. Washington, DC: World Bank. Shekar, M., C. McDonald, A. Subandoro, J. Dayton Eberwein, M. Mattern and J. K. Akuoku. 2014. “Costed Plan for Scaling Up Nutrition: Nigeria.” Health, Nutrition and Population (HNP) Discussion Paper. Washington, DC: World Bank. Stern, N. 2008. The Economics of Climate Change: The Stern Review. Cambridge, UK: Cambridge University Press. http://www.cambridge.org/ca/academic/ subjects/earth-and-environmental-science/climatology-and-climate-change/ economics-climate-change-stern-review Sunstein, C. and D. Weisbach. 2008. “Climate Change and Discounting the Future: A Guide for the Perplexed.” Reg Markets Center Working Paper No. 08-19. Harvard Law School, Cambridge, MA. http://papers.ssrn.com/ sol3/papers.cfm?abstract_id=1223448 UN DESA (United Nations, Department of Economic and Social Affairs), Population Division. 2015. World Population Prospects: The 2015 Revision, cus- tom data acquired via website http://esa.un.org/unpd/wpp/DataQuery/ UNICEF, WHO, and World Bank (United Nations Children’s Fund, World Health Organization, and World Bank). 2014. Joint Child Malnutrition Estimates. Global Database on Child Growth and Malnutrition. http://www.who.int/ nutgrowthdb/estimates2014/en/ (accessed February 1, 2015). ———. 2015. Joint Child Malnutrition Estimates. Global Database on Child Growth and Malnutrition, (accessed February 1, 2015), http://www.who.int/ nutgrowthdb/estimates2014/en/ Wethli, K. 2014. “Benefit-Cost Analysis for Risk Management: Summary of Selected Examples.” Background Paper for the World Development Report 2014, 38 An Investment Framework for Nutrition World Bank, Washington, DC. http://siteresources.worldbank.org/ EXTNWDR2013/Resources/8258024-1352909193861/8936935-1356011448215/ 8986901-1380568255405/WDR15_bp_BenefitCost_Analysis_for_Risk_ Management_Wethli.pdf WHO (World Health Organization). 2015. Global Targets Tracking Tool. http://www.who.int/nutrition/trackingtool/en/ (accessed March 2015). World Bank. 2016. World Development Indicators (database). Washington, DC: World Bank (accessed March 1, 2016), http://data.worldbank.org/ data-catalog/world-development-indicators Chapter 2  Overview of Methods 39 Chapter 3 Reaching the Global Target for Stunting Meera Shekar, Jakub Kakietek, Julia Dayton Eberwein, Jon Kweku Akuoku, and Audrey Pereira Key Messages • Reaching the stunting target is feasible but will require large coordinated investments in key interventions and a supportive enabling environment. • The analyses focus on key high-impact interventions with strong evidence of effectiveness in reducing stunting. Scale-up costs are estimated for a sample of 37 high-burden countries and extrapolated to all low- and middle-income countries. The Lives Saved Tool (LiST) is used to model the impact of scale-up on stunting. • Scaling up high-impact interventions in all low- and middle-income countries, along with expected improve- ­ ments in underlying determinants of undernutrition, would lead to a 40 percent decline in the number of stunted chil- dren by 2025 and allow the world to achieve the stunting target. The total financing needed to reach this target over 10 years is $49.5 billion. Chapter 3  Reaching the Global Target for Stunting 41 • This scale-up in intervention coverage, along with improve- ments in underlying determinants, would result in 65 mil- lion fewer children stunted in 2025. Furthermore, those interventions would, over 10 years, prevent about 2.8 mil- lion deaths among children under age five. S tunting is not only being short for one’s age but recent evidence suggests that it is also a predictor of many other developmental constraints, including cognitive deficits and future economic opportunities. In 2012 the World Health Assembly agreed on a global target to reduce the number of stunted children under age five by 40 percent by 2025. This chapter describes the methods used to estimate the financing needs for achieving this target, the estimated resources required, and the impact those investments will be expected to have on nutrition, health, and economic outcomes. Stunting Prevalence and Progress to Date The World Health Organization (WHO) defines stunting as height (or length) that is two or more standard deviations below the global WHO child growth standards reference (WHO 2016). In 2015, 159 million children under age five were stunted, with the highest burden concentrated in low- and middle-income countries (map 3.1; UNICEF, WHO, and World Bank 2015). Since the 1990s, the worldwide prevalence of stunting declined from 40 percent to just under 24 percent in 2014. However, stark regional differences per- sist, with South Asia and Sub-Saharan Africa remaining above the global average both in terms of prevalence and numbers of stunted children (figure 3.1). Indeed, South Asia is home to the largest num- ber of stunted children worldwide (figure 3.1; UNICEF, WHO, and World Bank 2015). Thirty-seven percent of all children under five were stunted in South Asia in 2014, although the share is down from 49 per- cent in 1990. Even though the prevalence of child stunting in Sub- Saharan Africa fell from 48 percent in 1990 to 35 percent in 2014, the total number of stunted children in Africa increased by 12.8 million 42 An Investment Framework for Nutrition Map 3.1: Stunting Rates among Low- and Middle-Income Countries Global stunting rates >40% 30% – 40% <30% HIGH-INCOME COUNTRIES NOT INCLUDED IN THE ANALYSES NO DATA Chapter 3  Reaching the Global Target for Stunting Budget, Performance Review & Strategic Planning General Services IBRD 42396 | Printing & Multimedia SEPTEMBER 2016 This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank Group, any judgment on the legal status of any territory, or any endorsement or acceptance of such boundaries. 43 Source: World Bank Group, internal map, 2016. Figure 3.1: Global and Regional Trends of Child Stunting under Age Five, 1990–2014 60 Pr v l nc (%) 40 20 0 1990 1995 2000 2005 2010 2014 Glob l E st Asi nd P cific Europ nd C ntr l Asi Sub-S h r n Afric Middl E st nd North Afric South Asi L tin Am ric nd th C ribb n Data source: UNICEF, WHO, and World Bank 2015. during the same period as a result of high fertility rates and lower rates of decline in stunting in Africa as compared with other regions (figure 3.2). Of all the regions, East Asia and Pacific have made the most progress in decreasing stunting. Stunting prevalence there fell by almost three- quarters, from 42 percent to 11 percent, and the number of stunted children decreased by 64 million between 1990 and 2014. Much of that decline, however, was driven by improvements in China, and many countries—such as Indonesia, the Lao People’s Democratic Republic, and Cambodia—continue to carry very high burdens of child stunting. Albeit more slowly than Asia, Europe, Latin America and the Carib- bean, the Middle East and North Africa have also made considerable progress in decreasing stunting, and stunting prevalence in those regions remains well under the global average. The combined share of the number of stunted children for these three regions decreased from 30 percent to 14 percent between 1990 and 2014. Based on current global trends, approximately 127 million children under five will be 44 An Investment Framework for Nutrition Figure 3.2: Trends in Number of Children under Five Stunted by Region, 1990–2014 300 Numb r of childr n ff ct d (millions) 250 An incr s of 12.4 million stunt d childr n in Afric 200 150 100 50 0 1990 1995 2000 2005 2010 2014 Europ nd C ntr l Asi E st Asi nd P cific Middl E st nd North Afric Sub-S h r n Afric L tin Am ric nd th C ribb n South Asi Data source: UNICEF, WHO, and World Bank 2015. stunted by 2025; the World Health Assembly goal is to decrease this number to no more than 100 million by 2025 (WHO 2014). Not only do stunting rates remain high in many low- and middle- income countries, but stunting affects all echelons of society and the richest groups are not immune (figure 3.3). Across many low- and middle-income countries, a similar pattern emerges: stunting rates are highest among the poorest wealth quintiles but they are unacceptably high even in the highest wealth quintile. This finding debunks a com- monly held view that stunting is caused by poverty alone. Instead, research shows that other factors, such as the burden of disease, access to adequate sanitation, food diversity, and optimal feeding and caregiving practices, also affect levels of stunting. Stunting-reduction strategies need to be designed with this in mind, so that free services that consume large public resources are targeted toward the poor, while the better-off are provided better knowledge and information through traditional and social media. Chapter 3  Reaching the Global Target for Stunting 45 Figure 3.3: Stunting Rates by Wealth Quintile, Selected Countries  The poorest are most likely to be stunted Ethiopi 60 Ni ri 60 Pr v l nc , % Pr v l nc , % 40 40 20 20 0 0 th nd st st st st nd th dl dl ur ur co co id id r r h h o o Fo Fo M M Po Po Hi Hi S S Indon si K n 60 60 Pr v l nc , % Pr v l nc , % 40 40 20 20 0 0 st st st st nd nd th th dl dl ur ur co co id id or or h h Fo Fo M M Po Po Hi Hi S Con o, D m. R p. S Indi 60 60 Pr v l nc , % Pr v l nc , % 40 40 20 20 0 0 h st st st nd nd st h dl dl rt rt co co id id u u r r h h o o Fo Fo M M Po Po Hi Hi S S Data source: UNICEF, WHO, and World Bank 2015. The Effects of Stunting Childhood stunting warrants serious policy attention because not only does it affect long-term health and cognitive ability, but it is also inextricably linked to sustainable and equitable growth of a whole society. The societal costs of stunting during childhood are high and include increased mortality, increased morbidity (both in childhood and later in adulthood), decreased cognitive ability, poor educational outcomes, lost earnings, and losses to national economic productivity. Conversely, investing in nutrition provides many benefits for pov- erty reduction and economic growth. A recent National Academy of Medicine paper (Huebner et al. 2016) reports on the opportunities in the U.S. context: “the return on investments during the prenatal and early childhood years average between 7 and 10 percent greater than investments made at older ages (Carneiro and Heckman, 2003). Although there are other opportunities to enhance human development, cost-effective strategic invest- ments made during children’s early years can mitigate the deleterious effects 46 An Investment Framework for Nutrition of poverty, social inequality, and discrimination, ultimately resulting in long- lasting gains that reap benefits for children and youth, families, communities, and nations” (Huebner et al. 2016, p. 1). Increased Child Mortality and Morbidity Stunting involves multiple pathological changes marked by linear growth retardation (low height-for-age z-score), which increases mor- bidity and mortality and decreases physical, neurodevelopmental, and economic capacity (Prendergast and Humphrey 2014). Malnutrition in the form of stunting, wasting, fetal growth retardation, suboptimum breastfeeding, and micronutrient deficiencies is an underlying cause of about 45 percent of the deaths of children under five years of age and one-fifth of maternal deaths in developing countries (Black et al. 2013). Furthermore, low gestational or preterm weight and suboptimal breastfeeding practices are among the main causes of neonatal deaths (Black et al. 2013). In several large studies reviewed by Prendergast and Humphrey (2014), a clear dose-response relationship could be seen between height-for-age z-scores and morbidity. Children with poor linear growth are more than 1.5 times more likely to contract respiratory infections and diarrhea; children with severe stunting are more than six times more likely to contract these conditions. Severely stunted children also have a threefold increased risk of mortality from other infections such as sepsis, meningitis, tuberculosis, hepatitis, and cellulitis (Prendergast and Humphrey 2014). Irreversible Cognitive Damage and Diminished Educational Attainment Conditions that give rise to stunting, such as poor feeding practices or persistent diarrhea, have detrimental effects on a child’s brain by causing changes in the temporal sequence of brain maturation, which in turn disturb the formation of neural circuits (Udani 1992) and result in cognitive deficits (Kar, Rao, and Chandramouli 2008). Wide- spread evidence from a range of settings and using diverse empirical approaches indicates that malnutrition leads to negative educational outcomes. Stunted children are more likely to start school late and to repeat a grade or drop out of school (Daniels and Adair 2004; Mendez and Adair 1999). Martorell et al. (2010) show that adults who were stunted at age two completed one less year of schooling. Adair et al. (2013) estimate that improving linear growth for children under two years of age by one standard deviation adds about half a grade of Chapter 3  Reaching the Global Target for Stunting 47 school attainment. Behrman et al. (2009) report increased schooling attainment and higher test scores from improved nutrition in early childhood. In studying the provision of lipid-based nutrition supple- ments for malaria and diarrhea treatment, Prado et al. (2016) show that the intervention independently affected developmental scores, such as motor and language skills. Links with Poverty Stunting and poverty are interrelated and exacerbate each other. A recent study (Hoddinott et al. 2011) concludes that children who are not stunted at 36 months are one-third less likely to live in poor households as adults. Poverty increases the risk of stunting and other forms of undernutrition by lowering poor households’ purchasing power, reducing access to basic health services, and exposing these households to unhealthy environments, thereby compromising food intake (both quality and quantity), reducing access to health services, and increasing exposure to infections. Poor households are also more likely to have frequent pregnancies, larger family sizes with high dependency ratios, more infections, and increased health care costs (Victora et al. 2003). At the same time, malnutrition contributes to poor health and poor cognitive development, resulting in poor human capi- tal and long-term productivity losses (Horton and Steckel 2013). Reduced Wages and Losses to GDP Undernutrition costs developing countries billions of dollars in lost revenue through reduced economic productivity, particularly through lower wages, lower physical and mental capabilities, and more days away from work as a result of illness. At the individual level, child- hood stunting is estimated to reduce a person’s potential lifetime earnings by at least 10 percent (World Bank 2006). Other studies have shown that a 1 percent increase in adult height results in a 2.4 percent increase in earnings (Thomas and Strauss 1997). The economic costs of undernutrition have the greatest effect on the most vulnerable in the developing world. A recent analysis estimates these losses at 4 to 11 percent of GDP in Africa and Asia each year (Horton and Steckel 2013)—equivalent to about $149 billion of productivity losses each year. Most of those losses are due to cognitive deficits. Another recent study by Lin, Lutter, and Ruhm (2016) shows that cognitive perfor- mance is positively linked to future labor market outcomes in terms of increased lifetime earnings. Fink et al. (2016) also find that growth 48 An Investment Framework for Nutrition faltering in children from developing countries leads to 0.5 years lost in educational attainment, resulting in global economic losses of more than $175 billion and average loss of lifetime earnings of $1,400 per child. As the world moves from economies based on unskilled manual labor to ones based on skilled labor requiring high mental capacity, the impact of childhood stunting and other forms of undernutrition on incomes and economies will likely increase. Because stunting is concentrated in low- and middle-income countries, it will weigh heavily on the ability of these countries to benefit from technological progress and catch up with high-income countries, potentially further exacerbating global income inequalities. Interventions That Reduce Stunting The etiology of stunting is complex. It is caused by the lack of appro- priate quality and quantity of foods, repeated bouts of disease, and/or poor birth outcomes including low birthweight and preterm delivery, which in turn may result from poor feeding behaviors and poor nutri- tion knowledge on the part of parents and caregivers, poor sanitation and hygiene, lack of access to health care services, low purchasing power of the household, insufficient supply of appropriate quality foods in the market, and other factors (Black et al. 2013). Preventing stunting therefore requires multifaceted and multisectoral approaches. To date the evidence base regarding the most effective strategies remains a work in progress. There is strong evidence regarding interventions that affect the proximal determinants of stunting—the nutrition-specific interven- tions. Two Lancet Series on Maternal and Child Nutrition (in 2008 and 2013) provide a summary of global evidence based on systematic literature reviews and meta-analyses. In contrast, the evidence base regarding the effectiveness of interventions that target more distal determinants of stunting (the nutrition-sensitive approaches) remains limited (see Ruel et al. 2013 for a review). Some evidence links poor water and sanitation to a greater incidence of diarrheal diseases, which is a risk factor for stunting (Bhutta et al. 2013). Evidence of the impact of nutrition-sensitive interventions on stunting—such as improving food security and dietary diversity as well as women’s education and empowerment—is more limited. Therefore this chapter focuses primarily on the nutrition-specific interventions, as outlined by Bhutta et al. 2013, where the evidence is the strongest and allows Chapter 3  Reaching the Global Target for Stunting 49 for estimating both the costs of the interventions and their impact on nutrition outcomes, including stunting. Interventions for Pregnant Women and Mothers of Infants and Young Children Interventions for pregnant women, such as micronutrient supplemen- tation, affect child stunting by improving fetal growth and reducing conditions effecting growth outcomes, such as iron deficiency anemia. Current evidence on the effectiveness of these interventions focuses primarily on birth outcomes rather than on the linear growth of children. Interventions included in this study are those with proven effectiveness. Other interventions that show great promise—such as small-quantity lipid-based nutrient supplements,1 and the provision of deworming tablets to prevent parasitic and helminth diseases—can be added as the evidence base grows. Antenatal micronutrient supplementation  Antenatal micronutri- ent supplementation consists of multiple micronutrient supplements, which are broadly characterized as containing more than two micro- nutrients.2 The UNICEF UNIMAP supplement contains 14 micronu- trients, including iron, folic acid, and vitamin A, at levels appropriate for daily intake during pregnancy. Although antenatal micronutrient supplements have been shown to reduce low birthweight and small- for-gestational-age births by 11 to 13 percent according to a Cochrane review (Haider and Bhutta 2015), other studies have shown little direct effect on child anthropometric outcomes, with the exception of child head circumference (Lu et al. 2014). Peña-Rosas et al. (2015) found that giving pregnant women any supplementation with iron increases birthweight in infants by over 20 grams as compared to giving no supplements or supplements without iron. Nonetheless, antenatal micronutrient supplements are a low-cost and feasible way to provide essential micronutrients to improve birth outcomes, which in turn reduce the risk of stunting (Haider and Bhutta 2015). In this 1 Despite some promising studies on small-quantity lipid-based nutrient supplements (Adu-­ Afarwuah et al. 2015; Ashorn et al. 2015), it is not clear which populations would benefit most from these supplements, nor are there global recommendations on its use. Furthermore, no large- scale production and distribution is yet available, leaving many cost and implementation issues unresolved. A World Bank–supported study on these lipid supplements is currently ongoing in Madagascar. 2 The intervention antenatal micronutrient supplementation is sometimes referred to by different names in the literature. Alternative names include maternal micronutrient supplementation, multiple micronutri- ent supplementation in pregnancy, multiple-micronutrient supplementation for women during pregnancy, and the acronyms MMN, MNS, and MMS. 50 An Investment Framework for Nutrition analysis, financing needs were estimated for antenatal micronutrient supplementation. Counseling for mothers and caregivers on good infant and young child nutrition and hygiene practices  This intervention name is shortened throughout this analysis to infant and young child nutrition counseling. Optimal feeding of infants and young children includes immediate initiation of breastfeeding, early and exclusive breastfeed- ing until six months of age, and age-appropriate complementary feeding from 6 to 24 months with continued breastfeeding until two years of age. Good infant and young child feeding and hygiene practices are promoted at various levels: health facilities, community/ home settings, and through mass media campaigns. Health facilities are the main outlet for nutrition counseling, but community health workers play an immensely important role in reaching outlying and hard-to-reach areas where the most vulnerable live. Education on complementary feeding alone, in food insecure populations, has been shown to significantly improve linear growth (height-for-age Z scores) and weight gain (weight-for-age Z scores) and decrease stunting rates (Lassi et al. 2013). Breastfeeding promotion and resulting increases in exclusive breastfeeding rate affect stunting by reducing diarrhea inci- dence. The impact estimate used in this analysis comes from Lamberti et al. (2011) which presented the effects of suboptimal breastfeeding on diarrhea incidence. Balanced energy-protein supplementation for pregnant women  Balanced energy-protein supplements refer to food supplements that contain less than 25 percent protein as their total energy content; they are intended for pregnant women who are undernourished or at risk of becoming undernourished, and promote gestational weight gain and improve birth outcomes. The 2013 Lancet Series on Maternal and Child Malnutrition reports a 34 percent reduction in the risk of small- for-gestational age babies and stillbirths from 16 studies. Furthermore, data from five studies demonstrate a 32 percent reduction in the risk of low birthweight, with effects more clearly pronounced in under- nourished women than in adequately nourished women (Imdad and Bhutta 2012). More recently, Ota et al. (2015) found an increase in mean birthweight and a significant reduction in the incidence of infants born small for gestational age with balanced energy protein supplementation. Intermittent presumptive treatment of malaria in pregnancy in malaria-endemic regions  The WHO recommends at least two doses, preferably four, of intermittent presumptive treatment of malaria in Chapter 3  Reaching the Global Target for Stunting 51 pregnancy with sulfadoxine-pyrimethamine as part of routine antena- tal care in areas of moderate to high malaria transmission, particularly Sub-Saharan Africa (WHO 2012). Trials of intermittent presumptive treatment of malaria in pregnancy in malaria-endemic regions to estimate their effect on birth outcomes have shown significant reduc- tions in low birthweight and increases in mean birthweight of infants (Garner and Gülmezoglu 2006; Radeva-Petrova et al. 2014), which in turn have significant effects on stunting. Further studies have also shown that, among first and second pregnancies in malaria-prevalent areas, prevention interventions such as intermittent presumptive treat- ment of malaria in pregnancy were found to have a pooled protective efficacy of 35 percent on reducing low birthweight (Eisele, Larsen, and Steketee 2010). Although this intervention stands out as the only non- nutrition intervention included in the analyses, its significant impacts on birth outcomes, and thus on stunting, justifies its inclusion. Interventions