INVESTING IN NUTRITION THE FOUNDATION FOR DEVELOPMENT AN INVESTMENT FRAMEWORK TO REACH THE GLOBAL NUTRITION TARGETS Shekar M, Kakietek J, D'Alimonte M, Walters D, Rogers H, Dayton Eberwein J, Soe-Lin S, Hecht R Every year, malnutrition claims the lives Assembly (WHA) endorsed the first- manner.7 To inform the action needed, of 3 million children under age five and ever global targets to improve nutrition the World Bank, Results for Development costs the global economy billions of focusing on six areas: stunting, exclusive Institute (R4D), and 1,000 Days, with dollars in lost productivity and health care breastfeeding, wasting, anemia, low birth support from the Bill & Melinda Gates costs. Yet those losses are almost entirely weight, and overweight. And while some Foundation and the Children’s Investment preventable. A large body of scientific of the targets were enshrined within Fund Foundation (CIFF) conducted an evidence shows that improving nutrition Sustainable Development Goal 2, which in-depth costing analysis and developed during the critical 1,000 day window commits to end malnutrition in all its forms an investment framework for achieving from a woman’s pregnancy to her child’s by the year 2030, the world is not on four of the six global nutrition targets second birthday has the potential to save track to achieve any of the six nutrition (see Table 1).a lives, help millions of children develop fully targets. and thrive, and deliver greater economic This brief summarizes the analysis of prosperity.1, 2, 3, 4, 5, 6 Accelerating progress against malnutrition the costs, impacts, and investments will require investment in both proven needed to achieve the targets and how There is an urgent need for global nutrition interventions and research to governments, donors, the private sector, action on nutrition. In 2012, the 194 understand how to bring promising foundations, and others can come member states of the World Health solutions to scale in a cost-effective together to finance these at scale. KEY MESSAGES 1 • Global action is urgently needed to tackle the pervasive problem of malnutrition. investment of just over $2 billion for the next 10 years. The majority of this annual investment would come from country • governments and donors, $1.4 billion and $650 million, 2 • Reaching the targets to reduce stunting among children and anemia in women, increase exclusive breastfeeding rates, and mitigate the impact of wasting will require an average • respectively, while innovative financing mechanisms and households fund the remaining gap. annual investment of $7 billion over the next 10 years. This is • in addition to the $3.9 billion the world currently spends on nutrition annually. 4 When combined with other health and poverty reduction efforts, this priority investment can yield significant returns: an estimated 2.2 million lives can be saved and there will be • 50 million fewer cases of stunting in 2025 compared to 3 • To catalyze progress toward the global nutrition targets, priority should be given to a set of the most cost-effective • in 2015. actions which can be scaled up immediately. Financing this more limited set of actions will require an additional annual 5 • Achieving the targets is within reach if all partners work together to immediately step up in investments in nutrition. INVESTING IN PROVEN INTERVENTIONS D ata and methods derived from country-level costing and 2015 baseline (see Figure 1). A detailed breakdown is shown in financing work were used to inform the analysis and Table 2. determine the set of evidence-based interventions needed to meet each target,1, 8, 9, 10, 11 while keeping in mind WHO While the potential returns on this investment are significant,4 it is recommendations for the actions needed to achieve the global important to note that a few of the interventions identified cannot nutrition targets.12 For each target, the analysis covered the be brought to scale in a cost-effective manner at this time. highest-burden countries and the results were extrapolated to all Moreover, based on what is currently known about preventing low- and middle-income countries. A technical advisory group wasting, it was not possible to estimate the costs of achieving guided the work to ensure all methodology and assumptions the wasting target. Therefore, the analysis included only scaling were technically sound.b up the treatment of severe acute malnutrition (SAM) as it is a proven life-saving therapy and can help countries reduce the The analysis underscores the need to scale-up interventions levels of wasting. that directly impact the