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 Executive Summary I n 2015, 159 million children under the age of five were early childhood reduces schooling attainment, decreases chronically malnourished or stunted, underscoring adult wages, and makes children less likely to escape a massive global health and economic development poverty as adults (Fink et al. 2016; Hoddinott et al. 2008; challenge (UNICEF, WHO, and World Bank 2015). In Hoddinott et al. 2011; Martorell et al. 2010). Conversely, 2012—in an effort to rally the international community reductions in stunting are estimated to potentially around improving nutrition—the 176 members of the increase overall economic productivity, as measured by World Health Assembly endorsed the first-ever global GDP per capita, by 4 to 11 percent in Africa and Asia nutrition targets, focusing on six areas: stunting, anemia, (Horton and Steckel 2013). Thus nutrition interventions low birthweight, childhood overweight, breastfeeding, are consistently identified as one of the most cost- and wasting. These targets aim to boost investments effective development actions (Horton and Hoddinott in cost-effective interventions, spearhead better imple- mentation practices, and catalyze progress toward decreasing malnutrition. Some of the 2025 Target targets (stunting and wasting) are further enshrined within the United Nations’ REDUCE THE NUMBER of stunt d STUNTING childr n und r fiv b 40% Sustainable Development Goal 2 (SDG 2), which commits to ending malnutrition in all its forms by the year 2030. REDUCE THE NUMBER of wom n of ANEMIA Nutrition Targets: Investment r productiv with n mi b 50% Case and Constraints Ending malnutrition is critical for eco- INCREASE THE RATE of xclusiv EXCLUSIVE br stf din in th first six months nomic and human development. Child- BREASTFEEDING up to t l st 50% hood stunting, an overarching measure of long-term malnutrition, has life-long con- sequences not just for health, but also for REDUCE AND MAINTAIN childhood w stin human capital and economic development, WASTING ( cut m lnutrition) to l ss th n 5% prosperity, and equity. Being stunted in 1 2014). Furthermore, investments in early nutrition yield aims to close these knowledge gaps by providing a more permanent and inalienable benefits. comprehensive estimate of costs as well as financing needs, linking them both to expected impacts, and laying Although the investment case for nutrition is strong, out a potential financing framework. An in-depth under- efforts to reach the nutrition SDG targets are constrained standing of current nutrition investments, future needs by a range of factors including insufficient financing, and their impacts, and ways to mobilize the required complexity in terms of implementation (that is, how to funds is included to move the agenda from a political bridge disciplines and sectoral borders), and determin- commitment to a policy imperative. ing the methods and costs (both financial and human resources) involved in monitoring SDG targets. In rela- tion to nutrition’s contribution to this whole-of-society Estimated Financing Needs approach to development, these challenges are exacer- bated because of the major gaps in knowledge regard- These analyses estimate financing needs for the targets ing the costs and resources required for scaling up these for stunting, anemia in women, exclusive breastfeed- interventions. Two earlier studies estimated the total ing for infants, and wasting among young children. The costs of scaling up nutrition interventions (Bhutta et al. analyses are not able to estimate the financing needs to 2013; Horton et al. 2010). However, those studies estimate achieve the wasting target, mainly because of a lack of the costs of a comprehensive package of evidence-based sufficient evidence on interventions to prevent wasting. interventions affecting child undernutrition at large but Instead, the analyses estimate costs for the scale-up of the do not focus on achieving specific outcomes (see chap- treatment of severe wasting. Two of the global nutrition ter 1 in the full report for a discussion of these studies). targets—those for low birthweight and for child over- Furthermore, neither of these studies provides estimates weight—are not included in these analyses because there of the costs of reaching the global nutrition targets, are insufficient data either on the prevalence of the condi- including the SDG targets. In addition, no previous study tion (low birthweight) or consensus on effective interven- has systematically linked the costs with the potential for tions to reach the goal (child overweight). impact and the interventions’ returns on investment, nor assessed the financing shortfall between what is required The expected effects of the proposed interventions on and what is currently being spent at the global level. the prevalence of stunting among children, anemia in Finally, no prior study has presented a comprehensive women, and rates of exclusive breastfeeding for infants global analysis of domestic financing from governments are estimated, along with their impacts on mortality. and official development assistance (ODA). This report Benefit-cost analyses are conducted for each intervention, 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 2 An Investment Framework for Nutrition Box ES.1. A Big Bang for the Buck: Figure 1: The Dramatic Benefits of Investing in Nutrition The Benefits of Investing in Nutrition With many competing development objectives, 40 the main challenge for policy makers is to decide 35 which actions should be prioritized. One way to do this is to compare benefit-cost ratios across R turn for v r $1 inv st d, in doll rs interventions and programs. Even though meth- 30 odologies 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 20 to investing in nutrition (Alderman, Behrman and Puett 2016; Copenhagen Consensus Center 2015; Hoddinott et al. 2013). The analyses in 12 11 this report support that conclusion and report 10 benefit-cost