for Infants and Young Children Vitamin A supplementation for children  Vitamin A deficiency causes visual impairment and blindness among children, and con- tributes to diarrheal diseases and child mortality. The WHO recom- mends the provision of 100,000 international units (IU) of vitamin A for infants 6–11 months of age, and 200,000 IU of vitamin A every four to six months for children age 12–59 months, in settings where night-blindness prevalence is 1 percent or higher among children 24–59 months, or where vitamin A deficiency is 20 percent or higher in infants and children age 6–59 months (WHO 2011). A Cochrane systematic review of 43 randomized controlled trials and clus- ter randomized controlled trials in community settings found no effect of vitamin A supplementation on linear growth (Imdad et al. 2010). However, vitamin A indirectly influences stunting, by reduc- ing diarrheal incidence, and the effects of vitamin A supplementa- tion on ­diarrhea-specific mortality among children have been well documented. Within the same systematic review, seven of the trials reported a 30 percent reduction in diarrhea-specific child mortal- ity with preventive vitamin A supplementation (Imdad et al. 2010). Results from an evaluation of 21 studies show that vitamin A supple- mentation reduces all-cause mortality in children 6–59 months by 25 percent and reduces diarrhea-specific mortality by 30 percent in children 6–59 months (Imdad et al. 2011). Prophylactic zinc supplementation  Zinc is an important micronu- trient that is associated with immune function, cellular growth and differentiation, and metabolism. A systematic review of 36 randomized 52 An Investment Framework for Nutrition controlled trials shows that mean height increased significantly, by 0.37 centimeters, and diarrheal incidence decreased by 13 percent in children who received prophylactic zinc supplementation for 24 weeks (Imdad et al. 2011). At present, the WHO does not have any specific recommendations on preventive zinc supplementation. Public provision of complementary food for children  Interventions to ensure adequate nutrient intake for children 6–24 months of age can provide anywhere from 100 to 1,500 additional calories, as well as essential micronutrients, to improve height-for-weight z-scores in these children. Imdad, Yakoob, and Bhutta (2011) found that comple- mentary food supplements with or without nutrition counseling, significantly improves weight and height z-scores. Furthermore, the provision of complementary food, with or without education, can reduce stunting by 67 percent in food-insecure populations (Lassi et. al. 2013). Analytic Approaches Specific to the Stunting Target This section considers the methods used in the analysis that are specific to the stunting target, looking at the applicable interventions, assumptions about delivery, the selection of sample countries, and the sources of data used as well as methods used to estimate impact. For more detail on methodology, see chapter 2. Interventions Included in the Analyses Seven key interventions have strong evidence of effectiveness in reducing stunting. Table 3.1 shows the pathways and estimates of the impact each intervention has on the likelihood of stunting. Four of these interventions are directed at pregnant women and mothers of infants and young children; three are directed at infants and young children (table 3.1). For women, antenatal micronutrient supplementa- tion and infant and young child nutrition counseling would be scaled up for all pregnant women, balanced energy-protein supplementation would be scaled up for all pregnant women living under the pov- erty line, and intermittent presumptive treatment of malaria would be scaled up only for pregnant women living in malaria-endemic regions.3 Vitamin A supplementation and prophylactic zinc supple- mentation would be scaled up for all children 6–59 months of age, and 3 For this analysis, all malaria-endemic countries are in the Sub-Saharan Africa region. Chapter 3  Reaching the Global Target for Stunting 53 Table 3.1: Interventions to Reach the Stunting Target Target Description and Intervention Evidence of effectiveness population delivery method For pregnant women and mothers of infants and young children Includes iron and folic acid, and at Recent reviews of multiple least one additional micronutrient supplementation Antenatal micronutrient, for (Haider and Bhutta 2015) show micronutrient Pregnant women approximately significant reductions in low birth­ supplementationa 180 days per weight and small-for-gestational age pregnancy. Delivered as of 10 percent (or effectiveness 0.10). part of antenatal care. Reanalysis by Sinha et al. (2015) for LiST shows that receiving breastfeeding promotion increased This intervention exclusive breastfeeding in infants comprises individual age 0–5 months [OR 2.5 in health or group-based system, OR 2.61 in home/community counseling sessions setting]. Lamberti et al. (2011) shows Infant and young Mothers to promote exclusive that infants 0–5 months had an child nutrition of children breastfeeding increased relative risk of diarrhea counseling 0–23 months old delivered in the if they are predominantly breastfed community and/or [RR 1.26, 95% CI 0.81–1.95], health facility, partially breastfed [RR 1.68, 95% CI depending on country 1.03–2.76], or not breastfed at all [RR context. 2.65, 95% CI 1.72–4.07]. Children 6–23 months have more than twice the risk of diarrhea if not breastfed at all [RR 2.07, 95% CI 1.49–2.88]. This intervention This intervention reduces the risk of provides food low-birthweight infants and infants supplementation born small for gestational age, and during pregnancy as such has an indirect impact on Balanced Undernourished to at-risk women stunting. Ota et al. (2015) have found energy-protein pregnant women (with no more than an increase in mean birthweight [MD supplementation living under 25 percent energy +40.96g, 95% CI 4.66–77.26] and a for pregnant the poverty line content contributed significant reduction in the incidence women a ($1.25/day) by proteins). Some of infants born small for gestational existing delivery age [RR 0.79, 95% CI 0.69–0.90] mechanisms are with balanced energy-protein through community- supplementation. based programs. Among first and second pregnancies Intermittent This intervention in malaria-prevalent areas, presumptive provides at least two prevention interventions such as Pregnant women treatment for doses of sulfadoxine- intermittent presumptive treatment (in malaria- malaria in pyrimethamine during for malaria in pregnancy are found endemic regions pregnancy in pregnancy. Delivered to have a pooled protective efficacy only) malaria-endemic as part of antenatal of 35 percent [95% CI 23–45%] on regions care. reducing low birthweight (Eisele, Larsen, and Steketee 2010). 54 An Investment Framework for Nutrition Table 3.1: Interventions to Reach the Stunting Target (continued) Target Description and Intervention Evidence of effectiveness population delivery method For infants and young children This intervention distributes two doses Vitamin A indirectly affects per year (100,000 stunting by influencing diarrheal international units (IU) incidence and mortality. Vitamin A Vitamin A for children age 6–11 supplementation has been shown to Children supplementation months and 200,000 reduce diarrhea-specific incidence 6–59 months old for children IU for children age [RR 0.85, 95% CI 0.82–0.87; 12–59 months), 13 studies] and mortality [RR 0.72, either through mass 95% CI 0.57–0.91; 7 studies] (Imdad campaigns or in et al. 2011). health facilities. This intervention provides zinc (10 mg/ Supplementation with 10 mg zinc/ day); 120 packets day for 24 weeks increases mean per child per year. gain in height (cm) [0.37, 95% Currently no delivery CI 0.12–0.62; 16 studies] compared Prophylactic zinc platforms exist with a placebo intervention Children supplementation at scale. Delivery (Imdad and Bhutta 2011). Zinc 6–59 months old for children a cost estimates are supplementation also reduces based on costs to diarrheal incidence [RR 0.87, 95% deliver multiple CI 0.81–0.94] in the intervention micronutrient powder group compared with a control group supplementation (Yakoob et al. 2011). programs. Bhutta et al. (2008) find that in food secure settings, 6–12 month Food supplementation old children of mothers who are for children (100– not given nutrition education are Children 1,500 kcal per day), Public 1.43 times more likely to become 6–23 months typically including provision of stunted. In food insecure settings, old living under micronutrients. Some complementary complementary food supplements the poverty line existing delivery foods for children with or without maternal nutrition ($1.25/day) mechanisms are education increases child stunting through community- OR to 1.60; and no supplements or based programs. education further increases child stunting OR to 2.39. Note: CI = confidence interval; kcal = kilocalories; MD = mean difference; OR = odds ratio; RR = relative risk; SMD = standard mean difference. a This intervention was awaiting updated WHO guidelines as of late 2016. Chapter 3  Reaching the Global Target for Stunting 55 the public provision of complementary food would be scaled up for all children living under the poverty line. The poverty line is defined as persons living on less than $1.25 per day (World Bank 2009).4 Assumptions about Delivery Platforms Several of the interventions—infant and young child nutrition coun- seling, vitamin A supplementation for children, and intermittent presumptive treatment of malaria in pregnancy in malaria-endemic regions—have existing large-scale delivery platforms that could be scaled up to increase coverage rates to full coverage. For other inter- ventions, however, there is little experience with large-scale program- ming and so assumptions have been made about delivery platforms. For prophylactic zinc supplementation for children, for the purposes of this analysis, zinc is assumed to be delivered in a manner similar to that of multiple micronutrient supplementation through community- based programs. Antenatal micronutrient supplementation is assumed to be delivered through existing antenatal and postnatal services. Bal- anced energy-protein supplementation for pregnant women could be delivered through existing food distribution and/or social safety net programs. Sample Selection Stunting cost estimates are based on a sample of 37 countries, which includes 20 countries with the highest absolute burden (the number of stunted children) and additional 17 countries with the highest stunt- ing prevalence (a prevalence exceeding 40 percent, which is the WHO threshold for a “very high” stunting prevalence) (see table 2.2 for the list of countries). The 20 countries with the highest absolute burden account for 77 percent of the burden worldwide and the 17 countries with the highest prevalence account for an additional 7 percent, so taken together this sample accounts for 84 percent of the global bur- den of stunting. Data Sources Population and population growth estimates are obtained from the UNDP World Population Prospects (UN DESA 2015a, 2015b). Current 4 At the time the analysis was conducted, the poverty line set by the World Bank was $1.25. Since then, the poverty line has been revised to $1.90. For more details, see http://www.worldbank.org/ en/topic/poverty/brief/global-poverty-line-faq 56 An Investment Framework for Nutrition intervention coverage data are extracted from the most recent Demo- graphic and Health Surveys. Current coverage for antenatal micronu- trient supplementation, balanced energy-protein supplementation for pregnant women, and prophylactic zinc supplementation is assumed to be 0 percent because no countries implement those interventions at scale. The cost and impact of intermittent presumptive treatment of malaria in pregnancy in malaria-endemic regions are estimated only for Sub-Saharan Africa, where malaria incidence is high enough to justify this intervention. Estimating Impact The additional effect of the seven nutrition interventions on stunting prevalence is modeled using LiST. The specific pathways and effect estimates used in LiST are shown in figure 3.4. Overall, 37 coun- try models are estimated and the results are combined to obtain a population-weighted reduction in the overall prevalence in the sample ­ of countries. The same relative prevalence change is assumed to occur in the remaining low- and middle-income countries not included in the sample. Reductions in the number of stunted children in all low- and middle-income countries are calculated by applying the relative reduction in the number of stunted children in the sample to the 2014 baseline estimate of the global number of stunted children worldwide—159 million (UNICEF, WHO, and World Bank 2015). ­ The impact of a scale-up of interventions is estimated in terms of (1) the number of cases of stunting prevented in 2025 as compared with the 2015 baseline; (2) the percent reduction in the number of chil- dren who are stunted; and (3) the number of deaths among children averted. It is widely recognized that linear growth is affected by both direct and indirect or underlying factors, and that improvements in the underlying determinants of malnutrition will lead to reductions in stunting prevalence. As such, our model estimates additional reduc- tions in stunting that would be accrued from improvements in food availability and food diversity; in women’s health status, education, and empowerment; and in water, sanitation and hygiene (WASH). For the WASH interventions, we estimated the impact on stunting using LiST for five interventions: handwashing with soap, improved excreta disposal, improved water source, hygienic disposal of chil- dren’s stool, and water connection at home. Chapter 3  Reaching the Global Target for Stunting 57 58 Figure 3.4: The Lives Saved Tool (LiST) and Underlying Model Used to Estimate Impact on Stunting Br stf din Hom /communit OR: 2.61 Br stf din Promotion H lth s st m OR: 2.50 Pr ctic s (D) Vit min A Pr domin nt EBF (0–5 months): RR 1.26 Suppl m nt tion (E) P rti l EBF (0–5 months): RR 1.68 Not EBF (0–5 months): RR 2.65 Not EBF (6–23 months): RR 2.07 Eff ctiv n ss: B l nc d En r Prot in 0.62 Suppl m nt tion (A) Birth Outcom s (G) OR: Di rrh Stuntin 1.04 Incid nc (I) Eff ctiv n ss: OR: 0.21 2.82 OR: T rm SGA Int rmitt nt 0.90 Proph l ctic Zinc Pr sumptiv Suppl m nt tion (J) Eff ctiv n ss: OR: Tr tm nt of 0.35 4.98 M l ri in Pr n nc (B) A (months): OR Pr -t rm 1–5: 11.20 Food s cur w/out promotion: OR 1.43 SGA 6–11: 268.70 Food ins cur , promotion + suppl m nt tion: OR 1.60 12–23: 67.30 Food ins cur , no promotion, no Eff ctiv n ss: 24–59: 67.30 suppl m nt tion: OR 2.39 0.10 Ant n t l Public Provision of Micronutri nt Stunt d in Compl m nt r Suppl m nt tion (C) th P st (F) F din (H) Data sources of effect sizes: (A) balanced energy-protein supplementation: Ota et al. 2015; (B) intermittent presumptive treatment of malaria in pregnancy: Eisele, Larsen, and Steketee 2010; (C) antenatal micronutrient supplementation: Haider and Bhutta 2015; Haider, Yakoob, and Bhutta 2011; (D) breastfeeding practices: Lamberti et al. 2011; (E) vita- min A supplementation: Imdad et al. 2011; (F) stunted in the past: LiST default values based on expert opinion; (G) birth outcomes: LiST default values based on expert opinion; (H) public provision of complementary food: Bhutta et al. 2008; An Investment Framework for Nutrition (I) diarrhea incidence: Bhutta et al. 2008; (J) prophylactic zinc supplementation: Bhutta et al. 2013; Yakoob et al. 2011. For each of the 37 countries in the sample, a linear expansion of cover- age is modeled from the level exhibited in 2016 to 90 percent in 2021 and maintenance of the 90 percent coverage from 2021 to 2025. These interventions were not included in the analysis of total financing needs because of the inability to proportionately allocate these costs to nutrition programming. Costs for WASH and other nutrition-sensitive interventions are likely much higher than those for the nutrition-­ specific interventions, and including them without proper apportion- ment will probably skew the costing estimates. The magnitude of the impact of the improvements in other underly- ing conditions, such as food availability and food diversity, women’s health status, education, and empowerment could not be directly estimated using LiST. Recognizing that changes in these conditions will also make a significant contribution to achieving the World Health Assembly stunting reduction target, we approximated their impact using estimates from Smith and Haddad (2015). Smith and Haddad use a country-level regression model to assess the impact of food availability (measured as average daily kilocalories consumed per capita), food diversity (measured as the percentage of total diet derived from non-staples), women’s education (measured as female secondary enrollment rate), and women’s health and empowerment (measured as female-to-male life expectancy ratio) on country-level stunting prevalence. For each of the 37 countries in the sample, a trend is calculated in each of the four variables based on the changes over the previous five years (2011–15), with the assumption that the same trend will continue over the 10-year period 2016–25. Using the regres- sion coefficients reported in Smith and Haddad, reductions in stunting during 2016–25, expected if the previous five-year trend continues, are calculated. Data on women’s secondary enrollment and female-to- male life expectancy ratio are from the World Development Indicators (WDI) database. Data on food availability and diversity are extracted from the Food and Agriculture Organization (FAO) food balance sheets. The potential reductions in stunting that result from improvement in WASH and the other underlying determinants are combined with the estimates from the 37 models to obtain a population-weighted reduc- tion in the overall prevalence in the sample of countries. Chapter 3  Reaching the Global Target for Stunting 59 Benefit-Cost Analyses Benefits of the scale-up of the key nutrition-specific interventions are calculated based on estimates of lives saved and cases of stunt- ing averted obtained from the LiST model (see figure 3.4). In the base case scenario, one life saved at age five was valuated as GDP per capita. One case of stunting averted is valuated at 21 percent of GDP per capita based on estimates of the impact of childhood stunting on adult wages (Hoddinott et al. 2013); this result is adjusted to account for the proportion of income from wages (see chapter 2 for detailed methodology). The economic benefits are approximated in all low- and middle- income countries using the same methods used to approximate the cost: multiply the total benefits by the inverse of the total proportion of the stunting burden in the 37 high-burden countries included in the sample (see chapter 2 for details). The benefit-cost ratio is calculated by dividing the total discounted monetary benefits that will accrue to the beneficiaries over their lifetime by the total discounted scale-up costs. As described in chapter 2, a 3 percent discount rate is used for both costs and benefits; in the sensitivity analysis, the discount rate is varied to 5 percent. Results This section presents the results of the analysis of the interventions described above for stunting, including costs, impacts, and benefit- cost analysis. Unit Costs Summary measures of the unit costs by intervention are shown in table 3.2. Micronutrient supplementation (vitamin A and prophylactic zinc for children and antenatal micronutrient supplementation) have the lowest unit costs, each at less than $4 a year (or $4 per pregnancy in the case of antenatal micronutrients). The unit cost for intermittent presumptive treatment of malaria in pregnancy in malaria-endemic regions is equally low-cost: about $2.00 per pregnancy. The public pro- vision of complementary food for children entails higher unit costs, but it is important to note that these interventions are much more narrowly targeted to those living under the poverty line. The cost of providing one year of public provision of complementary foods for 60 An Investment Framework for Nutrition Table 3.2: Minimum, Maximum, and Mean Unit Costs for Interventions to Meet the Stunting Target (Annual) U.S. dollars Intervention Minimum Maximum Mean unit cost For pregnant women and mothers of infants Antenatal micronutrient supplementation  1.80   7.55  2.80 Infant and young child nutrition counseling  0.07  12.00  6.62 Balanced energy-protein supplementation for pregnant 16.93  54.72 24.07 women Intermittent presumptive treatment of malaria in  2.27   2.27  2.27 pregnancy in malaria-endemic regions For infants and young children Vitamin A supplementation for children  0.03   4.81  0.32 Prophylactic zinc supplementation for children  2.40   6.19  3.89 Public provision of complementary foods for children 29.03 115.28 42.93 Note: The mean unit costs are population-weighted means. children living in poverty is about $43 per year per child, and the cost for providing balanced energy-protein supplementation for pregnant women living in poverty is about $24. Appendix C provides detailed unit costs and data sources for each target. Total Scale-Up Costs The total 10-year costs of scaling up the package of the seven interventions affecting stunting are estimated to be $49.5 billion (table 3.3). This includes $44.2 billion in direct service delivery and an additional $5.3 billion for monitoring and evaluation, capacity building, and policy development. Prophylactic zinc supplementation and the public provision of comple- mentary food for young children together account for about 60 percent of the intervention costs (32 and 29 percent, respectively). Infant and young child nutrition counseling (including breastfeeding promotion and counseling on appropriate complementary feeding) account for some 15 percent of the total cost, and balanced-energy protein supplementa- tion for 16 percent. Antenatal micronutrient supplementation, vitamin A supplementation for children, and intermittent presumptive treatment of malaria in pregnancy in malaria-endemic regions account for the remainder of the estimated direct scale-up costs (5 percent, 2 percent, and 1 percent, respectively). Chapter 3  Reaching the Global Target for Stunting 61 Table 3.3: Total Financing Needs to Meet the Stunting Target US$, millions Total 10-year Share of total Intervention intervention costs 10-year cost For pregnant women and mothers of infants Antenatal micronutrient supplementation  2,309   5% Infant and young child nutrition counseling  6,823  15% Balanced energy-protein supplementation for pregnant  6,949  16% women Intermittent presumptive treatment of malaria in pregnancy    416   1% in malaria-endemic regions For infants and young children Vitamin A supplementation for children    716   2% Prophylactic zinc supplementation for children 14,212  32% Public provision of complementary foods for children 12,750  29% Subtotal 44,175 100% Program (monitoring and evaluation, capacity strengthening,  5,301 n.a. and policy development) Total 49,476 n.a. Note: n.a. = not applicable. During the five-year scale up period (2016–20), the expected resource requirement is $16.3 billion; during the five-year maintenance phase (2021–25) an additional $33.1 billion would be required (figure 3.5) (for the rationale for the two phases of scale-up, see chapter 2). About 50 percent of the estimated global cost ($23.5 billion) is needed for the scale-up of nutrition interventions in Sub-Saharan Africa (fig- ure 3.6), with South Asia and East Asia and the Pacific each accounting for a little over 20 percent ($10.8 billion and $10.4 billion, respectively). Two countries, India and China, account for about a quarter of the global cost (26.3 percent) because of the large size of their populations of children under age five and pregnant women, the beneficiaries of the interventions included in the analyses. The costs in South Asia and other regions decrease from 2020 through 2025 even though the intervention coverage level is maintained through this period (see figure 3.7). This is because of the projected population declines with greater uptake of family planning programs and families having fewer children. In contrast, in Sub-Saharan Africa, 62 An Investment Framework for Nutrition Figure 3.5: Annual Financing Needs to Meet the Stunting Target by 2025 US$, millions 8,000 7,000 6,586 6,604 6,626 6,649 6,670 