nutritional status of women and children. Many of the highest-impact interventions are found in the 1,000 As the global community gears up to address critical day window and several contribute to achieving multiple targets implementation challenges and rapidly advance the (see Table 3). Investments in nutrition interventions alone are understanding of how to prevent wasting, the analysis suggests not enough to reach the targets—improvements in water and that priority should be given to a set of the most cost-effective sanitation, agriculture, women’s health and education, and interventions, all of which can be scaled up immediately.c This other areas are also necessary to accelerate progress against smaller package requires an annual investment of just over $2 malnutrition. billion, or approximately $22 billion over ten years above current baseline spending (see Table 2). Scaling up this set of priority It is estimated that an additional $7 billion per year over the next interventions could save about 2.2 million lives and—together ten years is needed to reach the global targets for stunting, with anticipated progress in food availability and diversity, anemia in women, and exclusive breastfeeding and to mitigate women’s health and education, and investments in water and the impact of wasting. This investment of $70 billion over the sanitation—could result in 50 million fewer children stunted in next ten years can yield tremendous returns: 3.7 million child 2025 compared to 2015. lives saved, at least 65 million fewer stunted children, and 265 million fewer women suffering from anemia as compared to the Curt Carnemark, World Bank 2 TABLE 1: NUTRITION TARGETS AND WHY THEY MATTER 2025 Target Why it matters Stunting is the largely irreversible outcome of chronic undernutrition and affects 40% reduction in the 159 million children under the age of five.13 Stunted children have weaker immune Stunting number of children under systems, making them more susceptible to death and disease, and diminished 5 who are stunted cognitive capacity which impacts their ability to learn in school and earn higher incomes later in life.14, 15 Anemia affects half a billion women of reproductive age worldwide—impairing 50% reduction of anemia their health and economic productivity. In pregnant women, anemia can lead to Anemia among women of maternal death and can have serious health consequences for infants reproductive age including stillbirths, prematurity, and low birth weight. Low Birth 30% reduction in low birth Low birth weight is a major predictor of prenatal mortality and morbidity, and NOT INCLUDED Weight weight increases the risk for noncommunicable diseases later in life. No increase in childhood Childhood overweight and obesity increase risks of noncommunicable diseases, Overweight overweight premature death, and disability in adulthood. Increase the rate of exclusive Breastfeeding boosts a child’s immune system, protects from diseases, increases Exclusive breastfeeding in the first 6 intelligence, and is essential for healthy growth. Scaling up of breastfeeding to a breastfeeding months up to at least 50% near universal level could save an estimated 823,000 lives per year.2 Reduce and maintain Severely wasted children are, on average, 11 times more likely to die than their Wasting childhood wasting (acute healthy counterparts. Two million children die from wasting every year.19 malnutrition) to less than 5% A NEW FINANCING PARTNERSHIP: GLOBAL SOLIDARITY C urrently, investments in nutrition are minimal compared Under the global solidarity investment framework, donor to the scale of the problem. It is estimated that country financing is front-loaded in the first five years (2016-2020) in governments currently spend $2.9 billion and donors low-income and lower middle-income countries to help catalyze provide just under $1 billion annually to address stunting greater domestic investment and scale nutrition interventions reduction, wasting, anemia, and exclusive breastfeeding. This quickly. Additional contributions are expected to come from means that on average, countries are spending just 1% of their innovative financing mechanisms such as the Power of health budgets on the kind of high-impact nutrition-specific Nutrition18 and the Global Financing Facility in support of Every programs that save lives and pay significant dividends down Woman, Every Child as well as from households.19 the road. Nutrition-specific spending accounts for less than 1% of Official Development Assistance (ODA), despite the fact that In the scenario in which $70 billion is needed to