ratios well above 1, the breakeven point, under a range of assumptions (see the 4 figure in this box). The benefits of investments to increase rates of exclusive breastfeeding are 0 wom n An mi in particularly high: $35 in returns for every dollar W stin Exclusiv Stuntin stf din invested. Not only are investments in nutrition one of the best value-for-money development br actions, they also lay the groundwork for the success of investments in other sectors. translating the results into benefits in relation to stunting report recommends that investments should kick-off with and anemia cases prevented, increased numbers of chil- scaling-up interventions with the highest returns (that is, dren breastfed, cases of wasting treated, lives saved, and those that maximize allocative efficiency) and those that potential earnings gained over adult working life. Issues are scalable now (that is, those that maximize technical of technical and allocative efficiency as they relate to the efficiency), with the strong caveat that scaling up only implementation of scaling-up efforts are also addressed. this priority set of interventions would not achieve the global targets. Financing this more limited set of actions This report finds that an additional investment of $70 billion will require an additional investment of $23 billion over 10 years is needed to achieve the global targets for over next 10 years. When combined with other health stunting, anemia in women, exclusive breastfeeding and the and poverty reduction efforts, this priority investment scaling up of the treatment of severe wasting. The expected approach could still yield significant returns: an esti- impact of this increased investment is enormous: 65 million mated 2.2 million lives would be saved and there would cases of stunting and 265 million cases of anemia in women be 50 million fewer cases of stunting in 2025 than in 2015. would be prevented in 2025 as compared with the 2015 baseline. In addition, at least 91 million more children under In terms of financing sources—as with other areas that the five years of age would be treated for severe wasting and SDGs aim to address—a mix of domestic on-budget 105 million additional babies would be exclusively breastfed allocations from country governments combined with during the first six months of life over 10 years. Altogether, Oversees development aid (ODA), and newly emerging investing in interventions to reach these targets would also innovative financing mechanisms coupled with house- result in at least 3.7 million child deaths averted. hold contributions, could finance the remaining gap. This underscores again the extent to which a whole-of-society In an environment of constrained resources, if the world effort is needed for financing the achievement of the could not afford the $70 billion needed to achieve the tar- nutrition targets in the context of the broader sustainable gets but instead could invest in only a subset of interven- development goals; this mix of financing is also in line tions, it would have to set priorities. In this context, this with other SDG challenges. Executive Summary 3 These analyses also confirm the high returns on invest- ment that come from investing in nutrition among chil- dren and women (box ES.1). Not only do investments in nutrition make one of the best value-for-money develop- ment actions, they also lay the groundwork for the suc- cess of investments in other sectors. Achieving the targets is within reach if partners work together to immediately step up in investments in nutri- tion. Indeed, some countries (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 in the report for a discussion of coun- try 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 breastfeeding 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 invest- ment, it pales in comparison to the $500 billion per year (nearly $1.5 billion/day) that is currently spent on agri- 3. Some areas of future research need to be priori- culture subsidies (Potter 2014) and the $550 billion per tized. These include: year (over $1.5 billion/day) spent on fossil fuel subsidies (International Energy Agency 2014), or $19 billion per Research on scalable strategies for delivering high-impact year on HIV-AIDS (UNAIDS 2016). interventions is necessary, including how to address bottlenecks to scaling up, for example through results- The nutrition-specific investments presented in this based budgeting approaches or other ways of incentiv- report are expected have large benefits: 65 million izing results. Such research will not only facilitate faster cases of stunting and 265 million cases of anemia in scale-up, but it would also have the potential to increase women would be prevented in 2025 as compared the technical efficiency and delivery costs for these inter- with the 2015 baseline. In addition, at least 91 million ventions, thereby reducing the global financing needs. more children would be treated for severe wasting and 105 million additional babies would be exclu- Another critical area for future research is the assessment sively breastfed during the first six months of life over of allocative efficiency—that is, identifying the optimum 10 years. Altogether, achieving these targets would funding allocation among different interventions or an allo- avert at least 3.7 million child deaths. And, every dol- cation that maximizes the impact under a specific budget lar invested in this package of interventions would constraint. The present analyses show cost per outcome, yield between $4 and $35 in economic returns. This is allowing for only limited comparisons of cost-effectiveness in line with previous studies suggesting returns of $18 among different interventions for the same targets. (Hoddinott et al. 2013). Research to improve the technical efficiency of nutrition spend- 2. Recent experience from several countries suggest ing is also urgently needed. This includes identifying new that meeting these targets is feasible, although some strategies