Presented on June 6, 2022 at Africa Health Excon in Egypt. It presents an approach to prioritize and select affordable high impact nutrition specific and sensitive interventions in low resources settings at national and local levels.

1. Investing in Stunting
Prevention and Reduction
The Case of Sudan
Dr. Alaa Hamed
June 6, 2022

2. Outline
 What is Stunting?
 Sudan’s Human Capital
 What evidence-based interventions reduce stunting?
 Why do we need to prioritize stunting in Sudan?
 Epidemiology of Stunting in Sudan
 The Key Drivers of Stunting in Sudan
 Sudan’s Nutrition Investment Case (SNIC2014)
 How can a multisectoral strategy to reduce stunting produce the
desired results?
 Preventing and Reducing Stunting in Sudan – An Incremental-
Based Approach
 Preventing and Reducing Stunting in Sudan – A Regional-Phased
Approach
 The Cost-Benefit Analysis of the Different Scale Up Scenarios

3. Stunting is one of
Sudan’s most
important
underlying causes
of the country’s
total disease
burden impacting
the country’s
economic
development.
 Sudan is one of the 14 countries where 80 percent of
the world’s stunted children live.
 Stunting is a reduced growth rate in human
development reflecting failure to reach linear growth
potential because of long-term undernutrition or
illness, or a combination of both.
 A stunted child faces a higher risk of dying from
infectious disease (1.9 to 6.5 times more likely to die),
and the child is likely to perform less well in school
(equivalent to two to three years’ loss of education).

4. Stunting is one of
Sudan’s most
important
underlying causes
of the country’s
total disease
burden impacting
the country’s
economic
development.
 Stunting is associated with impaired brain
development, compromised mental functioning
leading to significantly reduced learning.
 Adults stunted as children earn less income in life than
their well-nourished peers (on average, 22 percent
less), exacerbating their deprivation.
 For any given country, stunting can result in a loss of
GDP of 9 to 10 percent per year.

5. Sudan’s Human Capital

6. Sudan ranked
139 among 157
countries
according to the
Human Capital
Index (HCI)
 Sudan’s Human Capital Index (HCI)
value of 0.38 in 2018 indicates that
a child born today will achieve only
38 percent of her productive
potential if she fully pursues
education and maximizes her
health condition
 In terms of educational
achievements, Sudan has one of
the largest numbers of out-of-
school children in the Middle East
and North Africa region.
 There are 2.4 million Sudanese
children who are not in primary
school, making for a primary gross
enrollment rate of 77 percent, and
the country’s mean years of
schooling is only 7.3.

7. What evidence-based
interventions reduce
stunting?

8. Evidence-
based
interventions
that reduce
stunting
 Strong evidence regarding interventions that affect the
proximal determinants of stunting or nutrition-specific
interventions
 In contrast, evidence regarding the effectiveness of
interventions that target more distal determinants of
stunting, the nutrition-sensitive approaches, remains
limited.
 Nutrition-specific interventions can be grouped into:
 those for pregnant women and the mothers of infants
and young children
 those for infants and young children.

9. Interventions for Pregnant
Women and the Mothers of
Infants and Young Children
 Antenatal micronutrient
supplementation
 Counseling for mothers and
caregivers on good infant and young
child nutrition and hygiene practices.
 Balanced energy-protein
supplementation for pregnant
women.
 Intermittent presumptive treatment
of malaria in pregnant women in
malaria-endemic regions.
Interventions for Infants and
Young Children
• Vitamin A supplementation for
children.
• Prophylactic zinc supplementation.
• Public provision of complementary
food for children

10. Why do we need to
prioritize stunting in
Sudan?

11. Seven reasons
for prioritizing
stunting in
Sudan
 Stunting is One of the four World Health Assembly global
nutrition targets, Second of the United Nations’ Sustainable
Development Goals.
 Stunting Could be a life sentence, must not be accepted as
the “new normal.”
 The most stunted children come from the most
disadvantaged population groups.
 Undernutrition in Sudan is due to the highly synchronized
occurrence of both wasting and stunting (WaSt). Tackling
stunting would also contribute to prevention of wasting.
 Stunting is one of five indicators used to measure the Human
Capital Index (HCI).
 Stunting has lifelong consequences not just for the health of
the population but also for economic development,
prosperity, and equity.
 Stunting has long-term repercussions that reverberate across
generations.