Annu l ddition l costs in 37 countri s (US$, millions) 6,000 5,472 5,000 4,364 4,000 3,262 3,000 2,166 2,000 1,077 1,000 0 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 Figure 3.6: Ten-Year Total Financing Needs to Meet the Stunting Target, by Region 0% 4% 6% 21% 47% 22% Oth r r ions E st Asi nd P cific Middl E st nd North Afric Sub-S h r n Afric L tin Am ric nd th C ribb n South Asi Chapter 3  Reaching the Global Target for Stunting 63 64 Figure 3.7: Estimated Total Financing Needs to Meet the Stunting Target, by Region US$, millions 3,337 3,390 3,500 3,231 3,284 3,179 3,000 2,604 2,500 2,048 1,871 1,847 1,823 2,000 1,801 1,777 1,511 1,593 1,295 US$, millions 1,500 990 988 1,398 1,388 1,380 1,371 1,363 1,000 668 1,162 487 929 500 695 338 462 230 0 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 Sub-S h r n Afric South Asi Oth r r ions An Investment Framework for Nutrition the costs of these interventions increase over the same period of time because of projected population increases and slower uptake of family planning programs. Low-income countries account for about 30 percent of the total scale- up cost (figure 3.8). Lower-middle income countries account for about 50 percent of the total scale-up cost, largely because three of the four countries with the largest populations (India, Nigeria, and Pakistan) are in that income group. Upper-middle-income countries account for about 20 percent of the total scale-up cost; this is mostly driven by China, because of its large population. Figure 3.8: Ten-Year Total Financing Needs to Meet the Stunting Target, by Country Income Group 20% 30% 50% Low-incom countri s Upp r-middl -incom countri s Low r-middl -incom countri s Impact Together, scaling up the key nutrition-specific interventions to 90 per- cent coverage along with expected improvements in the underlying determinants of stunting are estimated to lead to about a 40 percent decline in the number of stunted children by 2025, enabling the achievement of the global target for stunting (figure 3.9). Scaling up nutrition-specific interventions would result in a reduction of 19.5 per- cent in the number of stunted children in the 37 high-burden countries Chapter 3  Reaching the Global Target for Stunting 65 66 Figure 3.9: Costs and Impacts of a 10-Year Scale-Up of Interventions to Reach the Stunting Target 175 159 million childr n stunt d 150 Und rl in d t rmin nts of stuntin fiv , millions WASH ~ 65 million f w r 125 childr n stunt d in 2025 Nutrition-sp cific int rv ntions ~ 100 million stunt d T r t: 40% r duction 100 in stuntin b 2025 Stunt d childr n und r ~ 2.8 million child 75 d ths v rt d 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 ov r 10 rs $16.3 billion r quir d for 2016–2020 $33.1 billion r quir d for 2021–2025 Tot l $49.5 billion ov r 10 rs Note: a. Includes food availability and diversity, women’s education, women’s empowerment and health, and water, sanita- An Investment Framework for Nutrition tion and hygiene (WASH). by 2025.5 The changes in the underlying determinants drive the remaining decline in stunting. Assuming a similar relative reduction in the other countries with the remaining 15.7 percent of the global stunting burden, this translates into 65 million fewer children stunted in 2025 than the 159 million children stunted in 2015. In addition, the interventions would, over 10 years, prevent about 2.8 million deaths in children under five years of age. Comparing the costs and impacts of specific interventions shows that the promotion of good infant and child nutrition and hygiene prac- tices and vitamin A supplementation for children have the lowest cost per case of stunting averted ($273 and $266, respectively) (table 3.4).6 5 The model incorporates a country-specific population growth of children under five years of age. 6 In this analysis, the two components of the promotion of good infant and young child nutrition and hygiene practices—complementary feeding education and breastfeeding promotion—are evaluated separately and then together. The low cost per case of stunting averted is driven largely by comple- mentary feeding education. Table 3.4: Total Costs, Cost per Case of Stunting Averted, and Cost per Death Averted Total 10-year Cost per case Cost per death Intervention costs (US$, of stunting averted (US$) billions)* averted (US$) For pregnant women and mothers of infants Antenatal micronutrient supplementation  2.59  3,637  7,376 Infant and young child nutrition counseling (complementary feeding education and  7.64    467  7,353 breastfeeding promotion)   Complementary feeding education  4.28    273 16,122   Breastfeeding promotion  3.36  4,761  4,347 Balanced energy-protein supplementation for  7.78 29,949 37,054 pregnant women Intermittent presumptive treatment of malaria  0.47  1,535  6,594 in pregnancy in malaria-endemic regions For infants and young children Vitamin A supplementation for children  0.8    266  4,270 Prophylactic zinc supplementation for children 15.92    988 23,642 Public provision of complementary food for 14.28  1,724 67,787 children Note: In this analysis, the two components of the infant and young child nutrition ­ counseling—complementary feeding education and breastfeeding promotion—are evaluated separately and then together. * All intervention costs include additional 12 percent of overhead costs. Chapter 3  Reaching the Global Target for Stunting 67 Despite having low relative impact on stunting prevalence (because vitamin A supplementation is modeled via diarrhea incidence), vitamin A supplementation is a very low cost intervention, making it highly cost-effective. Other interventions, especially those target- ing pregnant women (for example, balanced energy-protein supple- mentation for pregnant women) have a much higher cost per case of stunting averted and are relatively less cost-effective. It is also worth noting that some interventions that have a relatively high cost per case of stunting averted have a relatively low cost per death averted (for example, breastfeeding promotion) and vice versa (complementary feeding education). Chapter 7 offers a more in-depth discussion of cost-effectiveness and technical and allocative efficiency of interven- tions targeting stunting and the other three nutrition targets consid- ered in this report. Benefit-Cost Analyses Under the base case scenario, the scale-up of the key nutrition-specific interventions is estimated to generate about $417 billion in annual eco- nomic benefits over the productive lives of beneficiaries (discounted at 3 percent) in low- and middle-income countries. The bulk of the benefits (about 98 percent) would be the consequence of the cognitive losses avoided in children under age five and the resulting improve- ments in economic productivity. The remaining 2 percent would result from premature mortality averted by the interventions. Comparing those benefits with discounted costs yields a benefit-cost ratio of 10.5. This means that one dollar invested in stunting reduction will gener- ate more than 10 dollars in economic returns. Changing the discount rate from 3 percent to 5 percent changes the benefits from $417 billion to as much as $172 billion over the produc- tive lives of the beneficiaries, with a benefit-cost ratio varying from 10.5 to 5.0. The results are sensitive to discount rate changes because, although most of the costs are incurred immediately and are not much affected by discounting, most of the benefits accrue in the future and thus are affected by discounting much more than the costs (see table 3.5). However, it needs to be noted that even under the more conservative scenario with a 5 percent discount rate, the benefit-cost ratio remains very comfortably above 1, indicating that preventing stunting is a sound economic investment. 68 An Investment Framework for Nutrition Table 3.5: Benefit-Cost Ratios of Scaling Up Interventions to Meet the Stunting Target, 3 and 5 Percent Discount Rates 3% discount rate 5% discount rate Present Present Present Present Benefit- Benefit- value value value value Region cost cost benefit (US$, cost (US$, benefit (US$, cost (US$, ratio ratio billions) billions) billions) billions) By region Sub-Saharan  66.8 15.8  4.2  26.3 13.7  1.90 Africa* South Asia* 121.4  8.0 15.1  50.6  7.0  7.20 East Asia and 125.0  7.9 15.8  52.4  6.9  7.60 Pacific* By country income group Low-income  17.9 10.4  1.7   4.1  9.0   .50 countries* Lower-middle- 232.4 18.4 12.6  98.2 16.0  6.15 income countries* Upper-middle- 103.4  4.8 21.6  44.0  4.2 10.60 income countries* Pooled 417.4 39.7 10.5 172.8 34.4  5.02 Median  4.0  1.60 Note: *Sample countries only. Discussion The analyses make a number of important contributions to the exist- ing literature. First, they provide estimates for the costs of reaching the global targets for stunting. They find that significant investments in both the high-impact interventions costed here and in underlying determinants of stunting are required in order to achieve the target. Cost estimates are consistent with the extant literature (see table 3.6). Horton et al. (2010) combine hygiene promotion and community-level WASH behavior change interventions with breastfeeding promotion and complementary feeding education. This is probably why their total costs are higher than those estimated by Bhutta et al. (2013) and by our study. Also, the Horton et al. study includes the cost of iron supplementation in pregnancy rather than multiple micronutrient supplementation, which is the probably the reason that their estimates of the cost of this intervention are lower. Chapter 3  Reaching the Global Target for Stunting 69 Table 3.6: Comparison across Three Studies of Unit Costs and Annual Financing Needs for Nutrition Interventions Annual financing needs Unit costs (US$, millions) Bhutta Horton Bhutta Horton et al. Current Current Intervention et al. et al. et al. 2010 study study 2013 2010 2013 For pregnant women and mothers of infants Antenatal micronutrient 2.00  6.15  2.80    85   479   309 supplementation Infant and young child 7.50 19.59  6.62 2,900   922   904 nutrition counseling Balanced energy-protein n.a. 25.00 24.07 n.a. 1,041   936 supplementation for pregnant women For infants and young children Vitamin A supplementation for 1.20 2.85 0.32   130   106    96 children Prophylactic zinc supplementation for n.a. 4.20–5.90 3.89 n.a. 1,182 1,893 children Public provision of complementary food 40.00–80.00 50.00 42.93 3,600 1,359 1,722 for children Note: Intermittent presumptive treatment of malaria in pregnancy in malaria-endemic regions is not included in these above-mentioned studies since financing for this inter- vention is assumed to come from other health budgets; n.a. = not available. Unlike the two previous studies, which estimate the cost of scaling up from current coverage to 90 percent in one year, these analyses model more realistic scale-up over 10 years and incorporates the under-five population change dynamics. Bhutta et al. (2013) assumed these inter- ventions would lead to a 20 percent reduction in stunting. In contrast, these analyses directly model the stunting decline in each country separately. For this reason, this model provides a more explicit analy- sis of the declines in stunting prevalence over 10 years, rather than assuming a given level of decline. Another difference from previous studies is that the estimates pre- sented here show higher costs for Sub-Saharan Africa than for South Asia. This is mainly because, although the number of stunted children 70 An Investment Framework for Nutrition is greater in South Asia, the costs of addressing stunting are greater in Sub-Saharan Africa because of high unit costs, particularly costly food supplements. The estimated target populations are larger in Sub-­ Saharan Africa for two of the three most costly interventions: the public provision of complementary foods for young children and balanced energy-protein supplementation for pregnant women (see table 3.7). The unit costs of nutrition interventions are assumed to be fixed over the coming decade. Future analyses should assess new delivery mod- els that could reduce unit costs and help nutrition technologies and services become more efficient; this should be done through a combi- nation of research and development, economies of scale, and changes in service delivery models. Some of the interventions costed here are ready for immediate scale-up, but there are binding constraints for others (see chapter 7 for a detailed discussion of binding constraints). For example, rates for vitamin A supplementation for children are already relatively high and could be scaled up to full coverage rela- tively easily. There are some important limitations to the analyses presented above. The cost estimates focus on the impact of nutrition-specific interven- tions and do not include nutrition-sensitive interventions—those delivered through sectors such as the agriculture, education, and WASH sectors that have the potential to have an impact on nutrition outcomes. The cost of improving women’s health and education and the cost of food availability and diversity could not be estimated here because there are no specific and well-defined intervention packages to improve those outcomes. While assumptions, informed by the literature, were made regarding how increasing female-to-male life expectancy by 0.1 may affect stunting prevalence, without a well- defined package of interventions it was not possible to estimate how much increasing female-to-male life expectancy by 0.1 would cost. WASH interventions are an exception to this rule. Estimates of the impact of these interventions on diarrhea incidence are available and their indirect impact on child nutrition outcomes, including stunting, can be modeled. Therefore the LiST tool was used to model the impact of WASH interventions on stunting prevalence. The costs of scaling up WASH interventions have been estimated elsewhere (Hutton 2015). Those estimates are not included here, because—while indispens- able for achieving the stunting target—expanding the coverage of the WASH interventions will be financed by the water and sanitation sector. It needs to be noted that the benefit-cost analyses presented Chapter 3  Reaching the Global Target for Stunting 71 72 Table 3.7: Population Covered and Unit Costs to Meet the Stunting Target in the Full Sample, Sub-Saharan Africa, and South Asia Full sample Sub-Saharan Africa South Asia Intervention Population covered Population- Population covered Population- Population covered Population- over 10 years weighted average over 10 years weighted average over 10 years weighted average (millions) unit cost (US$) (millions) unit cost (US$) (millions) unit cost (US$) For pregnant women and mothers of infants Antenatal micronutrient supplementation   698 $2.80 222 $3.49 255 $1.82 Infant and young child nutrition counseling   874 $6.62 280 $5.96 330 $4.78 Balanced energy-protein supplementation   245 $24.07 136 $25.00 81 $16.93 for pregnant women Intermittent presumptive treatment of malaria in pregnancy in malaria-endemic   155 $2.27 155 $2.27 n.a. n.a. regions For infants and young children Vitamin A supplementation for children 1,916 $0.32 391 $0.62 782 $0.09 Prophylactic zinc supplementation for 3,092 $3.89 899 $4.61 1,135 $2.40 children Public provision of complementary food for   252 $42.93 132 $53.65 95 $29.03 children Note: n.a. = not available. 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Chapter 3  Reaching the Global Target for Stunting 77 Chapter 4 Reaching the Global Target for Anemia Dylan Walters, Julia Dayton Eberwein, Lucy Sullivan, and Meera Shekar Key Messages • Anemia is a condition where red blood cells in the body are not able to deliver oxygen to tissues. This leads to a higher risk of infections and impaired cognitive function and physical work capacity. Maternal anemia is associated with intrauterine growth restriction. The three particularly vulnerable groups are: pregnant women (age 15–49 years), non-pregnant women (age 15–49), and pre-school children (age 6–59 months). • Interventions to prevent anemia in pregnant and non-­ pregnant women include antenatal micronutrient supple- mentation, intermittent presumptive treatment of malaria in pregnancy in malaria-endemic regions, iron and folic acid supplementation for non-pregnant women of repro- ductive age, and staple food fortification. • Achieving the global target of reducing anemia in women of reproductive age would require $12.8 billion over 10 years. This includes scaling up micronutrient interven- tions for non-pregnant women to unprecedented levels, and thus will require strong political will and effective delivery platforms. Chapter 4  Reaching the Global Target for Anemia 79 • At full scale-up, investment in these four key interven- tions will reduce anemia for 265 million women globally over 10 years and reduce anemia prevalence to 15.4 percent among all pregnant and non-pregnant women of reproduc- tive age, averting nearly 800,000 child deaths. Preventive treatment for malaria in pregnant women, in particular, will prevent 7,000–14,000 maternal deaths. • The net return on this investment in low- and middle- income countries is $110.1 billion with a pooled benefit-cost ratio of 12.1. A nemia is a widespread public health problem with vast human, social, and economic consequences. In 2012, the World Health Assembly called for a 50 percent reduction of anemia among women of reproductive age (15 to 49 years), including both non-pregnant and pregnant women (WHO and 1,000 Days 2014).1 This chapter reports on the costs of scaling up a set of key interven- tions necessary to reach the anemia target, the impact of reaching the target, and potential returns on investments. Anemia and Its Effects Anemia is defined as a low concentration of hemoglobin in the blood or a low red-blood cell (also called erythrocyte) count. This condition inhibits the delivery of oxygen to the body’s tissues. Anyone can be affected by anemia, although children and women of reproductive age in low- and middle-income countries are at highest risk. Anemia can result in adverse health and developmental effects, including maternal and perinatal mortality, intrauterine growth restriction, and low birthweight of newborns. The morbidity associ- ated with anemia in women of reproductive age can lead to lower work productivity as a result of impaired cognitive functioning and 1 Although anemia is a concern in both women of reproductive age (15–49 years of age) and young children (6–59 months of age), the anemia target as set by the World Health Assembly refers only to anemia in women of reproductive age—that is, both pregnant and non-pregnant women aged 15–49. Throughout this report we use the term anemia in women to refer to anemia in women of reproduc- tive age. 80 An Investment Framework for Nutrition higher risk of infections and reduced physical work capacities (Ste- vens et al. 2013; WHO 2015b; WHO and 1,000 Days 2014). In 2011 the global prevalence of anemia was estimated to be 29 percent for non-pregnant women and 38 percent for pregnant women—over half a billion women total. Among these women, it is estimated that 19 million non-pregnant and 750,000 pregnant women suffer from severe anemia (see table 4.2). Even though the prevalence of anemia in women has declined by 12 percent since 1995, it remains a moderate to severe public health problem in 142 of 182 World Health Organiza- tion (WHO) member states (Stevens et al. 2013; WHO 2015b; WHO and 1,000 Days 2014). Causes of Anemia The determinants of anemia (see figure 4.1) cover the spectrum of political, social, and economic factors as well climate change and food diversity (Balarajan et al. 2011). Poorer and less-educated women are more likely to be anemic, which, in turn, can be a strong predictor of child anemia status. The WHO estimates that, because iron deficiency is the most common direct cause of anemia, half of the world’s anemia burden in women could be eliminated with iron supplementation (WHO 2015b). It is estimated that the prevalence of iron deficiency anemia alone is 19 percent in pregnant women and 18 percent in children under five years of age around the world (Black et al. 2013). The remaining cases are attributable to a number of other nutritional causes (for example, folate, vitamin B12, and vitamin A deficiencies) and non-nutritional causes (for example, hookworm, sickle-cell, thal- assemia, malaria, chronic infection, schistosomiasis, genetic condi- tions, and so on) (Kassebaum et al. 2014; Stevens et al. 2013). Interventions That Effectively Prevent Anemia The 2013 Lancet Series on Maternal and Child Nutrition costed and recommended the scale-up of one intervention—multiple micronutri- ent supplementation—to prevent anemia in pregnancy, but did not address the issue of anemia in the broader non-pregnant population (Bhutta et al. 2013). In order to achieve the new global anemia target, a multisectoral approach for both pregnant women and the larger non- pregnant population of women is needed, plus efforts to address other Chapter 4  Reaching the Global Target for Anemia 81 Figure 4.1: Conceptual Model of Determinants of Anemia Politic l conom Ecolo , clim t , o r ph Educ tion W lth Cultur l norms nd b h vior Ph siolo ic l vuln r bilit of wom n nd childr n E rl ons t of childb rin , hi h p rit , short birth sp cin Acc ss to Acc ss to Acc ss to h lth Acc ss to Acc ss to cl n div rs food fortifi d food s rvic s nd knowl d nd w t r nd sourc s (qu lit sourc s int rv ntions duc tion bout s nit tion, nd qu ntit ) ( , iron n mi ins cticid - suppl m nt - tr t d b dn ts tion, d wormin ) In d qu t Exposur nd nutri nt G n tic r spons to int k nd h mo lobin inf ctious bsorption disord rs dis s D cr s d r throc t production Incr s d r throc t loss An mi Source: Balarajan et al. 2011, p. 2125, © Elsevier. Reproduced with permission from Else- vier; further permission required for reuse. underlying determinants of anemia, such as poverty, a lack of educa- tion, lack of dietary diversity, and gender equity. Micronutrient Supplementation It is estimated that approximately half of anemia in high-burden coun- tries is the result of iron deficiency, but figures may vary by context. 