for addressing complex nutritional problems of the targets—especially those for reducing stunting such as stunting and anemia, as well as technologies to in children and anemia in women—are ambitious and help take these solutions to scale more rapidly and at will require concerted efforts in financing, scale-up, and lower cost. Because of the multifactorial nature of ane- sustained commitment. On the other hand, the target mia, research is underway to clearly determine what for exclusive breastfeeding has scope to be much more fraction of the problem can be addressed by nutrition ambitious. interventions; the estimates presented in this report may 4 An Investment Framework for Nutrition An Affordable Package of Nutrition-Specific Interventions 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 need to be revised accordingly once results become avail- and sanitation sectors, among others. It is evident that able. Additionally, some micronutrient deficiencies are stunting, as well as anemia, are multifactorial and can not included here (i.e., iodine deficiencies), because these be improved through increasing quality, diversity, and were not included in the global targets, even though they affordability of foods, increasing the control of income by have significant impacts on morbidity, mortality, and women farmers, and also by reducing exposure to fecal economic productivity. pathogens by improved water, sanitation, and hygiene practices. However, the attributable fraction of the burden Strengthening the quality of surveillance data, unit cost data that can be addressed by these interventions is unknown. for interventions in different country contexts, and build- The last five years have seen a proliferation of studies to ing stronger data collection systems for estimating current improve clarity on these issues, as well as on the use of investments in nutrition (from both domestic governments social programs as a platform for reaching the most vul- and ODA) are also crucial. Further research is needed nerable. Future work in this area should take into account on the costs of interventions such as maternity protec- such new evidence as studies are published. tion 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 Call to Action monitoring spending and ensuring accountability, and to As the world stands at the cusp of the new SDGs, with undertake national-level public expenditure reviews. global poverty rates having declined to less than 10 per- cent for the first time in history (World Bank 2016), there A dedicated effort to understanding which interventions is an unprecedented opportunity to save children’s lives, prevent wasting is urgently needed. It is also essential to build future human capital and gray-matter infrastruc- learn more about cost-effective strategies for managing ture, and provide equal opportunity for all children to moderate acute malnutrition, and whether or not these drive faster economic growth. These investments in the can contribute toward the prevention of wasting. critical 1,000 day window of early childhood are inalien- able and portable and will pay lifelong dividends—not More evidence is needed on the costs and impacts of nutrition- only for the children directly affected but also for us all in sensitive interventions—that is, interventions that improve the form of more robust societies—that will drive future nutrition through agriculture, social protection, and water economies. Executive Summary 5 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. 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Paris, France: International Energy Agency. http://www .worldenergyoutlook.org/weo2014/ Martorell, R., B. L. Horta, L. S. Adair, A. D. Stein, L. Richter, C. H. D. Fall, S. K. Bhargava, S. K. Dey Biswas, L. Perez, F. C. Barros, C. G. Victora, and Consortium on Health Orientated Research in Transitional Societies Group. 2010. “Weight Gain in the First Two Years of Life Is an Important Predictor of Schooling Outcomes in Pooled Analyses from Five Birth Cohorts from Low- and Middle- Income Countries”. Journal of Nutrition 140: 348–54. Potter, G. 2014. “Agricultural Subsidies Remain a Staple in the Industrial World.” Vital Signs, 28 February. Washington, DC: World Watch Institute. http://vitalsigns.worldwatch.org/vs-trend/agricultural-subsidies-remain-staple-industrial-world UNAIDS. 2016. Fast-Track Update on Investments Needed in the AIDS Response. Geneva: UNAIDS. http://www.unaids.org/sites/ default/files/media_asset/UNAIDS_Reference_FastTrack_Update_on_investments_en.pdf UNICEF, WHO, and World Bank (United Nations Children’s Fund, World Health Organization, and World Bank). 2015. Joint Child Malnutrition Estimates: Levels and Trends. Global Database on Child Growth and Malnutrition. http://www.who.int/nutgrowthdb/ estimates2014/en/ (accessed October 2015). World Bank. 2016. Global Monitoring Report 2015/2016: Development Goals in an Era of Demographic Change. Washington, DC: World Bank. http://www.worldbank.org/en/publication/global-monitoring-report. Results for Development Institute contributed the financing analyses and 1,000 Days was a key advocacy partner in this work. Funding was provided by the Bill & Melinda Gates Foundation and Children’s Investment Fund Foundation (to Results for Development Institute) 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; Obey Assery- Nkya, Tanzania Office of the Prime Minister; Helen Connolly, American Institutes for Research; Luz Maria De-Regil, Micronutrient Initiative; Kaia Engesveen, World Health Organization; Augustin Flory, Children’s Investment Fund Foundation; 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; 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. For additional information go to www.worldbank.org/health For the full report see: http://www.worldbank.org/en/topic/nutrition/publication/an-investment-framework-for-nutrition-reaching- the-global-targets-for-stunting-anemia-breastfeeding-wasting 6 An Investment Framework for Nutrition