reach the malnutrition contributes to 45% of all deaths of children under stunting, anemia, and breastfeeding targets and mitigate the age 5.17 impact of wasting, national governments will need to mobilize an average of $4 billion more per year, and donors an additional Mobilizing the resources needed to accelerate progress against $2.6 billion annually over the next 10 years. For a more detailed malnutrition will require that donors, countries, innovative understanding of this financing scenario, see Table 2 and financing mechanisms, businesses, and even consumers Figure 2. themselves act in “global solidarity.” National ownership and domestic financing must be maximized and each partner will need to contribute according to its financing capacity and comparative advantage. 3 TABLE 2: ADDITIONAL FINANCING BY YEAR These per year investments by source are meant to show the scaling up and tapering of investments as appropriate for full scale up to reach the targets, as well as to scale up a package of priority interventions. Scenario A: Full Scale Up to Reach Targets, Scenario B: Scale Up of Priority Interventions, (millions, USD) (millions, USD) Total over Total over Source In 2016 In 2021 In 2025 Source In 2016 In 2021 In 2025 10 years 10 years Country $ 39,676 $ 707 $ 4,519 $ 7,104 Country $ 14,095 $ 285 $ 1,527 $ 2,486 governments governments Donors $ 25,628 $ 622 $ 3,940 $ 2,063 Donors $ 6,536 $ 151 $ 950 $ 619 Other $ 4,142 $ 194 $ 509 $ 525 Other $ 1,687 $ 68 $ 216 $ 216 Sources ** Sources ** Total $ 69,446* Total $ 22,318* *Financing of IPTp (antimalarial medicine provided during regular prenatal visits) of $0.5 billion is covered by other health initiatives, including the President’s Malaria Initiative, the Global Fund to Fight AIDS, TB and Malaria, and to some extent national governments. **Sources include innovative financing mechanisms as well as household contributions to appropriate interventions. THERE IS NOW A SHARED OPPORTUNITY TO SAVE MILLIONS OF LIVES AND UNLOCK HUMAN POTENTIAL. 4 FIGURE 1: MEETING THE TARGETS 2 5 THE SHARED OPPORTUNITY T hough decades of underinvestment have led to slow budget tracking are needed to facilitate prioritization and smart and uneven progress against malnutrition, there is now investment decisions as well as to ensure accountability and a shared opportunity to alter this trajectory, save millions progress. Finally, more evidence is needed to better understand of lives and unlock human potential. The financing scenario how actions in areas like water, sanitation and hygiene, food presented is undoubtedly ambitious. However, these levels security, agriculture, and women’s empowerment and education of investment are within reach if pursued in conjunction with can contribute to reductions in malnutrition. other critical health and development frameworks and if the effectiveness and efficiency of current and future spending are As the world stands at the cusp of the new Sustainable improved.f Rapid success is possible as countries like Peru and Development Goals with global poverty rates having declined Senegal have shown. Moreover, the investments in nutrition to less than 10% for the first time in history,20 there is an proposed herein are minimal compared to the trillions spent on unprecedented opportunity to act decisively on malnutrition. fuel subsidies and food subsidies. Investing in nutrition today can have an immediate payoff in terms of lives saved and suffering averted as well as significant Additional funding to scale up what we know works is long-term impacts on the health and development of economies. absolutely critical. However, more work is needed to ensure The second Nutrition for Growth (N4G) Summit provides an the cost-effectiveness of existing spending on nutrition, important opportunity to bring forward new financial and policy address implementation bottlenecks and knowledge gaps, and commitments to accelerate progress to meet the global nutrition strengthen delivery mechanisms for high-impact interventions. targets and ensure the bright futures of families and nations. A dedicated effort to address the prevention of wasting is also urgently needed. On the financing side, better data and FIGURE 2: GLOBAL SOLIDARITY SCENARIO FOR FULL SCALE UP Donor contributions rise rapidly from 0.9% of total ODA in 2015 to 2.8% in 2021, and then taper to 1.8% in 2025. On average for all countries, total government contributions, including what is already being spent, gradually rise from 1.0% of government health expenditures in 2015 to 1.9% in 2021, and further to 2.9% in 2025.