82 An Investment Framework for Nutrition A Cochrane review of daily iron supplementation during pregnancy estimates a 70 percent reduction in anemia among pregnant women (Peña-Rosas et al. 2012). Antenatal multiple micronutrient supple- ments, such as the UNICEF Multiple Micronutrient Preparation (UNIMAP) supplement that contains 14 micronutrients, may provide additional benefits to neonatal outcomes and early childhood stunt- ing, although there is no difference in its effectiveness for reducing maternal anemia compared to iron and folic acid supplementation (Haider and Bhutta 2015). Therefore, despite the two to three times higher costs, prioritizing the scale-up of antenatal multiple micronu- trient supplementation may deliver the best long-term benefits for both mother and child. For non-pregnant women, an intermittent (weekly) dosage of iron and folic acid supplementation is estimated to lead to a 27 percent reduction of anemia (Fernández-Gaxiola and De-Regil 2011; WHO 2011a). In areas of high prevalence (greater than 40 percent), the WHO recommends daily iron supplementation for this group (WHO 2016). Table 4.1 shows recommended dosages for non-pregnant and preg- nant women based on country anemia prevalence. Three other emerging supplementation interventions have been con- sidered to address anemia, but these are not yet recommended by the WHO for full scale-up. Micronutrient powders were found to have effects similar to those of multiple micronutrient supplementation Table 4.1: Recommended Iron and Folic Acid Dosages for Non-Pregnant and Pregnant Women Country anemia Target population Iron and folic acid dosage prevalence (%) Non-pregnant women > 40 Daily 30–60 mg elemental iron1 age 15–49 > 20 Weekly 60 mg iron + 2.8 mg folic acid2 > 40 Daily 60 mg iron + 0.4 mg folic acid3 Pregnant women < 40 Daily 30–60 mg elemental iron + 0.4 mg folic acid3 Non-anemic pregnant < 20 Weekly 120 mg elemental iron + 2.8 mg folic acid4 women Women diagnosed with All settings Daily 120 mg elemental iron and 0.4 mg folic acid2 anemia in clinical setting Data sources: 1. WHO 2016; 2. WHO 2011a; 3. WHO 2012a; 4. WHO 2012b. Note: mg = milligrams. Chapter 4  Reaching the Global Target for Anemia 83 (WHO 2011b) and WHO guidelines for scaling up supplements are forthcoming. Small quantity lipid-based nutrient supplements also had effects similar to iron and folic acid supplementation in some studies, but evidence of effectiveness is not yet conclusive (Choud- hury et al. 2012; Suchdev, Peña-Rosas, and De-Regil 2015). Further- more, evidence of the effect of vitamin A supplementation on anemia in adolescents and pregnant women remains mixed (Michelazzo et al. 2013). Because these interventions have not yielded significant results, there are no WHO guidelines for scaling these up as yet. Food-Based Interventions Food-based approaches—mainly through the fortification of sta- ple grains and cereals and, less commonly, salt, sauces, and milk products—have also shown to be effective in reducing anemia in ­ women (Gera, Sachdev, and Boy 2012). However, less is known about the impact of these interventions at scale. Fortification of wheat flour with iron and other micronutrients—which include zinc, folic acid, and B vitamins—is mandatory in 81 countries, some of which also require fortification of maize flour. Although Pachon et al. (2015) found limited effectiveness of flour fortification reducing prevalence of anemia in women, another review found that countries that fortify wheat flour at WHO guideline levels, after controlling for the level of development as measured by the Human Development Index and for malaria prevalence, yield a 2.4 percent reduction in the odds of ane- mia in non-pregnant women per year compared with countries that do not fortify (Barkley, Wheeler, and Pachon 2015). Therefore fortifica- tion can prove beneficial for large-scale reduction in anemia in general populations, and particularly among non-pregnant women. Interventions to improve iron intakes through greater dietary diver- sity of food produced on the homestead, biofortification, and increas- ing meal frequency may have potential for future impact but are dif- ficult to measure and have limited evidence of impact at scale to date (Cercamondi et al. 2013; Olney et al. 2009). Treatment of Diseases and Infections In areas of moderate-to-high risk of malaria transmission, particularly Sub-Saharan Africa, WHO guidelines recommend that all pregnant women receive intermittent presumptive treatment in pregnancy with sulfadoxine-pyrimethamine at each scheduled antenatal care visit starting as early in the second trimester as possible, but coverage 84 An Investment Framework for Nutrition remains low (WHO 2014). Intermittent presumptive treatment of malaria in pregnancy has shown to reduce the risk of moderate-to- severe anemia by 40 percent and the risk of any anemia by around 17 percent among women in their first or second pregnancy (Radeva- Petrova et al. 2014). Evidence suggests that the use of insecticide- treated bed nets to prevent malaria during pregnancy reduces anemia by 5 to 12 percent, but these results are not statistically significant (Gamble, Ekwaru, and ter Kuile 2006). Overall, preventing anemia by reducing malaria transmission can be an effective intervention for pregnant women. Although hookworm infection and human immu- nodeficiency virus (HIV) are associated with anemia, deworming and antiretroviral therapy have not been shown to reduce anemia.2 Analytic Approaches Specific to the Anemia Target This section lays out the methods used in the analyses that are specific to estimating the financing needs, impact, and benefit-cost ratios of reach- ing the anemia target. For more detail on methodology, see chapter 2. Measurement of Anemia in Women Anemia in women refers to anemia in women of reproductive age, which includes all non-pregnant women 15 to 49 years of age and all pregnant women. Anemia in women, for the purposes of the World Health Assembly target, is measured by the prevalence of any form of anemia spanning from mild to severe forms (WHO 2015a; WHO and 1,000 Days 2014) in the above-mentioned target groups (table 4.2). Data on anemia, or low concentrations of hemoglobin, are collected through the Demo- graphic and Health Surveys (DHS), Malaria Indicator Surveys (MIS), Reproductive Health Surveys (RHS), national micronutrient sur- veys or Multiple Indicator Cluster Surveys (MICS), or other similar national surveys and modeled to estimate the prevalence of women below the cutoff of 110 grams of hemoglobin per liter of blood for 2 Hookworm infection is associated with the prevalence of anemia in both pregnant and non- pregnant women (Smith and Brooker 2010), but a review of deworming interventions, such as antihelminthics, shows that they do not significantly impact hemoglobin levels or anemia prevalence (Salam et al. 2015). Anemia is also a strong predictor of disease progression and death among people infected with HIV, including those who have initiated anti-retroviral therapy (ART). Generally ART improves hemoglobin status but it does not always resolve anemia and, in some contexts, leads to a higher risk of anemia (Johannessen et al. 2011; Takuva et al. 2013; Widen et al. 2015). Chapter 4  Reaching the Global Target for Anemia 85 Table 4.2: Anemia Severity Thresholds in Women Grams of hemoglobin/liter blood Anemia severity threshold Non-pregnant women (g/L) Pregnant women (g/L) Mild 110–119 100–109 Moderate  80–109  70–99 Severe <80 <70 Data source: WHO 2011c. Note: g/L = grams per liter. pregnant women and 120 grams per liter for non-pregnant women. Anemia prevalence as of 2011 was 38 percent in pregnant women and 29 percent in non-pregnant women, translating to 32 million pregnant women and 496 million non-pregnant women, respectively (Stevens et al. 2013). In the country sample used in the analyses, prevalence of anemia among women ranges from 14.4 percent in Mexico to 57.5 percent in Senegal, with 12 of 26 countries above 40 percent (high prevalence) and 5 countries below 20 percent prevalence (high absolute burden). Interventions Included in the Analyses In order to achieve the World Health Assembly target for anemia in women, the target population benefiting from anemia prevention and control interventions will need to be significantly expanded from the 125 million pregnant women to reach 1.5 billion non-pregnant women of reproductive age. Achieving this ambitious target will require approaches across multiple sectors. The analyses estimate the costs and impact of scaling up a minimum core set of interventions that (1) are applicable to all countries, (2) have a strong evidence base for effectiveness in preventing anemia, and (3) together can plausibly achieve the proposed target. Applying these criteria in consultation with the Technical Advisory Group (see appendix A), the analyses estimate the financing needs for scaling up four core anemia prevention interventions: (1) antenatal micronutrient supplementation, (2) intermittent presumptive treat- ment of malaria in pregnancy in malaria-endemic regions; (3) iron and folic acid supplementation in non-pregnant women 15–49 years of age, and (4) staple food fortification (wheat flour, maize flour, and 86 An Investment Framework for Nutrition rice) with iron for the general population at WHO guideline levels (see table 4.3). Since targeting the fortification of staple foods to a subgroup of women would not be feasible, nor is it recommended, and since anemia affects men as well, the target beneficiaries for staple food fortification are the entire general population (males and females of all ages). Table 4.3: Interventions to Reach the Anemia Target Target Description and delivery Intervention Evidence of effectiveness population methods For pregnant women A review by Peñas-Rosas et al. (2012) finds that daily iron supplements in pregnancy lead to a 70 percent reduction This is broadly defined as a in maternal anemia [RR 0.30, micronutrient supplementation 95% CI 0.19–0.46]. Although that contains iron and at least antenatal multiple micronutrient two or more micronutrients. supplementation is not more The cost is calculated for Antenatal effective at reducing anemia Pregnant supplementation containing micronutrient than iron and folic acid women 15 micronutrients/vitamins, supplementationa supplementation alone, it is including iron and folic acid, recommended because of its for 180 days per pregnancy. effectiveness in improving Supplementation is delivered birth outcomes (it prevents through antenatal care low birthweight and newborns programs. who are small for gestational age) and thereby preventing childhood stunting (see table 3.1 in chapter 3). Intermittent Radeva-Petrova et al. (2014) This intervention provides presumptive Pregnant estimate that intermittent at least two doses of treatment of women in presumptive treatment of sulfadoxine-pyrimethamine malaria in malaria- malaria in pregnancy results in during pregnancy. Treatment pregnancy in endemic a 17 percent reduction in the is delivered through antenatal malaria-endemic regions risk of any anemia [RR 0.83, care. regions 95% CI 0.74–0.93]. For all women of reproductive age Delivery of weekly iron and folic acid supplement in school-based A review by Fernández-Gaxiola Iron and Non- programs for girls age 15–19 and De-Regil (2011) finds folic acid pregnant enrolled in school, and delivery that weekly iron and folic acid supplementation women age via community health workers, supplementation results in a for non-pregnant 15–49 years health facility outpatient visits, 27 percent reduction in anemia women and/or via private marketplace [RR 0.73, 95% CI 0.56–0.95]. for all others. (continued) Chapter 4  Reaching the Global Target for Anemia 87 Table 4.3: Interventions to Reach the Anemia Target (continued) Target Description and delivery Intervention Evidence of effectiveness population methods For the general population A review of wheat flour fortification programs by Barkley, Wheeler, and Pachon (2015) finds that fortification Fortification of wheat flour, at WHO guideline levels is maize flour, and rice with Staple food General associated with a 2.4 percent iron at WHO guideline levels fortification population reduction in the odds of anemia and delivered through the in non-pregnant women per marketplace. year [prevalence odds ratio 0.976, 95% CI 0.975–0.978]. A similar impact of fortification of maize and rice is assumed. Note: CI = confidence interval; RR = relative risk. a. WHO guidelines are expected in late 2016. Antenatal micronutrient supplementation is included in the analyses for pregnant women instead of iron and folic acid ­ supplementation— despite its higher costs—because of its effectiveness in improving birth outcomes and thereby preventing childhood stunting. In addi- tion, this allows the analysis for the anemia target to align with the stunting target and to avoid any underestimation. New WHO guide- lines on antenatal micronutrient supplementation are expected in late 2016, after which this strategy can go to scale.3 Daily iron and folic acid supplementation for non-pregnant women is recommended by the WHO for countries where the prevalence of anemia is greater than 40 percent. For the large population of non-­ pregnant women, weekly iron and folic acid supplementation is included in the analyses because of the greater feasibility of delivering a weekly supplement than a daily supplement. In this population, the analysis assumes supplementation is delivered to adolescent girls age 15–19 through school programs and to other non-pregnant girls and women through community health workers, outpatient visits, and the private marketplace (see table 4.4). This report focuses on costing a package of primarily preventive nutrition-specific interventions that have proven efficacy in averting 3 As of the writing of this report, the WHO website indicated that a guideline containing recommen- dations relevant to this intervention is planned for release in 2016. See http://www.who.int/elena/ titles/micronutrients_pregnancy/en/ 88 An Investment Framework for Nutrition Table 4.4: Assumed Delivery Platforms for Iron and Folic Acid Supplementation for Women, by Secondary School Enrollment and Poverty Status Women age 15–19 enrolled in school Women age 15–49 not enrolled in school (%) (%) Delivery  ➡ platform Community School-based Hospital/nurse Private retailer health worker delivery delivery delivery Poverty status delivery ➡     Below the poverty line 100 70 30  0 Above the poverty line 100 49 21 30 anemia (table 4.3). Though not included in this package, it is also important for the health system to provide for the treatment for ane- mia where feasible; this may require medical consultations, testing, and diagnosis of the cause in addition to micronutrient supplemen- tation. This may be particularly important for women with severe anemia, which has a prevalence of only 1.8 percent in non-pregnant women and 2.0 percent in pregnant women globally (Stevens et al. 2013). Sample Selection The analysis for the anemia target is based on a sample of 26 coun- tries, which includes 20 countries with the highest absolute bur- den and an additional 6 countries with the highest prevalence (see table 2.2 for the list of countries). The threshold for highest prevalence is a prevalence rate of anemia in women of reproductive age greater than 50 percent. Altogether, the sample accounts for 82 percent of the global burden of anemia in women of reproductive age.4 Estimating Costs The total additional costs of achieving the anemia target is the sum of the annual costs of scaling up the four selected core interventions from baseline coverage levels in 2015 to full coverage over a 10-year timeframe for the sample of countries identified in chapter 2 (see table 2.2). 4 For the purposes of this report, the term anemia in women of reproductive age has been shortened to anemia in women. Chapter 4  Reaching the Global Target for Anemia 89 Unit costs for these interventions are derived from either the pro- gram or the ingredients approaches, depending on data availability. The cost of the iron and folic acid supplement per woman per year ($0.12) is obtained from the OneHealth Tool manual (Futures Institute 2013), to which a 10 percent transportation cost is added. In addi- pregnant tion, the costs of four different delivery platforms for non-­ women are included since there is no existing platform from which to extrapolate (table 4.4). The cost of delivery through school-based programs for girls age 15–19 enrolled in secondary school (World Bank 2016) includes an additional program cost of $0.33 for the Sub- Saharan Africa and South Asia regions and $0.50 for other regions (WHO 2011c).5 Up to 30 percent of women living above the poverty line are assumed to potentially purchase iron and folic acid supple- ments through private retailers similar to coverage levels achieved with micronutrient powder distribution in some cases (Bahl et al. 2013), although this could vary widely across contexts. Bahl et al. (2013) find that, on average, multiple micronutrient supple- ments are sold with an 83 percent markup. Therefore this analysis assumes that private retailers would mark up the cost of iron and folic acid supplements to the same degree. Of the remaining women and girls above and below the poverty line, 70 percent are assumed to be able to access iron and folic acid supplements through consul- tations with a community health worker and 30 percent through a consultation in a hospital setting with a nurse. The distribution of iron and folic acid supplements to a woman is estimated to require two consultations of five minutes each with a health worker per year. Human resources for health costs are estimated by multiplying the time allocation for all annual consultations by salary estimates for community health workers, which range from $80 to $917 per month (Casey et al. 2011; Dahn et al. 2015; Maternal and Child Health Inte- grated Program 2011), and nurse salaries, which range from $3,047 to $40,265 per annum in sample countries (WHO 2005). Five countries in the sample have a prevalence of anemia in women below the WHO threshold of 20 percent for this intervention, but were selected because of their high absolute burden of anemia. However, a maximum attain- able coverage of 75 percent is assumed for countries with a prevalence of between 15 and 19 percent (that is, China, Brazil, and Ethiopia) and 50 percent for countries with a prevalence below 15 percent (that is, Mexico and Vietnam. 5 A program unit cost, in addition to the cost of the micronutrient supplement, is included in order to develop and sustain the infrastructure with the education system and schools for the effective delivery to adolescent girls. 90 An Investment Framework for Nutrition Estimating the costs of staple food fortification is challenging since there are large gaps in data regarding food consumption and forti- fication coverage as well as a wide variability of fortification costs between settings (Fiedler and Puett 2015; Fiedler, Sanghvi, and Saunders 2008). Primary sources of cost and coverage data are from the Global Alliance for Improved Nutrition (GAIN) costing model (Ghauri et al. 2016) and the Food Fortification Initiative (FFI) coverage data (Pachon 2016). The per capita fortification unit costs are lowered to 0 percent, 25 percent, and 50 percent if the available data suggest that there is, respectively, no, low, or moderate demand for consump- tion for each particular type of food staple in each country—this is an attempt to take into account dietary differences across populations. Baseline coverage of fortified foods is assumed to be 50 percent in countries that have legislated mandatory fortification of wheat flour, maize flour, and rice to reflect the fact that small and medium-sized mills and food producers may be excluded from legislation. The estimated total cost is the product of the unit cost for each food in each country and the gradual scale-up of fortification to the whole country between baseline coverage in 2015 and full potential coverage. Following the GAIN costing model, domestic governments and donors would each be responsible for approximately 5 percent of the total costs—mainly for start-up programs and social marketing costs—and the remaining 90 percent would be borne by the private sector to be recouped through consumer sales of fortified products. The costs of fortifying all other foods, such as vegetable oil, dairy products, and other vegetables or grains, are not included, nor are the costs of biofortification explicitly included since there may be overlap or redundancy in fortification vehicles. Costing of two interventions— antenatal micronutrient supplementation and intermittent presump- tive treatment of malaria in pregnancy in malaria-endemic regions— uses a methodology similar to the stunting target (see chapter 3). Estimating Impact For the impact analysis, a model in Microsoft Excel was developed to parallel the pathways for interventions that affect anemia in women in the Lives Saved Tool (LiST) (Bhutta et al. 2013; Walker, Tam, and Friberg 2013; Winfrey, McKinnon, and Stover 2011). The specific pathways and effect sizes used in this model are shown in figure 4.2. Preventative interventions for the non-pregnant female population are included in this model, but not other modeling tools. Effect sizes of interventions are taken from recent systematic reviews (see table 4.3). Chapter 4  Reaching the Global Target for Anemia 91 92 Figure 4.2: Underlying Model Used to Estimate the Impact of Interventions on Anemia in Women St pl food fortific tion Int rmitt nt pr sumptiv 2.4% d cr s An mi Eff ctiv n ss: tr tm nt of p r r 0.83 m l ri in pr n nc in m l ri - nd mic Non-pr n nt Pr n nt r s wom n wom n Eff ctiv n ss: Eff ctiv n ss: Iron nd folic cid 0.73 0.30 suppl m nt tion Ant n t l for non-pr n nt micronutri nt wom n suppl m nt tion Note: Effectiveness is the proportionate reduction in each outcome that results from the intervention. It is used in conjunction with an affected fraction value to estimate the impact of an intervention on each outcome. See table 4.3 for sources. An Investment Framework for Nutrition The Excel model computes the number of cases of anemia in women averted in each sample country over the 10-year scale-up of interven- tions compared with the baseline. A limitation of all these models is the inability to differentiate between mild, moderate, and severe cases of anemia (see table 4.2). The number of child and maternal deaths averted attributed to the scale-up of interventions that affect anemia is estimated using LiST.6 Because it is not possible to distinguish between the effects of iron and folic acid supplementation and those of food fortification on mortality in the model, it is assumed that the child deaths averted are attributable to the combined impact of the two interventions. The analyses did not estimate potential reductions in low birthweight and small for gestational age of children born to anemic mothers. In addition, a historical trend for declining anemia rates is assumed to extend over the next 10 years. The modeled 1.1 percent decline per year in anemia rates is based on the WHO Global Nutrition Tracker dataset (WHO 2015a). This trend may capture the effects of underly- ing determinants of anemia—such as food diversity, levels of women’s education, and previous delivery of interventions at lower coverage levels. The cost per case-year of anemia averted and the cost per death averted by these interventions are also estimated in order to assess the allocative efficiency of each intervention and the full package. Benefit-Cost Analyses The benefit-cost analysis of investing in the selected anemia inter- ventions uses a methodology similar to that for the stunting target (see chapter 3). Monetary benefits, are estimated for three economic outcomes attributed to reductions in the prevalence of anemia in women: (1) female earnings gained as a result of increased productiv- ity, (2) earnings gained as a result of maternal deaths averted, and (3) earnings gained as a result of child mortality averted. The outputs from the Excel model for projected anemia prevalence reductions and the LiST results for the number of maternal and child deaths averted over the 2016–25 period are inserted as inputs into the benefit-cost analysis. This approach is used by Horton and Ross (2003, 2007) and Casey et al. (2011) for estimating the earnings gained by women as a result of increased productivity in terms of gross domestic prod- uct (GDP) per capita, in which a 50 percent labor share of GDP is assumed. The earnings gained are estimated as the product of the 6 A beta version of LiST (version 5.41 beta 13) is used for the analyses. Chapter 4  Reaching the Global Target for Anemia 93 number of cases of anemia averted because of interventions and the higher wages in manual occupations because of higher produc- tivity without anemia (wages are 5 percent higher for light labor, 17 percent higher for heavy manual labor, and 4 percent for other work). The female labor force participation rate is also factored in using the International Labour Organization’s ILOSTAT database so as not to overestimate the number of employed women (ILO 2015). Productivity-related earnings gained in adults are assumed to be ­ incurred in the same year as the intervention is delivered (Horton and Ross 2003). Estimating the earnings gained related to mortality averted uses the same methodology as in the stunting target analysis, which assumes that earning gains would be incurred for children over their work- ing lives from age 18 until mean life expectancy in each country or 65 years of age, whichever is lower. For earnings gains due to maternal mortality averted as a result of the intermittent presumptive treatment of malaria in pregnancy in malaria-endemic regions, earnings gained between the mean maternal age in each country until the mean life expectancy or 65 years of age, whichever is lower, is estimated (World Bank 2016). A 3 percent GDP growth rate is assumed across countries, which is lower than the historical average of low- and middle-income countries. The analysis varies the discount rates of benefits and costs to 3 percent and 5 percent for comparison, as done in Horton and Hoddinott (2014). This benefit-cost analysis does not include potential benefits, includ- ing savings from reduced health care costs for the diagnosis and treat- ment of anemia, other indirect consequences of anemia in women, and benefits of reduced anemia in children and men attributed to the scale-up of staple food fortification. In that sense, the total benefits described are underestimates. Sensitivity Analyses As mentioned above, there are gaps in data required for the analy- ses, particularly related to projections for feasible scale-up scenarios of interventions, the effectiveness of