* Governments in low-income countries increase national funding to reach 50% of the total by 2025. Lower-middle income countries cover 70% or more of the additional cost by the end of the 10 year period, and upper middle-income countries are expected to cover the full extra cost through their domestic budgets and household contributions. *Averages are weighted by population. 6 TABLE 3: TO MEET THE TARGETS Intervention and target addressed Description and assumptions For pregnant women and mothers of infants Micronutrient* supplementation for pregnant Includes iron and folic acid supplementation, and at least one additional micronutrient, women (stunting, anemia) for approximately 180 days per pregnancy. Delivered as part of antenatal care. Promotion of good infant and young child Individual or group based counseling sessions to promote exclusive breastfeeding nutrition and hygiene practices (0-5 months of age) and continued breastfeeding, and timely introduction and appro- (stunting, exclusive breastfeeding) priate quality and quantity of complementary foods for children (6-23 months of age). Nutritional supplementation during pregnancy for pregnant women living under the Balanced energy-protein* supplementation poverty line ($1.25/day). Delivered through existing community, health facility, or (stunting) social-safety net programs. Intermittent preventive treatment for malaria Two doses of sulfadoxine-pyrimethamine for pregnant women (in malaria endemic in pregnancy (stunting, anemia) areas only) delivered as part of antenatal care. For infants and young children Vitamin A supplementation for children Two doses per year for children 6-59 months old delivered through mass campaigns. (stunting) 120 packets of zinc (10mg/day) per child per year for children 6-59 months old. Prophylactic zinc* supplementation (stunting) Delivered through community mechanisms similar to MNP supplementation. Supplemental foods for children 6-23 months of age living under the poverty line Public provision of complementary foods ($1.25/day) delivered through community-based nutrition programs or existing public (stunting) food distribution/social-safety net programs. Treatment of SAM using ready to use therapeutic foods (RUTF) in children 6-59 Treatment of severe acute malnutrition (SAM) months of age with Weight for Height<-3SD or MUAC<115mm. Outpatient treatment (severe wasting) for uncomplicated cases and inpatient treatment (in the stabilization phase) for patients with complications. For all women of reproductive age Weekly supplementation of 60mg iron + 0.4mg folic acid delivered through public Iron and folic acid supplementation for provision via schools, community health workers, hospitals, and private distribution non-pregnant women (anemia) for a share of women above the poverty line. For the general population Fortification of wheat and maize flour as well as rice with iron and folic acid and Staple food fortification (anemia) distributed through the marketplace. Policies, legislation, and monitoring and enforcement of policies related to the Pro-breastfeeding social policies International Code of Marketing of Breast Milk Substitutes and subsequent (exclusive breastfeeding) resolutions, WHO Ten Steps integration into hospital accreditation, and maternity protection/leave. National breastfeeding promotion campaign Large-scale efforts and use of mass media to promote breastfeeding. (exclusive breastfeeding) Interventions with an asterisk (*) await updated WHO guidelines. 7 NOTES a Assessment of the WHA nutrition targets on childhood overweight and low birthweight were not included in this analysis; additional research is needed to determine what interventions would support achievement of these targets. b The research team is deeply grateful to the following members of the Technical Advisory Group for their contributions to this work: Victor Aguayo, UNICEF; Hugh Bagnall-Oakley, Save the Children UK; Robert Black, Johns Hopkins University; Helen Connolly, American Institutes for Research; Luz Maria De-Regil, Micronutrient Initiative; Kaia Engesveen, World Health Organization; Patrizia Fracassi, Scaling Up Nutrition Movement Secretariat; Robert Greener, Oxford Policy Management; Saul Guerrero, Action Against Hunger UK; Lawrence Haddad, International Food Policy Research Institute (IFPRI); Rebecca Heidkamp, Johns Hopkins University; Sue Horton, University of Waterloo; David Laborde, International Food Policy Research Institute (IFPRI); Ferew Lemma, Ethiopia Ministry of Health; Kedar Mankad, ONE Campaign; Saul Morris, Children's Investment Fund Foundation; Sandra Mutuma, Action Against Hunger UK; Obey Assery-Nkya, Tanzania Office of the Prime Minister; Kelechi Ohiri, Nigeria Ministry of Health; Anne Peniston, USAID; Clara Picanyol, Oxford Policy Management; Ellen Piwoz, Bill & Melinda Gates Foundation; Amanda Pomeroy-Stevens, JSI/SPRING Project; and William Winfrey, Avenir Health. c This priority package of interventions for urgent scale up includes: vitamin A supplementation for children, promotion of good infant and young child nutrition and hygiene practices, antenatal micronutrient supplementation, intermittent preventive treatment of malaria for pregnant women, iron and folic acid supplements for adolescent girls, staple food fortification, pro-breastfeeding social policies, use of available mass and social media to promote breastfeeding, and treatment of severe acute malnutrition. d Investing in the treatment of wasting alone is not enough to meet the target and a better understanding of interventions that can be brought to scale to prevent wasting is urgently needed. 860,000 child lives saved is a conservative lower bound estimate of the impact. e The aggregate cost of $69.9 billion is not the sum of the costs of the four individual targets because some interventions are shared among different targets and costs for those interventions overlap. f In addition, improvements are needed in resource tracking for ODA spent on nutrition so that it is clearer where both nutrition-specific and nutrition-sensitive investments are made. REFERENCES 1 Bhutta, Z et al. (2013). Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? The Lancet 382: 452-477. 2 Victoria, C et al. (2016). Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet 387: 475-490. 3 Rollins, N et al. (2016). Why invest, and what will it take to improve breastfeeding practices? The Lancet 387: 491-504. 4 Studies estimate that every $1 invested in nutrition generates $18 in economic returns. Reference: Hoddinott, J et al. (2013). The economic rationale for investing in nutrition. Maternal and Child Nutrition 9(Suppl. 2): 69-82. Median estimate for a sample of 17 high burden countries used by the authors. 5 Bhutta, Z (2016). Early nutrition and adult outcomes: pieces of the puzzle. The Lancet 382: 486-487. 6Horton, S and Steckel, R (2013). Global economic losses attributable to malnutrition 1900-2000 and projections to 2050. Assessment Paper for Copenhagen Consensus on Human Challenges. 7 International Food Policy Research Institute. 2015. Global Nutrition Report 2015: Actions and Accountability to Advance Nutrition & Sustainable Development. Washington, DC. 8 Shekar, M et al. (2014). Costed plan for Scaling Up Nutrition: Nigeria. Health, Nutrition, and Population (HNP) Discussion Paper. Washington, DC: The World Bank Group. 9 Shekar, M et al. (2015a). Scaling Up Nutrition in the DRC: What Will It Cost? Health, Nutrition, and Population (HNP) Discussion Paper. Washington, DC: The World Bank Group. 10Shekar, M et al. (2015b). Scaling Up Nutrition for a More Resilient Mali: Nutrition Diagnostics and Costed Plan for Scaling Up. Health, Nutrition, and Population (HNP) Discussion Paper. Washington, DC: The World Bank Group. 11Shekar, M et al. (2015c). Costed Plan for Scaling Up Nutrition: Togo. Health, Nutrition, and Population (HNP) Discussion Paper. Washington, DC: The World Bank Group. 12World Health Organization. Global Nutrition Targets 2025: Policy brief series. http://www.who.int/nutrition/publications/globaltargets2025_policybrief_overview/ en/ (Accessed March 23, 2016). 13 UNICEF, WHO 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). 14 Martorell R, Horta BL and Stein AD et al. 2010. Weight gain in the first two years of life is an important predictor of schooling outcomes in pooled analysis from 5 birth cohorts from low- and middle-income countries. Journal of Nutrition. 140:348-54. 15Hoddinott J, Maluccio JA, Berhman JR, Flores R and Martorell R. 2008. Effects of a nutrition intervention during early childhood on economic productivity in Guatemalan adults. Lancet. 371:411-16. 16World Health Organization and 1,000 Days. WHA Global Nutrition Targets 2025: Wasting Policy Brief. http://www.who.int/nutrition/topics/globaltargets_wasting_ policybrief.pdf (Accessed April 8, 2016). 17 Black, R et al. (2013). Maternal and child undernutrition and overweight in low-income and middle-income countries. The Lancet 382: 427-451. 18 More information available at Powerofnutrition.org 19 More information available at GlobalFinancingFacility.org 20 World Bank. 2015. Global Monitoring Report 2015. http://www.worldbank.org/en/publication/global-monitoring-report (accessed 31 Dec 2015). 8