fortification, and unit costs for emerging delivery platforms. One-way sensitivity analyses are presented for the key drivers of costs, impacts, and benefit-cost ratios by altering several variables for each analysis. Sensitivity analyses are presented for the total 10-year costs of anemia interventions with the following variable changes: (1) removing public sector human 94 An Investment Framework for Nutrition resource for health delivery costs for iron and folic acid supplementa- tion, (2) adjusting the target coverage of iron and folic acid supple- mentation in the five countries with a prevalence of anemia below the 20 percent WHO guideline threshold to coverage ranging from 0 percent to 100 percent (signifying fully including or excluding in those countries),7 and (3) lowering the maximum scale-up coverage achievable for all interventions from 90 percent to a more feasible 50 percent or 75 percent. The impact sensitivity analysis shows the change in impact expected by varying the same last two variables as in the cost sensitivity plus the effectiveness of food fortification equal to no effect (0 percent reduction of anemia per year) and the effective- ness of the other three interventions to the lower and upper bounds of the 95 percent confidence interval estimates stated in the literature. Results This section presents the results of the analyses of the interventions described above, including costs, impacts, and benefit-cost results. Unit Costs The unit costs employed in the analyses for the interventions targeting pregnant women are the same as those used for the stunting target in chapter 3. The costing literature for interventions for anemia preven- tion in non-pregnant women is less well established, and micronutri- ent costs are known to vary widely between contexts (Fiedler, Sang- hvi, and Saunders 2008; Fiedler and Semakula 2014). See table 4.5 for a list of the minimum, maximum, and population-weighted mean unit cost by intervention used across the sample countries. Gaps in cost data are filled by proxy values from a similar country in the same region or income group. Total Scale-Up Costs The total additional costs of scaling up the selected core set of inter- ventions necessary to meet the World Health Assembly anemia target in low- and middle-income countries is approximately $12.9 bil- lion from domestic government resources and official development assistance (ODA) from 2016 to 2025. Under this scale-up scenario, the The five countries with anemia prevalence below 20 percent are Brazil, China, Ethiopia, Mexico, and 7 Vietnam (Stevens et al. 2013). Chapter 4  Reaching the Global Target for Anemia 95 Table 4.5: Minimum, Maximum, and Mean Unit Costs of Interventions to Meet the Anemia Target (Annual) U.S. dollars Mean Intervention Minimum Maximum unit cost Antenatal micronutrient supplementation 1.80 7.55 2.99 Intermittent presumptive treatment of malaria in pregnancy 2.06 2.06 2.06 in malaria-endemic regions Iron and folic acid supplementation for non-pregnant women   School-based program delivery 0.46 0.63 0.55   Community health delivery 0.21 1.78 0.73   Hospital/nurse delivery 0.54 5.54 1.78   Private retailer delivery 0.24 0.24 0.24 Staple food fortification   Wheat flour 0.08 0.29 0.18   Maize flour 0.09 0.29 0.13  Rice 0.08 1.41 0.74 Note: The mean unit costs are population-weighted means. total annual additional costs would escalate from baseline to $1.7 bil- lion by 2021 (see figure 4.3), and would then increase slightly over the maintenance phase because of the population growth in women of reproductive age in low- and middle-income countries. The majority of domestic government and ODA financing needs are for iron and folic acid supplementation for non-pregnant women ($6.7 billion) and smaller investments for staple food fortification for the general population ($2.4 billion), for antenatal micronutrient supplementation ($2.0 billion), and for intermittent presumptive treatment of malaria in pregnancy in malaria-endemic regions ($337 million). In addition, there are further household costs in the amount of $505 million for the purchase of iron and folic acid supplementation by a share of women above the poverty line and $19.1 billion for the expected incremental additional cost of fortified foods (compared with unfortified foods) purchased by households (table 4.6). East Asia and the Pacific region requires a $5.24 billion share of the total financing needs, while Sub-Saharan Africa ($2.50 billion) and South Asia ($2.45 billion) each require smaller shares of the total 10-year public sector/official development assistance cost, respectively 96 An Investment Framework for Nutrition Figure 4.3: Annual Financing Needs to Meet the Anemia Target U.S. dollars, millions 5,000 4,500 4,347 4,366 4,385 4,404 4,327 4,000 3,589 3,500 3,000 2,858 US$, millions 2,500 2,132 2,000 1,500 1,414 1,000 633 500 0 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 Tot l priv t /hous hold Dom stic ov rnm nt/ODA Note: ODA = official development assistance. (figure 4.4). The total cost for East Asia and the Pacific is greater than it is for South Asia and Sub-Saharan Africa in this model primarily because of the higher quantity of fortified rice expected to be con- sumed proportional to other less costly fortified foods in other regions as well as higher delivery costs for iron and folic acid supplementa- tion than in the South Asia and African regions. By income group, low-income countries account for 13 percent of the total costs, lower- middle-income countries for 40 percent, and upper-middle-income countries for 47 percent (figure 4.5). Sensitivity Analyses of Estimates of Financing Needs The total costs for reaching the anemia target are sensitive to changes in several key variables. One of the uncertainties pertaining to this analysis is the unprecedented scale-up of iron and folic acid supple- mentation for non-pregnant women, which is needed to meet the Chapter 4  Reaching the Global Target for Anemia 97 Table 4.6: Ten-Year Total Financing Needs to Meet the Anemia Target Total 10-year Share of total intervention Intervention 10-year cost costs (%) (US$, millions) Antenatal micronutrient supplementation 2,017  6 Intermittent presumptive treatment of malaria in pregnancy in 337  1 malaria-endemic regions Iron and folic acid supplementation for non-pregnant women 6,705 22 Iron and folic acid supplementation for non-pregnant women 505  2 (household cost) Staple food fortification (wheat flour, maize flour, and rice) 2,443  8 Staple food fortification (wheat flour, maize flour, and rice) 19,067 61 (household/private sector cost) Subtotal Program (capacity strengthening, monitoring and evaluation, and 1,380 n.a. policy development) Total (excluding household/private sector cost) 12,882 n.a. Total (including household/private sector cost) 32,453 n.a. Note: n.a. = not applicable. Figure 4.4: Ten-Year Total Financing Needs to Meet the Anemia Target, by Region 5% 20% 19% 7% 8% 41% South Asi Middl E st nd North Afric E st Asi nd th P cific Sub-S h r n Afric L tin Am ric nd Europ nd th C ribb n C ntr l Asi 98 An Investment Framework for Nutrition Figure 4.5: Ten-Year Total Financing Needs to Meet the Anemia Target, by Country Income Group 40% 47% 13% Low-incom countri s Upp r-middl -incom countri s Low r-middl -incom countri s target. The sensitivity analysis tornado diagram (figure 4.6) shows that, if public health system personnel costs are removed (which would be possible only if this intervention could be bundled with an already existing intervention for this population group), the total 10-year financing needs would decrease by $7 billion. Another factor that has a large effect on total financing needs is the scale-up of iron and folic acid supplementation for non-pregnant women in the five countries that have less than a 20 percent prevalence of anemia. Ini- tially either 50 percent or 75 percent of the female populations in these countries have been included as potential target beneficiaries. Exclud- ing the scale-up in countries with less than 20 percent national preva- lence would reduce the global costs by about $3 billion over 10 years, but there would be a tradeoff in terms of prevalence reductions. Lowering the maximum attainable coverage level for all interventions to 75 percent or 50 percent would be more realistic and would lower the total 10-year costs by $4 billion and $2 billion, respectively. Replac- ing the private sector delivery of iron and folic acid supplementation for non-pregnant women living above the poverty line with public sector delivery would add about $2 billion in human resource costs for delivery over 10 years. Chapter 4  Reaching the Global Target for Anemia 99 100 Figure 4.6: Sensitivity Analysis for 10-Year Total Financing Needs to Meet the Anemia Target 0 2 4 6 8 10 12 14 16 18 R mov public h lth s st m p rsonn l costs from iron nd folic cid suppl m nt tion for non-pr n nt wom n Excludin or includin th sc l -up of iron nd folic cid suppl m nt tion for non-pr n nt wom n in ll countri s with n n mi pr v l nc < 20% 50% sc l -up cov r of iron nd folic cid suppl m nt tion for non-pr n nt wom n Assum no priv t suppl of iron nd folic cid suppl m nt tion for non-pr n nt wom n bov th pov rt lin (th t is, dd public s ctor hum n r sourc s/impl m nt tion costs) 75% sc l -up cov r of iron nd folic cid suppl m nt tion for non-pr n nt wom n Tot l lob l low- nd middl -incom 10- r costs, US$, billions Hi h r costs Low r costs An Investment Framework for Nutrition Impact The model suggests that there is a scenario, albeit an ambitious one, whereby the World Health Assembly target for anemia in women can be achieved by 2025. This investment in anemia prevention interven- tions is projected to result in 265 million fewer anemic women in the year 2025 compared with the baseline in 2015 (see figure 4.7). Under this scenario, the prevalence of anemia is projected to decrease to 15.4 percent in 2025, resulting in 799,000 child deaths averted in the next 10 years. This includes the impact of the four nutrition interven- tions plus the continuation of the 1.1 percent per year annual rate of reduction (that is, the historical trend) across all low- and middle- income countries, based on the WHO Global Nutrition Tracker dataset (WHO 2015a). In addition, the scale-up of intermittent presumptive treatment of malaria in pregnant women in malaria-endemic regions would prevent between 7,000 and 14,000 maternal deaths over the next 10 years. The five countries with the highest total child deaths averted in the projected scenario are India, Nigeria, Pakistan, China, and Bangladesh,8 which together account for 63 percent of estimated child deaths averted across all low- and middle-income countries. In terms of allocative efficiency, both micronutrient interventions demonstrate a relatively low cost per case-year for anemia compared with the cost for intermittent presumptive treatment of malaria in pregnancy in malaria-endemic regions. Not surprisingly, the two interventions targeting pregnant women—antenatal micronutrient supplementation and intermittent presumptive treatment of malaria in pregnancy in malaria-endemic regions—demonstrate lower cost per death averted than the interventions for non-pregnant women and the population at large (table 4.7). The effects of iron and folic acid supple- mentation and staple food fortification on child mortality are not mod- eled separately because they have overlapping causal pathways for anemia and mortality and are modeled jointly in LiST. Sensitivity Analyses of the Impact of the Scale-Up This global projection for achieving the World Health Assembly target for the reduction in anemia prevalence over the next 10 years depends on major assumptions about the collective ability to secure financing and implement interventions on an unprecedented scale. The sensitiv- ity analyses for impacts (see figure 4.8) demonstrate that reducing the 8 The estimated number of child deaths averted is 286,854 in India; 83,612 in Nigeria; 65,762 in Paki- stan; 36,825 in China; and 33,989 in Bangladesh. Chapter 4  Reaching the Global Target for Anemia 101 102 Figure 4.7: Costs and Impacts of a 10-Year Scale-Up of Interventions to Meet the Anemia Target 35 Exp ct d ch n du to historic l tr nd 30 • 799,000 child d ths v rt d 25 ov r 10 rs Int rv ntions for non-pr n nt wom n • 265 million 15–49 (%) 20 c s s of n mi pr v nt d 15 T r t: 50% r duction in n mi b 2025 Wom n Int rv ntions for Tot l public/ODA pr n nt wom n 10 costs = $12.9 billion ov r 10 rs 5 Tot l hous hold 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 costs = $19.6 billion ov r 10 rs Note: ODA = official development assistance. a. This trend represents an extension of average annual rate of reduction of anemia rate without scale-up. An Investment Framework for Nutrition Table 4.7: Total Cost, Cost per Case-Year of Anemia Averted, and Costs per Death Averted Total 10- Cost per case- Costs per child Intervention year costs year of anemia death averted (US$, billions) averted (US$) (US$) Antenatal micronutrient supplementation  2.26 11 6,740 Intermittent presumptive treatment of malaria in pregnancy in malaria-endemic  0.38 62 4,531 regions Iron and folic acid supplementation for non-  7.51 10 pregnant women 26,914a Staple food fortification  2.74  7 Full package 12.88  9 16,121 Note: Because of rounding, the total 10-year costs do not equal the sum of the cost of each intervention. a. This figure is the combined cost per death averted estimated to result from iron and folic acid supplementation for non-pregnant women and the cost of staple food fortifi- cation in the pre-conceptual stage, since it was not possible to independently estimate the impact on mortality of these interventions in the model. attainable level of scale-up coverage or varying the effectiveness of staple food fortification of other micronutrient interventions results in underachieving the target by 5 to 10 percentage points. Furthermore, if the assumption on the extension of the historic trend in declining anemia rates does not continue, then the prevalence will underachieve by an additional 0 to 10 percentage points. Benefit-Cost Analyses The benefit-cost analysis of investing in the modeled package of interventions to prevent anemia in women suggests that there would most likely be a positive return on investment for low- and middle- income countries in the sample. Assuming a 3 percent GDP growth rate across countries and 3 percent discount of costs and benefits proj- ects a total net benefit from the investment in anemia prevention of $110.1 billion over 10 years and a pooled benefit-cost ratio of 12.1 (the median ­ benefit-cost ratio in sample is 10.6). When pooled by income group, the result is a benefit-cost ratio of 4.2 for low-income countries, 15.2 for lower-middle-income countries, and 10.9 for upper-middle- income countries, respectively (table 4.8). By region, this translates into a benefit-cost ratio of 13.1 for Sub-Saharan Africa, 14.0 for South Asia, and 10.9 East Asia and the Pacific. Chapter 4  Reaching the Global Target for Anemia 103 104 Figure 4.8: Sensitivity Analyses of the Impact of Interventions to Meet the Anemia Target 0.05 0.1 0.15 0.2 0.25 0.3 Fortific tion i lds 0% n mi r duction p r r 95% confid nc int rv l ff ct si for th iron nd folic cid suppl m nt tion for non-pr n nt wom n, nt n t l micronutri nt suppl m nt tion, nd int rmitt nt pr sumptiv tr tm nt of m l ri in pr n nc in m l ri - nd mic r s int rv ntions 50% sc l -up cov r of iron nd folic cid suppl m nt tion for non-pr n nt wom n 75% sc l -up cov r of iron nd folic cid suppl m nt tion for non-pr n nt wom n Excludin or includin iron nd folic cid suppl m nt tion for non-pr n nt wom n in ll wom n in countri s with n mi pr v l nc < 20% Pr v l nc of n mi (%) N tiv ff ct Positiv ff ct Note: This package is estimated to reach 15.4 percent prevalence; the sensitivity analyses show potential deviations from this estimate. An Investment Framework for Nutrition Table 4.8: Benefit-Cost Ratios of Scaling Up Interventions to Meet the Anemia Target, 3 and 5 Percent Discount Rates 3% discount rate 5% discount rate Region Present Present Benefit- Present Present Benefit- value benefit value cost cost value benefit value cost cost (US$, billions) (US$, billions) ratio (US$, billions) (US$, billions) ratio By region Sub-Saharan 16.1 1.2 13.1  9.4 1.1 8.6 Africa* South Asia* 25.9 1.9 14.0 14.2 1.6 8.7 East Asia and 33.0 3.0 10.9 21.2 2.7 7.9 the Pacific* By country income group Low-income 2.6 0.6  4.2  1.5 0.6 2.6 countries* Lower-middle- income 47.9 3.2 15.2 27.0 2.8 9.7 countries* Upper-middle- income 40.1 3.7 10.9 3.3 7.9 countries* 26.0 Pooled 110.1 7.6 12.1 66.1 8.1 8.2 Median* 10.6 7.4 Note: *Sample countries only. Using 5 percent discount rates for comparison, the benefit-cost ratios decrease slightly across the sample. This more conservative model projects a total net benefit of over $66 billion and a pooled 8.2 benefit- cost ratio across countries (median benefit-cost ratio in sample is 7.4). In general, the benefit-cost analyses suggest that there would be a positive return on investment and substantial productivity gains to be generated from preventing anemia in women. Discussion Achieving the anemia target will improve the lives of millions of women and their newborns and may contribute toward a more pro- ductive economy. However, achieving this ambitious goal will be a challenge because the current trend in the decline of prevalence rates is vastly insufficient to reach the target. A major investment is needed to rapidly scale up evidence-based interventions that reduce the bur- den of anemia among women. Chapter 4  Reaching the Global Target for Anemia 105 Expanding micronutrient programs from the current focus on chil- dren and pregnant women to all the 1.5 billion non-pregnant women in low- and middle-income countries requires a leap in supply chain logistics and increased availability and access to health services. Reaching the target also depends on large-scale expansion of food fortification. Staple food fortification has been shown to be highly effective and—with further advances in research and implementa- tion at scale—could well be part of the solution. For example, iodized salt is one of the most effective interventions for reducing disabilities including cognitive losses due to iodine deficiency. It is mandated in several countries throughout the world, but in most regions, cover- age has reached only 50 percent to 70 percent of households (Mannar 2014). It is not, however, incorporated into this analysis because iodine deficiency is not included in the global targets. The analyses are limited by the quality of the data and the validity of assumptions made in their place. The cost analysis could be vastly improved with more rigorous unit cost data and food consumption coverage data. Additional ex-post evaluations and a review of case studies on real-world scale-up scenarios as well as an analysis of both barriers and enablers to scale up would also be helpful so that the models can more accurately reflect reality. Anemia in women is easily preventable through low-cost interven- tions that provide positive returns on investment and reduce its signif- icant mortality costs. Reducing anemia in women may also contribute to reducing gender wage gaps and help some women escape poverty. Governments, donors, and communities should together seize the opportunity to increase investment in anemia prevention and control. References Bahl, K., E. Toro, C. Qureshi, and P. Shaw. 2013. 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Chapter 4  Reaching the Global Target for Anemia 111 Chapter 5 Reaching the Global Target for Breastfeeding Dylan Walters, Julia Dayton Eberwein, Lucy Sullivan, and Meera Shekar Key Messages • Optimal breastfeeding promotes child growth and cogni- tive and socio-emotional development, prevents childhood illness and death, and protects against maternal morbidity, including breast cancers. It also protects against diseases in adulthood and enhances future incomes and labor-market productivity of children in adulthood. • The World Health Assembly set the target of increasing exclusive breastfeeding for infants up to six months of age from 37 percent in 2012 to 50 percent by 2025. • Creating an enabling culture and environment in support of breastfeeding requires interventions to provide education and counseling to mothers, widespread media campaigns to promote optimal breastfeeding practices, as well as the development of appropriate policies and legislation to pro- tect exclusive breastfeeding. • The estimated global financing required to scale up a core set of interventions across all low- and middle-income countries to achieve the World Health Assembly target for exclusive breastfeeding by 2025 is $5.7 billion, or approxi- mately $4.70 for every newborn. Chapter 5  Reaching the Global Target for Breastfeeding 113 • The extension of maternity leave cash benefits from cur- rent status to six months in duration, which may increase breastfeeding rates and generate other social, health, and developmental benefits, is estimated to cost an additional $24.1 billion over 10 years, albeit these resources will need to come from other sectors. • This investment in protecting and promoting breastfeed- ing is estimated to prevent over 520,000 child deaths over 10 years and to generate a pooled benefit-cost ratio of 35. • Although achieving this target requires substantial effort, it appears less ambitious than the other global nutrition targets. The sensitivity analyses presented in this chapter show that there may be scope to go beyond the current target by 2025 or 2030. T he World Health Assembly set a global nutrition target to “increase the rate of exclusive breastfeeding in the first six months to 50 percent” globally by 2025 (WHO and UNICEF 2014). This chapter reports on the estimated global financing needs of key breastfeeding interventions needed to reach this target and presents the estimated impacts and returns on investment of those interventions. These results are intended to inform the prioritization of investments by governments, official development assistance, and other stakeholders. Optimal Breastfeeding and Its Benefits Exclusive breastfeeding is defined as the practice of giving an infant only breastmilk for the first six months of life, with no other food, other liquids, or even water (UNICEF 2011). Optimal breastfeeding practices also include the early initiation of breastfeeding immediately after birth and continued breastfeeding until two years of age and beyond. Optimal breastfeeding could have the single largest potential impact on child mortality of any preventive intervention (Bhutta et al. 2013). The evidence of the health, nutritional, cognitive, and long-term eco- nomic benefits of breastfeeding is clear. Breastfeeding has protective 114 An Investment Framework for Nutrition effects for newborns and young children that prevent common diseases such as diarrhea and pneumonia, which are the major causes of child mortality (Victora et al. 2016). Breastfeeding may also reduce the risk of childhood obesity and diabetes and, for nursing mothers, reduce the risk of breast cancer later in life. Exclusive breastfeeding for the first six months is also a natural contraceptive that can be helpful in increasing birth spacing (Victora et al. 2016). Recent evidence shows that breastfeeding is also associated with higher intelligence quotients (IQs) (Horta, Loret de Mola, and Victora 2015) and, in the longer term, with enhanced labor market and economic outcomes (Lutter 2016; Rollins et al. 2016). The State of Breastfeeding Worldwide Victora et al. (2016) report that only 37 percent of infants younger than six months globally are exclusively breastfed (Victora et al. 2016; WHO and UNICEF 2014).1 The Global Nutrition Report suggests that 47 countries are off-course for reaching the breastfeeding target, and a further 110 have missing data for this indicator (IFPRI 2016). Sub- Saharan Africa and South Asia have experienced significant increases in exclusive breastfeeding rates in the last two decades; however, rates in the East Asia and Pacific region (excluding China) have been stagnant (Cai, Wardlaw, and Brown 2012). Although beyond the scope of this report, many high-income countries also have very low rates of exclusive breastfeeding, and comparable data for many high-income countries are lacking. In low- and middle-income countries with available time-series breastfeeding data, the rates of exclusive breastfeeding have increased from 24.9 percent in 1993 to 35.7 percent in 2013 (Victora et al. 2016). Furthermore, 36.3 million newborns and infants age 0–6 months in low- and middle-income countries were not being properly fed at the time of the most recent survey (see footnote 1) and face a preventable risk of disease, cognitive and economic losses, and death. The recent Lancet breastfeeding series estimates that optimal breastfeeding could help prevent 823,000 child deaths per year and 20,000 maternal deaths from breast cancer per year (Rollins et al. 2016; Victora et al. 2016). In addition, the current low breastfeeding rates globally are estimated to result in economic losses of about $302 billion annually, or 0.49 percent of world gross national income (Victora et al. 2016). 1 This finding is based on the most recent survey reports from countries included in the analysis. Chapter 5  Reaching the Global Target for Breastfeeding 115 The determinants of breastfeeding are complex. There are numerous social, cultural, economic, and commercial forces that act as barriers to breastfeeding or promote inadequate breastfeeding, as outlined in figure 5.1 (Rollins et al. 2016). The pressures to not breastfeed also increase as a country transitions to a higher income level. Although there have been modest gains in exclusive breastfeeding rates globally in recent years, the trends are not expected to continue without investment in comprehensive breastfeeding strategies. Cur- rent levels of investment in breastfeeding, though largely undocu- mented, are perceived to be insufficient to increase rates beyond where they are now (Holla-Bhar et al. 2015; Piwoz and Huffman 2015). Given the undeniable benefits of breastfeeding and proven returns on investment in terms of economic and human development gains, greater investment is needed toward this highly cost-effective strategy. Interventions That Effectively Promote Breastfeeding Having a comprehensive breastfeeding strategy at the national level is the most effective way to influence the powerful social, economic, and cultural forces affecting a mother’s decision to breastfeed (Rollins et al. 2016) (see figure 5.1). A comprehensive breastfeeding strategy is composed of several types of interventions; the exact mix of interventions may vary from coun- try to country, depending on the local context. For the purposes of the analyses, two interventions for pregnant women and mothers of young children (infant and young child nutrition counseling and maternity leave cash benefits),2 as well as two interventions directed at the entire society (pro-breastfeeding social policies and national breastfeeding promotion campaigns) (table 5.1), are assumed to comprise a minimum core of the comprehensive strategy applicable to most contexts, which can be adapted and added to as need be. In the analyses, maternity leave cash benefits refers to the actual cash transfer to the woman, not the 2 policy that required it. Any policies or guidelines on maternity leave benefits are included within the pro-breastfeeding social policies intervention. 116 An Investment Framework for Nutrition Figure 5.1: Conceptual Framework for an Enabling Environment That Supports Breastfeeding D t rmin nts Int rv ntions Structur l Sociocultur l nd m rk t cont xt Soci l mobilis tion nd m ss m di H lth s st ms F mil nd Workpl c nd + S ttin s L isl tion, polic , fin ncin , nd s rvic s communit mplo m nt monitorin , nd nforc m nt + Couns lin , support, nd l ct tion m n m nt Moth r nd Moth r-inf nt Individu l Chapter 5  Reaching the Global Target for Breastfeeding inf nt ttribut s r l tionship E rl Exclusiv Continu d int ntion br stf din br stf din Source: Rollins et al. 2016, p. 162, © Elsevier. Reproduced with permission from Elsevier; further permission required for reuse. 117 Counseling for Mothers and Caregivers on Good Infant and Young Child Nutrition and Hygiene Practices This intervention includes individual or group-based counseling ses- sions delivered in the community and/or health facility to promote exclusive breastfeeding, depending on country context. Breastfeed- ing counseling or education delivered at the community level may be required in countries with weak health systems and lack of access to health facilities. A review by Haroon et al. (2013) demonstrates that breastfeeding counseling results in a 90 percent increase in rates of exclusive breastfeeding in infants age 0–5 months. Sinha et al. (2015) also find that counseling delivered in a health facility or in the com- munity increases the likelihood of breastfeeding when compared with not receiving any counseling. Pro-Breastfeeding Social Policies Pro-breastfeeding social policies are designed to create an enabling environment for breastfeeding and motivate maternal and house- hold decision-making toward optimal child care and feeding prac- tices. Among countries with an exclusive breastfeeding rate below 30 percent, those that rate high on a composite indicator for pro-­ breastfeeding social policies are estimated to have seen improvements in exclusive breastfeeding by 1 percent per year, or five times higher than countries with a low rating on this indicator (Rollins et al. 2016). Estimating the effect sizes for each individual policy intervention is challenging given their varying timing, degree of implementation, and number of cofounders. In particular, the adoption and enforcement of national legislation in line with the World Health Organization Inter- national Code on Marketing of Breastmilk Substitutes is considered necessary to address aggressive marketing of breast milk substitutes (Baker et al. 2016).3 Access to maternity leave is associated with higher rates of breast- feeding (Sinha et al. 2015) and even lower infant mortality in some countries (Nandi et al. 2016). For new mothers who are working, one study found that national policies guaranteeing breastfeeding breaks in the workplace were associated with an increase in the rate of exclusive breastfeeding of infants younger than six months of age 3 To date, 39 countries have fully legislated the International Code on Marketing of Breastmilk Substi- tutes while another 96 have some legal measures in place, although many continue to lack resources for monitoring implementation and enforcement against violations of the Code (WHO, UNICEF, and IBFAN 2016). 118 An Investment Framework for Nutrition by 8.9 percentage points (Rollins et al. 2016). Although most low- and middle-income countries have some form of maternity leave and pro- tection policies in position, only a few have adequate enforcement of laws or a sustainable financing scheme in place. The Baby Friendly Hospital Initiative, established in 1991 by the WHO and UNICEF as a broad program designed to strengthen the culture of breastfeeding in hospitals (Labbok 2012), may also be a policy option for certain countries. The integration of the WHO Ten Steps of Suc- cessful Breastfeeding (WHO 1998) into existing hospital accreditation systems is an important policy approach in that direction. The specific orientation of pro-breastfeeding social policies in each country will vary because of country context, but the core policies that foster a culture that supports breastfeeding need resources for development, legislation, monitoring, and enforcement. Extension of Maternity Leave Benefits Maternity leave cash benefits refer to a cash transfer to the woman, from public funds or private employers, for a stipulated duration and level of compensation, which varies widely by country. Cash benefits reduce the opportunity cost for mothers of taking maternity leave for caregiving of newborns and infants. Sinha et al. (2015) show that maternity leave is associated with a 52 percent increase in exclusive breastfeeding, but this is not specific to the effect of the extension of maternity leave cash benefits or to certain durations or levels of cash transfers. Maternity leave for new mothers probably also results in broader social, developmental, and health benefits for working moth- ers and their newborns. Furthermore, the high rates of informal sector work in low- and middle-income countries adds to the low coverage of maternity leave cash benefits and, therefore, limits the popula- tion reach of these benefits. However, these benefits will be more and more important for working mothers as wealthier and transitioning economies develop (Rollins et al. 2016). More research is needed on the effect of maternity leave cash benefits and workplace interventions on breastfeeding. National Breastfeeding Promotion Campaigns Evidence suggests that mass media campaigns to promote breast- feeding are important elements in increasing national breastfeeding rates. Sinha et al. (2015) show that strategies with media intervention integrated with counseling and community mobilization may have Chapter 5  Reaching the Global Target for Breastfeeding 119 Table 5.1: Interventions to Meet the Breastfeeding Target Target Intervention Description Evidence of effectiveness population For mothers of infants Reanalysis by Sinha et al. This intervention comprises (2015) for LiST shows that individual or group-based Infant and receiving breastfeeding Mothers of counseling sessions to promote young child promotion increased exclusive children age exclusive breastfeeding nutrition breastfeeding in children age 0–11 months delivered in the community counseling 0–5 months [OR 2.5 in health and/or health facility, system, OR 2.61 in home/ depending on country context. community setting]. Sinha et al. (2015) show that maternity leave is associated with a 52 percent increase This consists of an extension of in exclusive breastfeeding maternity leave cash benefits [RR 1.52, 95% CI 1.03–2.03], from the level and duration of Mothers of but this is not specific to the Maternity leave benefits provided at baseline children age effect of the extension of benefits to six months at 67 percent 0–11 months maternity leave cash benefits wage level from public payer in or to certain durations or line with International Labour levels of cash transfers. This Organization recommendations. intervention is included in the costing analysis but not the impact model. For the general population This intervention consists of policies, legislation, and monitoring and enforcement of policies related to the Pro- WHO’s International Code This intervention is included in General breastfeeding on Marketing of Breastmilk the costing analysis but not the population social policies Substitutes, the WHO Ten Steps impact model. of Successful Breastfeeding integration into hospital accreditation, and maternity protection/leave. Sinha et al. (2015) show that strategies with media intervention integrated with counseling and community National This intervention uses mass mobilization may have a breastfeeding General advertising and campaigns to significant effect on increasing promotion population promote breastfeeding. exclusive breastfeeding rates campaigns [RR 1.17, 95% CI 1.01–1.14]. This intervention is included in the costing analysis but not the impact model. Note: CI = confidence interval; LiST = Lives Saved Tool; OR = odds ratio; RR = relative risk. 120 An Investment Framework for Nutrition a significant effect on increasing exclusive breastfeeding rates. As an example of what is possible, the integrated Alive & Thrive program in Vietnam (see box 9.3 in chapter 9)—which includes a mass media cam- paign at scale in addition to infant and young child nutrition counsel- ing and advocacy for pro-breastfeeding social policies—demonstrated a total 28.3 percentage point increase in exclusive breastfeeding for the first six months compared to control sites over the period 2010–14 (Walters et al. 2016). There are positive signs that investing in large- scale media promotion and social marketing are important for coun- teracting the influence of marketing for breastmilk substitutes and developing a culture that supports optimal breastfeeding. Analytic Approaches Specific to the Breastfeeding Target The methods for estimating costs, impacts and benefit-cost ratios are presented in chapter 2; this section reviews important definitions, sample selection, and data specific to the breastfeeding target. Measuring Exclusive Breastfeeding In 2012, the indicator selected to measure progress with regard to exclusive breastfeeding was the prevalence of exclusive breastfeeding for all infants in the first six months of age (WHO and UNICEF 2014). The primary source of breastfeeding practice data for this analysis, the Demographic and Health Surveys (DHS) and Multiple Indica- tor Cluster Surveys (MICS) household surveys, asks mothers if they have breastfed their infants within the last 24 hours. Exclusivity of breastfeeding is determined by mothers reporting that infants did not receive any liquids or foods while breastfeeding. The data on national exclusive breastfeeding for this analysis is drawn from the WHO/ UNICEF Global Nutrition Tracker (September 2015 version) (WHO 2015). India’s exclusive breastfeeding rate of 65 percent, found in the recent Rapid Survey of Children (RSOC), is included in this analysis since the previous survey reported was a decade ago (Government of India and UNICEF 2015). Sample Selection The estimates in this chapter are based on a sample of 27 coun- tries (20 with the highest absolute burden and 7 with exclusive Chapter 5  Reaching the Global Target for Breastfeeding 121 breastfeeding prevalence lower than 10 percent). These 27 countries account for 78 percent of the burden of non-exclusively breastfed infants (up to six months of age) (see table 2.2 for the list of countries.) A multiplier of 1.28 was then used to extrapolate the sample cost to all low- and middle-income countries. Interventions Included in the Analyses As discussed above, the most effective way to increase rates of exclu- sive breastfeeding requires implementing a comprehensive strat- egy that includes, at minimum, pro-breastfeeding social policies, a national breastfeeding promotion campaign, and infant and young child nutrition counseling for expectant and new mothers. These inter- ventions are included because they (1) are applicable to all countries, (2) address multiple levels of complex factors affecting breastfeeding, and (3) together can plausibly achieve the estimated impact on the rate of exclusive breastfeeding. In the long term, it is also important to reduce the perceived opportunity costs of breastfeeding either through maternity leave and cash benefits or workplace supports. The analyses estimate the global costs of extending maternity leave cash benefits for working mothers in the formal sector, but these costs are not included in the package of nutrition-specific interventions since it is an intervention that aims to achieve multiple social, economic, and health outcomes and will need to be financed from other sectors. See table 5.1 for further descriptions and effect size estimates used in the impact analyses. While all these interventions may have an indepen- dent effect on exclusive breastfeeding, only the effect of nutrition counseling is included in the impact model, whereas the costs include the cost of scaling up all four interventions. Therefore the overall benefit-cost ratios are an underestimate. Estimating Unit Costs Because of a lack of cost data on policy and media interventions at scale, the annual national unit costs of the pro-breastfeeding social policies and national breastfeeding promotion campaigns are based on the experience of the Alive &Thrive program (Alive & Thrive 2013, 2014; Walters et al. 2016). The following assumptions are made: there are combined national costs for the pro-breastfeeding social policies and national breastfeeding promotion campaigns interventions of $1.0 million, $3.0 million, $5.0 million, and $10 million in countries with a population of less than 10 million, 10–50 million, 50–250 mil- lion, and more than 250 million, respectively. Twenty percent of the 122 An Investment Framework for Nutrition national costs are earmarked for the pro-social breastfeeding social policies and 80 percent for the national breastfeeding promotion campaigns. It is assumed that economies of scale could be achieved for these two interventions in larger countries. Unit costs for infant and young child nutrition counseling come from a review of literature on cost data (see appendix C). Since the target definition is specific to exclusive breastfeeding until six months, and not optimal breastfeed- ing until age two, costs include only one year of infant and young child nutrition counseling intervention delivery per mother and child pair.4 The unit costs for the extension of maternity leave cash benefits include the costs of extending cash benefits from current duration to six months paid from public sources at a rate of 67 percent of mini- mum wage level in each country (ILO 2015). Estimating Existing Levels of Coverage For breastfeeding counseling, the analyses rely on the Lives Saved Tool (LiST) default rate for breastfeeding promotion coverage in each country, which is equivalent to the exclusive breastfeeding rate of infants age 1–5 months. Although this measure has weaknesses, mainly because there is wide variation in what constitutes “counsel- ing” and coverage varies accordingly,5 it is considered the best avail- able measure at this time. Similar analyses in the future would benefit from standardized data on counseling coverage. Existing coverage of pro-social breastfeeding is estimated based on qualitative evidence of full or partial implementation of the International Code of Breast- milk Substitutes (WHO, UNICEF, and IBFAN 2016) and maternity leave policies (ILO 2015). Coverage of maternity leave cash benefits is estimated as the product of female labor force participation rate and the International Labour Organization (ILO) coverage in practice estimates for each country.6 Estimating Total Costs The costing methodology is similar to all other targets included in the analyses. The total additional financing needs of achieving the target This is different from what was costed to achieve the stunting target, which included two years of 4 promotion of good infant and young child nutrition and hygiene (see chapter 3). 5 For some, “counseling” may be a short interaction between a pregnant woman and a health care professional as part of antenatal care. At the other end of the spectrum, “counseling” may entail up to 15 nutritional consultations from pregnancy through the infant’s second year of life. 6 The ILO estimates the coverage in practice of maternity leave cash benefits for women in each country; this is defined as the number of people who have the right to receive benefits but are not necessarily currently beneficiaries. Chapter 5  Reaching the Global Target for Breastfeeding 123 is the sum of the annual additional costs of scaling up the core inter- ventions from baseline coverage level to full coverage, assuming the same linear scale-up scenarios from current to full coverage in the first five years plus a five-year maintenance phase is used. The number of beneficiaries (that is, mother-child pairs) for infant and young child nutrition counseling and maternity leave is calculated by subtracting the number of twin pairs at birth from the population of children at birth (WHO 2015). Estimating Impacts For the impact analyses, a Microsoft Excel model was developed to parallel the approach used by LiST (Bhutta et al. 2013; Walker, Tam, and Friberg 2013; Winfrey, McKinnon, and Stover 2011). Although multiple interventions are costed for the breastfeeding target, in the final analysis only one intervention—infant and young child nutri- tion counseling—is included in the impact model. The other policy and media-oriented interventions are recommended interventions, but there are too few effectiveness studies completed to confidently include their effects in the impact model. The formulae and odds ratios from the re-analysis of pooled estimates conducted by Sinha et al. (2015) for the LiST update (version 5.41 beta 13) are used in the model for estimating the impact of infant and young child nutrition counseling on exclusive breastfeeding prevalence (see table 5.1). The re-analysis suggests that children whose mothers receive breastfeed- ing promotion intervention delivered in the health system, home/ community setting, and both health and community settings have odds ratios of 2.5, 2.61, and 5.1, respectively, for being exclusively breastfed compared to children whose mothers do not receive the intervention. It is assumed that the effect size for delivery in the health system is most suitable for upper-middle-income countries and deliv- ery in home/community setting is suitable for low-income and lower- middle-income countries. In order to be conservative in the impact projections, the higher effect size option associated with the combined delivery of breastfeeding promotion in both health system and home/ community setting is not used in the model for the analyses. In LiST, breastfeeding promotion has an indirect effect on preventing neonatal and infant mortality through diarrhea and acute respiratory infections (that is, pneumonia). Therefore the breastfeeding counseling cover- age projections from the Microsoft Excel model are inserted into LiST to estimate the number of child deaths averted that is attributable to breastfeeding promotion. 124 An Investment Framework for Nutrition Benefit-Cost Analyses The benefit-cost analyses of investing in breastfeeding include two main types of monetary benefits attributed to increases in exclusive breastfeeding prevalence: (1) earnings gains related to all-cause child mortality averted and (2) earnings gains related to cognitive losses averted in children. For the estimation of cognitive losses, this analysis employs an approach similar to the method used in Rollins et al. 2016 and Walters et al. 2016. However, this analysis estimates the potential earnings gains due to cognitive losses averted in children over their entire adult working lives from age 18 until they reach their average life expectancy or 65 years of age, whichever is earlier, rather than potential earnings in a one-year steady-state period. Key factors for this calculation are that ever being breastfed results in a 2.62 point IQ increase compared to not being breastfed (Horta, Loret de Mola, and Victora 2015), and 1 standard deviation increase in IQ leads to a 17 percent increase in wage earnings (Hanushek and Woessmann 2008). Potential benefits not included are the savings from reduced health care costs for the treatment of diarrhea and pneumonia attrib- uted to inadequate breastfeeding, indirect costs borne by families related to the treatment of attributed childhood illnesses, costs of purchasing infant formula, and the mortality costs attributed to the higher risk of breast cancer in the mothers of non-breastfed children. The benefit-cost analyses are, therefore, conservative estimates. Sensitivity Analyses The analyses employ one-way sensitivity analyses for the key drivers of cost, impact, and benefit-cost ratio results. For the cost sensitivity analysis, the assumption about the baseline coverage of breastfeeding counseling varies in line with other plausible proxies. For the impact sensitivity analysis, the overall exclusive breastfeeding rate projec- tion in 2025 is presented, with the following changes in variables: (1) a less conservative delivery setting option in LiST for the effect size of breastfeeding promotion (combined delivery in health system and home/community setting) is included; (2) India’s exclusive breast- feeding result from the 2014 RSOC is excluded; (3) an effect of GDP growth across low- and middle-income countries (based on historical trends) is included, resulting in an average annual reduction in the rate of exclusive breastfeeding of 0.34 percentage points per year in Chapter 5  Reaching the Global Target for Breastfeeding 125 children 0–5 months of age (Victora et al. 2016);7 and (4) the average historical trend of increase in exclusive breastfeeding rates equivalent to +0.40 percentage points per year across low- and middle-income countries is extended into future projections (WHO 2015). Results This section presents the results of the analyses described above, including both costs and impacts. Breastfeeding Prevalence The WHO Global Nutrition Target Tracker reports the global exclusive breastfeeding prevalence as 38 percent (WHO 2015), similar to the findings in the Lancet Breastfeeding Series (Victora et al. 2016). Because of India’s size and influence over global nutrition indicators, the inclusion of India’s new exclusive breastfeeding rate from the RSOC increases the lower-middle-income country rate—from 38 percent in 2012 to 43 percent in 2015. Therefore India single-handedly achieves 40 percent of the global World Health Assembly target for breastfeeding. This new result for India is included in the baseline prevalence of exclusive breastfeeding for the analyses. Unit Costs The population-weighted mean unit cost estimate for good infant and young child nutrition counseling is $7.32 per year per mother and child pair, but country-level unit costs range from $0.7 per year in Guate- mala to $13.35 for Middle East and North Africa countries. The range of all unit costs for interventions included is shown in table 5.2. The unit costs of extending maternity leave cash benefits to six months vary greatly because of differences in country-level policies and wages. 7 The Lancet Breastfeeding Series suggests a strong inverse correlation between GDP and breastfeed- ing rates and estimates that for “each doubling in the gross domestic product per head, breastfeed- ing prevalence at 12 months decreased by ten percentage points” (Victora et al. 2016, 477). For this study, this effect size was modified to suit by the sensitivity analysis pertaining to exclusive breastfeeding rates and the low- and middle-income countries subject to this analysis. Assuming the 10-year historical (2004–14) GDP per capita growth rate in low- and middle-income countries of 5.5 percent (World Bank 2015) will continue, this is expected to yield only a 70 percent increase by 2025, not double. Furthermore, as estimated by Victora et al. (2016), the correlation between GDP per capita and exclusive breastfeeding is approximately half as strong (that is, −0.41) as at 12 months (that is, –0.84)). Therefore the authors’ calculations for an effect of GDP growth on exclusive breast- feeding in the context of the WHA target costing are: –10% * 70% * (−0.41/−0.84)/10 years = −0.34 percentage points per year. 126 An Investment Framework for Nutrition Table 5.2: Minimum, Maximum, and Mean Unit Costs to Meet the Breastfeeding Target (Annual) U.S. dollars Intervention Minimum Maximum Mean unit cost Cost is per person per year Infant and young child nutrition counseling 0.70 13.35 7.32 Extension of maternity leave cash benefits from current 0.00 1,401.96 273.64 duration to six months Cost is per country per year Pro-breastfeeding social policies 100,000 1,000,000 n.a. National breastfeeding promotion campaigns 2,000,000 8,000,000 n.a. Note: The mean unit costs are population-weighted means; n.a. = not applicable. Total Scale-Up Costs The total additional costs of scaling up the selected core set of inter- ventions necessary to meet the breastfeeding target in low- and middle-income countries is $5.7 billion over 10 years (see table 5.3). This translates to approximately $4.70 per newborn. The majority of costs are for infant and young child nutrition counseling ($4.2 billion) and smaller amounts for pro-breastfeeding social policies ($111 mil- lion) and national breastfeeding promotion campaigns ($906 million). The annual additional costs would increase from $136 million in 2016 to $763 million by 2021 as programs scale up to full coverage over five years (see figure 5.2). Table 5.3: Total Financing Needs to Meet the Breastfeeding Target Total 10-year costs Share of total Intervention 2016–25 (US$, millions) 10-year costs (%) Infant and young child nutrition counseling 4,159 80 Pro-breastfeeding social policies 111 2 National breastfeeding promotion campaigns 906 18 Subtotal 5,176 100 Program (capacity strengthening and 570 n.a. monitoring and evaluation) Total costs 5,746 n.a. Note: Maternity leave cash benefits are excluded from the package costs; n.a. = not applicable. Chapter 5  Reaching the Global Target for Breastfeeding 127 Figure 5.2: Annual Financing Needs to Meet the Breastfeeding Target US$, millions Sc l -up ph s M int n nc ph s 900 800 763 758 756 755 753 700 641 600 520 US$, millions 500 396 400 300 268 200 136 100 0 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 Note: Maternity leave cash benefits are excluded from the package costs. The total financing needs for the extension of maternity leave cash benefits from current status to six months in duration is estimated to be $24.1 billion over 10 years across low- and middle-income coun- tries. Since maternity leave cash benefits are important for other social, labor, gender, and development objectives—not only ­ breastfeeding— these costs are excluded from the nutrition-specific interventions package listed above. The East Asia and Pacific region requires a 38 percent share of the total costs ($2.3 billion), the Sub-Saharan Africa region requires one- quarter ($1.5 billion), South Asia ($0.7 billion), and other regions require smaller total scale-up costs (figure 5.3). By income group (see figure 5.4), the total costs are shared equally between lower-middle- income countries and upper-middle-income countries (45 and 46 per- cent, respectively); low-income countries require a much smaller share of the total (9 percent). 128 An Investment Framework for Nutrition Figure 5.3: Ten-Year Total Financing Needs to Meet the Breastfeeding Target, by Region 11% 8% 12% 5% 38% 26% South Asi Middl E st nd North Afric E st Asi nd P cific Sub-S h r n Afric L tin Am ric nd Europ nd th C ribb n C ntr l Asi Figure 5.4: Ten-Year Total Financing Needs to Meet the Breastfeeding Target, by Country Income Group 46% 45% 9% Low-incom countri s Upp r-middl -incom countri s Low r-middl -incom countri s Chapter 5  Reaching the Global Target for Breastfeeding 129 Sensitivity Analyses for Cost Estimates Adding a second year of infant and young child nutrition counseling, as per guidelines and in line with the costing of the stunting target, increases costs to a total of $8.7 billion. Coverage rates for infant and young child nutrition counseling may be the largest source of uncer- tainty in this model. The sensitivity analysis tornado diagram (see figure 5.5) shows that assuming a more conservative coverage rate— such as exclusive breastfeeding at 4–5 months as reported by DHS and MICS, or simply assuming no coverage at all (0 percent cover- age)—would bring the total target financing needs over 10 years to $6.3 billion or $7.3 billion, respectively. The minimum coverage level required to reach the target is 53 percent, but the reduced cost would come with the tradeoff of a substantial reduction in the number of child deaths and diseases averted. Expected Impacts of Scale-Up This investment in the breastfeeding intervention package is esti- mated to result in an additional 105 million children being exclu- sively breastfed globally over the next 10 years and an increase in the exclusive breastfeeding rate to 54 percent (see figure 5.6). Achieving this level of exclusive breastfeeding in low- and middle-income coun- tries will result in a cumulative total of 520,000 child deaths averted over the next 10 years. In addition, millions of cases of diarrhea and pneumonia will have been prevented, and more children will reach their potential in terms of cognitive development. The five countries with the highest total child deaths averted in the projected scenario are India, Pakistan, Nigeria, the Democratic Republic of Congo, and Ethiopia, which together account for 57 percent of estimated child deaths averted across all low- and middle-income countries. Though not calculated in the analyses, this increase in exclusive breastfeed- ing rates will also lead to substantially fewer women dying of breast cancer as a result of the protective effects that breastfeeding extends to the mother. It should be noted that the current modeling approach used by LiST and in the Excel model may be problematic for particular countries with extremely low-exclusive breastfeeding prevalence in the 0 to 10 percent range. Since the formulae determining the effect size of breastfeeding counseling are dependent on the problematic default indicator for coverage (that is, 1–5 month exclusive breastfeeding prevalence), countries with extremely low exclusive breastfeeding 130 An Investment Framework for Nutrition Figure 5.5: Sensitivity Analyses for 10-Year Total Financing Needs to Meet the Breastfeeding Target US$, billions 0 1 2 3 4 5 6 7 8 B s lin cov r of inf nt nd oun child nutrition couns lin = nt n t l c r (4+ visits) s prox Minimum sc l -up to r ch t r t (m ximum cov r of inf nt nd oun child nutrition couns lin = 53%) B s lin cov r of inf nt nd oun child nutrition couns lin = 0% B s lin cov r of inf nt nd oun child nutrition Chapter 5  Reaching the Global Target for Breastfeeding couns lin = xclusiv br stf din r t t 4–5 months Tot l 10- r costs (US$, billions) Hi h r costs Low r costs 131 132 Figure 5.6: Projected Exclusive Breastfeeding Prevalence and Child Deaths Averted with Scale-Up of Interventions to Meet the Breastfeeding Target 60 55 Proj ction = 54% xclusiv br stf din in 2025 stf d (%) 105 million mor childr n xclusiv l 50 T r t = 50% xclusiv br stf din br stf d ov r 10 rs 45 Child d ths v rt d: 520,000 40 in ov r 10 rs Int rv ntion s 0–5 months xclusiv l br 35 costs: US$ 5.7 billion ov r 10 rs 30 Inf nts M t rnit l v c sh b n fits would 25 dd $24.1 billion 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 An Investment Framework for Nutrition rates can achieve only a limited increase in breastfeeding rates in these models. For example, in the LiST model, Djibouti can achieve a rise in exclusive breastfeeding rates from 1 percent in 2015 to only 3.1 percent in 2025 despite scale-up to 90 percent coverage of counseling over 10 years. This is a limitation in the current LiST modeling of breast- feeding promotion which will affect the country-level projections for countries with low baseline rates. However, this limitation will have minimal impact on the global results of this analysis since most coun- tries in the sample were chosen on the basis of high absolute burden. Sensitivity Analyses of the Impacts of the Scale-Up With the confluence of factors affecting breastfeeding behaviors across different country contexts, it is challenging to make accurate predic- tions into the future. The sensitivity analyses show the change in exclusive breastfeeding projection if the effect size for breastfeeding promotion in LiST is set to the combined effect of counseling in both health system and home/community settings. Excluding the new India RSOC exclusive breastfeeding result from baseline exclusive breastfeeding prevalence reduces the global projection for 2025 from 54 percent to 50 percent. It also demonstrates the potential change in the exclusive breastfeeding rate projection in 2025 by considering the inclusion of an effect of GDP on future exclusive breastfeeding rates and extending the historical trend in exclusive breastfeeding (see fig- ure 5.7). In both cases, the target would still be achieved. Although achieving this target requires substantial effort, it appears less ambitious than the other global nutrition targets. These analyses show that there may be scope to go beyond the current breastfeeding target by 2025 or 2030. Benefit-Cost Analyses Investing in a comprehensive breastfeeding promotion and support package is an excellent investment for countries. Assuming a conser- vative 3 percent GDP growth rate and a 3 percent discount rate for costs and benefits yields an estimated net benefit of $298 billion over 10 years, a pooled benefit-cost ratio of 34.7, and a median benefit-cost ratio of 17.5 (see table 5.4). By region, this translates into a benefit- cost ratio of 18.2 for Sub-Saharan Africa, 37.0 for South Asia, and Chapter 5  Reaching the Global Target for Breastfeeding 133 134 Figure 5.7: Sensitivity Analyses of the Estimated Impact of Interventions on Exclusive Breastfeeding Rates Percent exclusively breastfed in 2025 0.45 0.5 0.55 0.6 0.65 Exp ndin inf nt nd oun child nutrition couns lin to both h lth s st ms nd hom /communit in mod l Excludin Indi RSOC xclusiv br stf din r sult (65% pr v l nc ) Includin ff ct of GDP on xclusiv br stf din (−0.34% p r r) Continu tion of historic tr nd of incr sin xclusiv br stf din r t s Exclusiv br stf din in 2025 (%) Positiv ch n N tiv ch n An Investment Framework for Nutrition Table 5.4: Benefit-Cost Ratios of Scaling Up Interventions to Meet the Breastfeeding Target, 3 and 5 Percent Discount Rates 3% discount rate 5% discount rate Group Present value of Present value of Benefit- Present value of Present value of Benefit- benefits (US$, billions) costs (US$, billions) cost ratio benefits (US$, billions) costs (US$, billions) cost ratio By region Sub-Saharan Africa* 20.0 1.1 18.2 8.6 1.0 8.9 South Asia* 36.1 0.9 37.0 14.5 0.9 16.8 East Asia and the Pacific* 108.2 3.2 33.8 43.3 2.8 15.2 By country income group Low-income countries* 3.5 0.6 6.3 1.3 0.5 2.5 Lower-middle-income countries* 81.7 3.0 27.7 33.3 2.6 12.8 Chapter 5  Reaching the Global Target for Breastfeeding Upper-middle-income countries* 147.2 3.2 46.3 59.5 2.8 21.1 Pooled 297.6 8.6 34.7 120.3 7.6 15.8 Median* n.a. n.a. 17.5 n.a. n.a. 7.6 Note: n.a. = not applicable. *Sample countries only. 135 33.8 for East Asia and Pacific. By income group, this translates into benefit-cost ratio of 6.3 for low-income countries, 27.7 for lower-­ a ­ middle income countries, and 46.3 for upper-middle income countries. When assuming a more conservative 5 percent discount rate, the median benefit-cost ratio decreases to 7.6 and the pooled rate to 15.8. Discussion Humans have known and science has shown that breastfeeding pro- vides unparalleled nutritional and immunological benefits for infants and young children. The analyses demonstrate that, although there may be notable costs to investing in breastfeeding promotion, protec- tion, and support, reaching the global target for breastfeeding can be achieved and would result in saving a large number of children’s lives and also in substantial reductions in maternal morbidity. In fact, there is potential to surpass the current target for breastfeeding and there may be scope to revise this target to be more ambitious. The return on the investment across countries is positive and strong: estimates show that the investment would generate a net present value of $298 billion in benefits over 10 years, a pooled benefit-cost ratio of 34.7, and median benefit-cost ratios of 17.5 (15.8 and 7.6, respectively, under more conservative discounting assumptions). Recent research shows that lifetime labor earnings gains for a breast- fed child would amount to approximately $20,000 in the United States (Lutter 2016). Although projected earnings gains estimated in the anal- yses are lower than those in the United States given the lower-income status of countries in the sample, this new finding further reiterates the need for the promotion of exclusive breastfeeding. The accuracy with which future behavior patterns can be predicted is only as good as the tools and data available and the assumptions made. These analyses were conducted with the best available data, but there is an urgent need for improved data on intervention coverage, costs, and effectiveness (for certain interventions). Interventions and policy levers such as maternity leave cash benefits currently generate high costs and cover only the formal labor sector. Since large numbers of women, especially in developing countries, work in the informal sector, reaching these women is essential for achieving greater impact. Better measurement of the coverage of infant and young child nutri- tion counseling, from pregnancy through age two, is urgently needed. 136 An Investment Framework for Nutrition It is expected that a recently added DHS survey question addressing breastfeeding counseling will help with the estimation of coverage of any counseling, but will not be sufficient to assess intervention cover- age of comprehensive counseling for new mothers all the way through to age two. There is also an urgent need for implementers and researchers to collect and publish cost data so that future costing studies can be based on stronger data. Impact modeling software also must adapt to include a variety of breastfeeding interventions and to make stron- ger projections for the highest-burden countries. Further advances in experimental and quasi-experimental methods are also needed to better understand the impact of interventions such as policies, media, and maternity leave, among others. Decades of underfinancing sup- port for nursing mothers have resulted in creating a culture, particu- larly among higher-income and emerging economies, that stigmatizes breastfeeding and downplays the tradeoffs of not breastfeeding. Now the case for investing in a breastfeeding renaissance in the 21st century is clear. The analyses show that scaling up a core set of interventions that enable optimal breastfeeding can have a major impact on prevent- ing child deaths and generating strong returns on investment over time for societies, labor markets, and their economies. References Alive & Thrive. 2013. Vietnam Costing Study: Implementation Expenditure and Costs. Hanoi: Alive & Thrive. ———. 2014. Country Brief: Alive & Thrive Program Approach and Results in Vietnam. June 2009 to December 2014. Hanoi: Alive & Thrive. http://alive andthrive.org/resources/country-brief-alive-thrives-program-approach-and- results-in-viet-nam-june-2009-to-december-2014/ Baker, P., J. Smith, L. Salmon, S. Friel, G. Kent, A. Iellamo, J. P. Dadhich, and M. J. Renfrew. 2016. “Global Trends and Patterns of Commercial Milk-Based Formula Sales: Is an Unprecedented Infant and Young Child Feeding Transi- tion Underway?” Public Health Nutrition 19 (14): 2540–50. Bhutta, Z. A., J. K. Das, A. Rizvi, M. F. Gaffey, N. Walker, S. Horton, P. Webb, A. Lartey, and R. E. Black. 2013. “Evidence-Based Interventions for Improve- ment of Maternal and Child Nutrition: What Can Be Done and at What Cost?” The Lancet 382 (9890): 452–77. Cai, X., T. Wardlaw, and D. W. Brown. 2012. “Global Trends in Exclusive Breastfeeding.” International Breastfeeding Journal 7: 12-4358-7-12. Chapter 5  Reaching the Global Target for Breastfeeding 137 Government of India, Ministry of Women and Child Development; and UNICEF. 2015. Rapid Survey on Children (ROSC) 2013–14: National Report. New Delhi. http://wcd.nic.in/sites/default/files/RSOC%20National% 20Report%202013-14%20Final.pdf Hanushek, E. and L. Woessmann. 2008. “The Role of Cognitive Skills in Eco- nomic Development.” Journal of Economic Literature 46: 607–68. Haroon, S., J. K. Das, R. A. Salam, A. Imdad, and Z. A. Bhutta. 2013. “Breast- feeding Promotion Interventions and Breastfeeding Practices: A Systematic Review.” BMC Public Health. 13 (Suppl 3): S20-2458-13-S3-S20. Epub 2013 Sep 17. Holla-Bhar, R., A. Iellamo, A. Gupta, J. P. Smith, and J. P. Dadhich. 2015. “Investing in Breastfeeding: The World Breastfeeding Costing Initiative.” International Breastfeeding Journal 10: 8. Horta, B. L., C. Loret de Mola, and C. G. Victora. 2015. “Breastfeeding and Intelligence: A Systematic Review and Meta-Analysis.” Acta Paediatrica 104: 14–19. IFPRI (International Food Policy Research Institute). 2016. Global Nutrition Report 2016: From Promise to Impact: Ending Malnutrition by 2030, Washington, DC: IFPRI. http://ebrary.ifpri.org/utils/getfile/collection/p15738coll2/ id/130354/filename/130565.pdf ILO (International Labour Organization). 2015. ILOSTAT (database). http:// www.ilo.org/ilostat/faces/oracle/webcenter/portalapp/pagehierarchy/ Page137.jspx?_afrLoop=52211198762802&clean=true#!%40%40%3F_afrLoop %3D52211198762802%26clean%3Dtrue%26_adf.ctrl-state%3Dtsep308c4_159 (accessed May 2, 2015). Labbok, M. H. 2012. “Global Baby-Friendly Hospital Initiative Monitoring Data: Update and Discussion.” Breastfeeding Medicine: The Official Journal of the Academy of Breastfeeding Medicine 7: 210–222. Lutter, R . 2016. “Cognitive Performance, Labor Market Outcomes, and Esti- mates of Economic Value of Cognitive Effects of Breastfeeding.” Unpublished manuscript. Charlottesville, VA, University of Virginia. Nandi, A., M. Hajizadeh, S. Harper, A. Koski, E. C. Strumpf, and J. Heymann. 2016. “Increased Duration of Paid Maternity Leave Lowers Infant Mortality in Low- and Middle-Income Countries: A Quasi-Experimental Study.” PLoS Medicine 13: e1001985. Piwoz, E. G. and S. L. Huffman. 2015. “The Impact of Marketing of Breast- Milk Substitutes on WHO-Recommended Breastfeeding Practices.” Food and Nutrition Bulletin 36 (4): 373–86. Rollins, N. C., N. Bhandari, N. Hajeebhoy, S. Horton, C. K. Lutter, J. C. Martines, E. G. Piwoz, L. M. RIchter, and C. G. Victora. 2016. “Why 138 An Investment Framework for Nutrition Invest, and What It Will Take to Improve Breastfeeding Practices?” The Lancet 387 (10017): 491–504. Sinha, B., R. Chowdury, M. J. Sankar, J. Martines, S. Taneja, S. Mazumder, N. Rollins, R. Bahl, and N. Bhandari. 2015. “Interventions to Improve Breast- feeding Outcomes: A Systematic Review and Meta-Analysis.” Acta Pediatrica 104 (467): 114–34. UNICEF (United Nations Children’s Fund). 2011. Infant and Young Child Feed- ing: Programming Guide. http://www.unicef.org/nutrition/files/Final_IYCF_ programming_guide_2011.pdf Victora, C., R. Bahl, A. Barros, G. V. A. França, S. Horton, J. Krasevec, S. Murch, M. J. Sankar, N. Walker, and N. C. Rollins. 2016. “Breastfeeding in the 21st Century: Epidemiology, Mechanisms and Lifelong Effect.” The Lancet 387 (10017): 475–490. Walker, N., Y. Tam, and I. K. Friberg. 2013. “Overview of the Lives Saved Tool (LiST).” BMC Public Health 13 (Suppl 3): S1-2458-13-S3-S1. Epub 2013 Sep 17. Walters, D., S. Horton, A. Y. Siregar, P. Pitriyan, N. Hajeebhoy, R. Mathisen, L. T. Phan, and C. Rudert. 2016. “The Cost of Not Breastfeeding in Southeast Asia.” Health Policy and Planning 31 (8): 1107–16. WHO (World Health Organization). 1998. Evidence for the Ten Steps to Success- ful Breastfeeding. Geneva: WHO. ———. 2015. Global Targets Tracking Tool. https://extranet.who.int/sree/ Reports?op=vs&path=%2FWHO_HQ_Reports/G16/PROD/EXT/ Targets_Menu&VSPARAM_varLanguage=E&VSPARAM_varISOCODE=ALB (accessed September 15, 2015). WHO and UNICEF (World Health Organization and United Nations Chil- dren’s Fund). 2014. Global Nutrition Targets 2025: Breastfeeding Policy Brief. http://apps.who.int/iris/bitstream/10665/149022/1/WHO_NMH_ NHD_14.7_eng.pdf?ua=1 WHO, UNICEF, and IBFAN (World Health Organization, United Nations Children’s Fund, and International Baby Food Action Network). 2016. Marketing of Breast-milk Substitutes: National Implementation of the International Code. Status Report 2016. Geneva: WHO. http://apps.who.int/iris/bitstr eam/10665/206008/1/9789241565325_eng.pdf?ua=1&ua=1 Winfrey, W., R. McKinnon, and J. Stover. 2011. “Methods Used in the Lives Saved Tool (LiST).” BMC Public Health 11 (Suppl 3): S322458-11-S3-S32. World Bank. 2015. World Development Indicators (database). http://data. worldbank.org/data-catalog/world-development-indicators (accessed 2015). Chapter 5  Reaching the Global Target for Breastfeeding 139 © SantiPhotoSS Chapter 6 Scaling Up the Treatment of Severe Wasting Jakub Kakietek, Michelle Mehta, and Meera Shekar Key Messages • Given the current state of evidence on the prevention of wasting, it is impossible to estimate the costs of reaching the global wasting target. Rapidly developing the evidence base and policy and intervention guidelines is imperative if the world is to meet this target. • Unlike prior chapters, the analyses included in this chap- ter focus on estimating the costs of treating severe acute malnutrition and mitigating its impacts. It does not include the costs or impacts of treating moderate acute malnutrition since the evidence base and World Health Organization (WHO) guidelines for treatment are lacking. • Scaling up the treatment of severe acute malnutrition for 91 million children in low- and middle-income countries will require about $9.1 billion over 10 years. This averages to about $110 per child in Africa and $90 per child in South Asia. • During that timeframe, the scale-up would prevent at least 860,000 deaths in children under age five. Chapter 6  Scaling Up the Treatment of Severe Wasting 141 • A conservative estimate is that the scale-up of treatment of severe acute malnutrition for children would result in at least $25 billion in annual increases in economic productiv- ity over the productive lifetimes of children who benefited from the program. Every $1 invested in treatment would result in about $4 in economic returns (discounted at 3 per- cent annually). • These are conservative estimates based only on mortality reductions. It is possible that wasting treatment has other benefits for child development (for example, reducing cognitive losses and physical disability). Such additional benefits have, however, yet to be quantified. • More research is needed on the pathways leading to the incidence of wasting; on understanding the cyclical nature of wasting (for example, whether and how frequently a given child experiences multiple bouts of wasting during a given year) and subsequent consequences and vulner- ability created by repeated episodes; and the relationship between wasting and stunting and the short-, medium-, and long-term impacts of wasting on children’s physical and cognitive development. Without a rapid investment in knowledge, it is not possible to build an effective global investment case for preventing wasting. Wasting and Its Effects Wasting, also known as acute malnutrition, is a reduction or loss of body weight in relation to height. The World Health Organization (WHO) classifies wasting as severe or moderate, according to the WHO growth standard for weight-for-height.1 Severe acute malnutri- tion is defined as severe wasting and/or mid-upper arm circumference (MUAC) less than 115 millimeters and/or bilateral pitting edema. Moderate acute malnutrition is defined as moderate wasting and/or mid-upper arm circumference greater than or equal to 115 millime- ters and less than 125 millimeters (WHO 2014). The variations in the 1 For details about the WHO growth standards for weight-for-height, see http://www.who.int/ childgrowth/standards/weight_for_height/en/ 142 An Investment Framework for Nutrition classification of wasting pose challenges in identifying children for treatment. Although neither weight-for-height nor mid-upper arm cir- cumference are shown to be good predictors of mortality, on balance, the mid-upper arm circumference has shown better predictive power (ENN et al. 2012). Because of this, clinical assessment of complications such as bilateral pitting edema are essential for distinguishing severe cases needing inpatient treatment versus uncomplicated cases that can be treated at community levels. Children suffering from severe acute malnutrition have a mortality risk 11 times higher than children who are not malnourished. The WHO estimates that wasting accounts for about 2 million deaths among children under age five globally—5 per- cent of all deaths in that age group (McDonald et al. 2013). In 2014, 50 million children globally were wasted (UNICEF, WHO, and World Bank 2015), one third of whom were severely wasted. Of the total number of wasted children, about 34 million live in South Asia and about 14 million live in Sub-Saharan Africa. India, Sri Lanka, Djibouti, and South Sudan face the greatest burden of wasting, with over 15 percent prevalence in each country, although the etiology and causes of wasting may be different across regions. Particularly in South Asia, wasting is often seen in children well below six months of age, pointing to more chronic and societal etiologies such as poor maternal nutrition, poor infant feeding practices, and lower class/ caste status contributing to wasting rates (Menon 2012). A grow- ing burden is also developing in the Middle East and North Africa, with countries such as Yemen seeing wasting rates of over 16 percent (UNICEF, WHO, and World Bank 2015). In total, 14 countries glob- ­ ally have wasting rates above the public health emergency range (greater than 10 percent prevalence). Unlike stunting, trends in wast- ing probably underestimate the true burden of wasting because this is a measure of acute or short-term incidences in malnutrition, which can occur during peak times of famine, crises, low harvest periods, or bouts of illness. Therefore during survey times, which may be outside of seasonal peaks in wasting, a relatively large prevalence of incidence cases may be missed. Nonetheless, wasting prevalence has remained steady at 8 percent globally with a recent minimal decline to 7.5 per- cent (UNICEF, WHO, and World Bank 2015). The 2012 World Health Assembly target is to reduce and maintain childhood wasting to less than 5 percent. Like the stunting target, the World Health Assembly target for wasting has been incorporated into Sustainable Development Goal 2 and its target 2.2. This target focuses Chapter 6  Scaling Up the Treatment of Severe Wasting 143 on reducing the prevalence of wasting and, consequently, on prevent- ing and treating wasting. In order to reach the target, effective strate- gies are needed to treat current cases and to prevent future cases of wasting. However, to date, evidence on how to prevent wasting is lim- ited and inconclusive. Coffey (2016) identifies five systematic reviews and a meta-analysis examining the impact of nutrition-specific inter- ventions on weight-for-height z-scores. The interventions include food supplementation and micronutrient supplementation (including lipid nutrient supplements, hot meals, and fortified milks, combined with nutrition, health, and hygiene education) for children under five, and weight-for-height is analyzed only as a secondary outcome of interest. Food supplementation shows no impact on weight-for-height. One meta-analysis shows a statistically significant but very small impact of zinc supplementation on weight-for-height (Ramakrishnan, Nguyen, and Martorell 2009). Evidence is also inadequate for the impact of nutrition-sensitive interventions on wasting. A Cochrane review of the literature on water, sanitation and hygiene (WASH) interventions finds no evidence of the impact of WASH on wasting (Dangour et al. 2013). The lack of documented impact is at least partly due to the poor quality of the studies reviewed and the fact that weight-for-height is included only as a secondary outcome (see Coffey 2016 for a more in-depth discussion). One study of cash transfer programs combined with food supplementation shows significant and substantial reduc- tion (84 percent) in the risk of wasting for children in a group that received unconditional cash transfers and food supplementation compared with children who received only food supplementation (Langendorf et al. 2014). However, more evidence is needed to estab- lish a robust evidence base of the impact of similar social protection programs. In sum, the extant literature has not focused on understanding the pathways leading to the incidence of wasting and the effectiveness of interventions to prevent it from occurring in different contexts. It is possible that a better understanding of the determinants of acute malnutrition could be gained by reanalyzing the data collected as part of the existing studies. However, to date, this has not been a priority for researchers. Most of the attention has been given to recovery and relapse. Therefore one of the conclusions from these analyses is to rec- ommend that more research be undertaken to document the evidence base for preventing wasting. 144 An Investment Framework for Nutrition On the other hand, the treatment of severe acute malnutrition in children has a strong and well-established evidence base (see Lenters et al. 2013 for a review). For this reason the analyses included in this chapter focus on estimating the costs of treating severe acute malnu- trition and mitigating its impacts.2 In the context of the global target for wasting, these analyses provide an estimate of the costs of not reaching the wasting target. In the absence of effective prevention strategies, the world will need to invest in an expansion of treatment programs in order to avoid deaths among children suffering from severe acute malnutrition. The Treatment of Severe Acute Malnutrition among Children The WHO recommends outpatient treatment of children with uncom- plicated severe acute malnutrition (85 to 90 percent of cases) using ready-to-use therapeutic food and a seven-day preventive course of antibiotics (WHO 2013). This treatment has been shown to reduce mortality and lead to recovery in about 80 percent of cases (Hossain et al. 2009; Khanum, Ashworth, and Huttly 1994, 1998; Lenters et al. 2013). Although the treatment of severe acute malnutrition has been proven to be highly effective, the scale-up of these interventions is limited: only about 15 percent of children with severe acute malnutrition have access to treatment (WHO 2014). One of the reasons for low access to treatment is its relatively high cost (see, for example, Bhutta et al. 2013; Horton et al. 2010). A number of studies examine different strate- gies for reducing costs and improving cost-effectiveness of severe acute malnutrition treatment interventions. Several authors compare out­patient and inpatient-based treatment regimens (Bachmann 2009, 2010; Greco et al. 2006; Puett et al. 2013; Sandige et al. 2004). Some authors compare the costs and cost-effectiveness of using locally pro- duced ready-to-use therapeutic food products (Greco et al. 2006; Singh et al. 2010). 2 In this report, the term wasting is used when discussing prevalence rates or reaching the global wasting target. However, since diagnosis is measured by wasting and/or mid-upper arm circumfer- ence and/or bilateral pitting edema, the term acute malnutrition is most appropriate when referring to treatment. The costs and impact analyses in this report are based specifically on the treatment of severe acute malnutrition. Chapter 6  Scaling Up the Treatment of Severe Wasting 145 This chapter presents an analysis of the investments needed to expand the current coverage of this intervention to reach 90 percent of children suffering from severe acute malnutrition in low- and middle-income countries by 2025 and the impact of such scale-up on child mortality. A benefit-cost analysis is also included here, along with a comparison of the investment costs and the estimated economic benefits resulting from the treatment of severe acute malnutrition in children. These analyses do not include the management of moderate acute malnutrition. Treatment of severe acute malnutrition is a well-defined intervention with supporting WHO guidelines (see WHO 2013). In contrast, the management of moderate acute malnutrition is much less well defined. No guidelines exist for the treatment of moderate acute malnutrition.3 As a result, different countries and different agencies use very different approaches. These variations range from blanket provision of fortified or unfortified staples including corn-soy blends and other specialty cereal-based products (such as SuperCereal), which targets populations at large to prevent acute malnutrition and to treat existing cases of moderate acute malnutrition in children, to programs that provide lipid-based nutrition supplements to target populations. In the absence of global guidelines or standards, the entry and exit criteria for benefiting from such feeding and supple- mentation programs vary widely. Furthermore, the literature on the impact of the treatment of moderate acute malnutrition is limited (see Lenters et al. 2013). In light of this, the treatment of moderate acute malnutrition is not included in these analyses. Analytic Approaches Specific to the Wasting Target The methods used in these analyses are described in chapter 2. A few key methodological considerations specific to the coverage expansion of the treatment of severe acute malnutrition for children are summa- rized below. Measuring the Incidence of Wasting The target population for the treatment of severe acute malnutrition is defined as children 6–59 months of age suffering from severe wasting, 3 To date, the WHO has issued only a Technical Note on the use of supplemental foods for the man- agement of moderate acute malnutrition; see WHO 2012 at http://apps.who.int/iris/bitstream/ 10665/75836/1/9789241504423_eng.pdf?ua=1 146 An Investment Framework for Nutrition determined by measurement of weight-for-height or mid-upper arm circumference, or clinical assessment of bilateral pitting edema. Rou- tinely collected data on the nutrition status of children—for example, through Demographic and Health Surveys (DHS) or Multiple Indica- tor Cluster Surveys (MICS)—includes information on the prevalence of severe wasting in a given year. However, annual prevalence very likely underestimates the number of children who require treat- ment for two reasons. First, severe wasting is an acute condition the prevalence of which likely varies within a year. In the lean season, or during periods of drought or other natural (or manmade) disas- ters, the percentage of children with acute malnutrition can increase rapidly. Second, it is possible, and even likely, that a single child can experience multiple episodes of acute malnutrition in a given year. At present, longitudinal data are limited to surveillance systems used in emergency situations, particularly in Ethiopia, Niger, and Sudan, where data on cases of severe acute malnutrition are captured over time in highly food insecure areas (Tuffrey 2016). This does not fully allow for estimating the incidence of severe acute malnutrition in a way that would capture seasonal variations and multiple episodes of acute malnutrition outside of emergency situations. For this analysis, the UNICEF programmatic guidance is used (UNICEF 2015). Follow- ing the methodology presented in that guidance, the annual incidence of severe acute malnutrition is approximated by multiplying the annual prevalence by a factor of 1.6. The annual population in need of severe acute malnutrition treatment is calculated as: (Number of children 6–59 months)  (Prevalence of severe wasting)  (1.6) Measuring Existing Treatment Coverage No country-level estimates of the coverage of the treatment of severe acute malnutrition for children currently exist. To develop baseline coverage, these analyses rely on data from the Coverage Monitoring Network on the percentage of children suffering from severe wasting at subnational levels (for example, districts) for a number of coun- tries.4 This database is based on information collected from organi- zations implementing programs in specific subnational geographic locations. For countries where coverage data were available from only one region, these data are used to represent coverage at the national level. For countries where data from multiple regions were available, The Coverage Monitoring Network is a consortium of nongovernmental organizations (led by 4 Action Against Hunger) that implement community-based management of acute malnutrition programs globally. Chapter 6  Scaling Up the Treatment of Severe Wasting 147 a population-weighted average is used as a proxy for the national level. It should be noted that this approach probably overestimates the current treatment coverage. For countries without available data, the current coverage of treatment is assumed to be zero. Baseline coverage data used in the analyses are presented in appendix B. Sample Selection The estimates of financing needs are based on a sample of 24 countries (20 countries with the highest absolute burden and 4 countries with wasting prevalence higher than 15 percent), together accounting for 82.9 percent of the burden of wasted children. The list of countries included in each sample for each target is shown in table 2.2. Unit Costs and Assumptions about Changes over Time Unit costs are obtained through a literature review from 2000 onward, a scan of gray literature, and websites of organizations providing treatment of severe acute malnutrition (UNICEF, Save the Children, Action Contre la Faim, and others). If no unit cost data were available for a given intervention in a given country, the average (mean) unit cost for other countries in that region is used. If there were no unit cost data for any country in a given region, the average from the countries with available unit costs is used. All costs are converted to U.S. dollars ($) and inflated to 2015 values. A list of unit costs used as well as unit cost data sources is included in appendix C. Treatment of severe acute malnutrition for children has higher unit costs than other nutrition interventions. This is partly because of the intensive curative nature of the intervention, which, even if delivered in the outpatient setting, requires a significant amount of time to be spent with health care providers (this includes initial triage, anthro- pometric measurement and diagnosis, assessment for complications, drug and ready-to-use therapeutic food dispensing, nutrition counsel- ing for mothers and/or caregivers, and weekly follow-up visits). In addition, ready-to-use therapeutic food is an expensive commodity as compared to those used in other nutrition interventions. Currently, dried skimmed milk is estimated to account for between 40 and 50 percent of the ready-to-use therapeutic food input costs and over one-third of the total ready-to-use therapeutic food manufacturing cost (Manary 2006; Santini et al. 2013). It is assumed that, in the next 10 years, a more cost-effective formulation of ready-to-use therapeu- tic foods will be developed to replace dried skimmed milk with an 148 An Investment Framework for Nutrition alternative source protein that is comparable to the current formula- tion with respect to recovery rate and time. Such an alternative formu- lation could potentially lead to a 33 percent reduction in ready-to-use therapeutic food price per kilogram. The estimated monetary value of the reduction is based on the average price charged by 17 global and local suppliers that sold ready-to-use therapeutic food to UNICEF in 2015. The average global price of a carton (15 kilograms) of ready-to- use therapeutic food was $51.57 (in 2015 U.S. dollars; UNICEF Supply Division 2015 data). The assumed 33 percent decline in the product cost is equivalent to a $17.02 cost reduction per case treated. Those cost reductions are assumed to be realized by 2020. A further 20 percent reduction in the cost of delivery of treatment of severe acute malnutrition for children over the 10-year period is also assumed. This is expected to result from improved protocols and better integration of the treatment of severe acute malnutrition into national health care delivery systems. Empirical literature on cost savings in nutrition programming that result from changes in deliv- ery platforms is very limited.5 However, the assumed cost reduction of 20 percent is consistent with the findings from Khan and Ahmed (2003), who examine the difference in cost per case of community nutrition services provided through a vertical program run by non- governmental organizations and a government program run through the health system in Bangladesh.6 Like the declines in prices of ready- to-use therapeutic food, those cost savings are assumed to be realized by 2020 (figure 6.1). Based on the assumptions presented above, the overall costs of the scale-up of the treatment of severe acute malnutrition for children globally is estimated to be 21 percent lower than if no cost savings were realized over the same period (see figure 6.1 for estimated annual costs for 2016 to 2025 under both sets of assumptions). This result is consistent with existing projections for cost declines in the treatment of severe acute malnutrition (for example, Shoham, Dolan, and Gostelow 2013). However, this assumption—of a 21 percent decline in costs by 2020—is probably optimistic. 5 Currently, randomized controlled trials are examining differences in delivery platforms. In particu- lar, integration of treatment of severe acute malnutrition for children into the existing community- level delivery within the health system is under way in Mali and Pakistan; preliminary results are expected at the end of 2016. 6 These cost reductions were not applied in East Asia because the unit cost used already assumed a fully integrated severe acute malnutrition delivery model (see Alive & Thrive and UNICEF 2013). Chapter 6  Scaling Up the Treatment of Severe Wasting 149 Figure 6.1: Total Annual Financing Needs for the Treatment of Severe Acute Malnutrition under Constant and Declining Unit Cost Assumptions, 2016–25 2,500 2,093 1,882 2,000 1,671 1,460 1,500 US$, millions 1,251 1,556 1,042 1,399 1,000 1,242 1,085 929 832 774 500 624 415 206 0 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 Const nt unit costs D clinin unit costs Assumptions about the Pace of the Scale-Up over 10 Years A gradual, linear scale-up was assumed for each country from the current coverage level to 90 percent by 2025. This coverage expansion scenario is different from the ones for stunting, anemia, and breast- feeding. For these three targets, a five-year rapid expansion phase and a five-year maintenance phase were modeled to allow for the full accrual of the full scale-up interventions for all children under age five (see chapter 2 for details). Because severe wasting is an acute condition, with treatment affecting the beneficiaries immediately, and because the treatment of severe acute malnutrition is not included under any of the other targets, a linear scale-up was assumed here. Given the nature of the causes of severe acute malnutrition and the fact that the treatment is resource intensive and costly, and to be consistent with the extant literature (Bhutta et al., 2013; Horton et al., 2010), it was assumed that 100 percent of coverage is unrealistic even in a 10-year timeframe. Thus, coverage expansion of up to 90 percent was modeled. Estimating Impact The Lives Saved Tool (LiST) is used to estimate the number of deaths averted. LiST models the impact of severe acute malnutrition mor- tality indirectly: in the model, severe acute malnutrition increases a child’s risk of dying from four specific conditions: post-neonatal diarrhea, post-neonatal measles, post-neonatal pneumonia, and 150 An Investment Framework for Nutrition post-neonatal other.7 Figure 6.2 summarizes the LiST severe acute malnutrition impact model. In LiST, the impact of severe acute malnutrition on child mortality depends critically on the incidence of the four key causes of mortality in a given country. Children suffering from severe acute malnutrition will be much more likely to die in a country where the incidence of diarrhea, pneumonia, measles, and other post-neonatal causes (see note 7) is high than in a country where the incidence of those diseases is low. This also means that the treatment of severe acute malnutri- tion will have a different impact in different countries depending on the incidence of these diseases. For example, if severe acute malnutri- tion increases the risk of dying from diarrhea by three times, and if 10 percent of all children who get diarrhea die, in country A where 10 percent of children get diarrhea, one would expect that among 1,000 children suffering from severe acute malnutrition there would be about 30 excess deaths from diarrhea. In contrast, in country B, where 50 percent of children get diarrhea, among the same num- ber of children suffering from severe acute malnutrition, 150 excess deaths would be expected. Furthermore, assuming that treatment cures 80 percent of the children suffering from severe acute malnutri- tion, treating all 1,000 children in country A would avert 24 deaths but treating all 1,000 children in country B would avert 120 deaths— almost six times more (see table 6.1). Using LiST, mortality is modeled in all sample countries separately; the impact is then extrapolated to all low- and middle-income coun- tries by multiplying the number of deaths averted in the sample by 1.2 (derived by 1/0.829, where 0.829 is the proportion of children suffer- ing from wasting in the sample countries). Benefit-Cost Analyses The economic benefits of the expansion of treatment coverage are estimated on the basis of mortality reductions. Each life saved as a result of the treatment is valued at one times GDP per capita per year (discounted); the assumption is that children would start work- ing and contributing to the economy at 18 years of age and continue working until they reach their country’s life expectancy or the age of 65, whichever is lower. It is possible, and indeed likely, that children experience multiple episodes of acute malnutrition before they reach 7 In the LiST model, “other” indicates a specific category of mortality. Chapter 6  Scaling Up the Treatment of Severe Wasting 151 152 Figure 6.2: LiST Model of the Impact of the Treatment of Severe Acute Malnutrition on Mortality in Children under Five R l tiv risk: WHZ>–1 = 1 Post-n on t l –2–1 = 1 Post-n on t l –2–1 R l tiv risk: Risk r duction: –2–1 = 1 78% Post-n on t l Tr tm nt –2–1 = 1 m lnutrition shifts childr n –2