12. Epidemiology of
Stunting in Sudan

13. Sudan’s
stunting level
of 38 percent
of children
under 5 years
old was above
WHO’s
emergency
threshold of
30 percent

14. Stunting have
risen since
2010 going
against the
general trend
of declining
prevalence on
the African
continent over
the past few
decades

15. Malnutrition in
Sudan is
geographically
widespread, with
more than half of
Sudan’s 18 states
having critically
high malnutrition
levels

16. Those in the
poorest
quintiles are
more likely to
be stunted
more than the
better off.

17. The Key Drivers of
Stunting in Sudan

18. There are six
key
determinants
of stunting
among
children aged
0 to 23 months
in Sudan
Mother’s educational status
 Children whose mothers attained at least a primary
education are less likely to be stunted than those with
mothers with no education.
Place of residence (urban or rural)
 The risk of being stunted is 38 percent higher among children
living in rural areas than among those living in urban areas,
which is an indication that urban children have more access
to improved water.
Household wealth
 Children from households in the middle wealth quintiles are
more likely to be stunted than those in the poorest
households
Child sex
 Females 0-23 months of age have lower odds of being
stunted compared to their male counterparts.

19. Low Birth
Weight
Every child who
is born with low
birthweight in
Sudan is 1.5
times at risk of
getting stunted.

20. Improved
Access to
Water and
Sanitation

21. There are two
key
determinants of
stunting among
children aged 6
to 23 months in
Sudan
Frequency of
Meals
 The share of children aged
between 6 and 23 months
who are on a minimum
acceptable diet is very low in
Sudan, and receiving this
minimum acceptable diet is
associated with a
considerable decline in the
odds of a child being stunted.

22. There are two key
determinants of
stunting among
children aged 6 to
23 months in
Sudan
Handwashing with
Clean Water and
Soap

23. Sudan’s Nutrition
Investment Case
(SNIC2014)

24. Sudan’s
Nutrition
Investment
Case
(SNIC2014)
argued for
substantial
investments to
reduce
undernutrition
in the country.
Sudan’s Nutrition Investment Case (SNIC2014) examined four
different scenarios:
 Business as usual (maintaining the status
quo)
 Implementing a UNICEF/World Food
Program/Federal Ministry of Health plan to
scale up investment in reducing
undernutrition, initially in five states;
 Scaling up interventions aimed at reducing
undernutrition to cover 50 percent of the
population;
 Scaling up investment interventions aimed
at reducing undernutrition to cover 90
percent of the population.

25. The Scaling up
investment
interventions
aimed at
reducing
undernutrition
to cover 90
percent of the
population
Scenario
 The SNIC2014 concluded that implementing a
package of selected nutrition-specific and
nutrition-sensitive interventions that covered
90 percent, the highest coverage for the
maximum effect on child undernutrition and
mortality reduction of the targeted population,
would be the most cost-effective investment for
reducing undernutrition and under-5 mortality
in Sudan.

26. The Scaling up
investment
interventions
aimed at
reducing
undernutrition
to cover 90
percent of the
population
Scenario
 This would translate into
a net gain for Sudan of
US$2 billion a year.
 The benefit value would
be substantially more
than the cost (estimated
at US$524 million
annually) and would
represent a fourfold
return on investment.

27. The SCN2014
Scenarios
Requires the
Need for
prioritization
 Considering Sudan’s fragile and unstable socio-political
and financial context, this level of investment may not
be feasible due to financing and capacity limitations.
 Therefore, the government will need to prioritize and
cost a package of cost-effective nutrition interventions
that could be implemented in the medium term within
a feasible budget envelop that the government can
afford.
 These nutrition interventions will need to be selected
carefully to include nutrition-specific interventions that
could be delivered in an integrated manner as part of
Sudan’s essential health package of services as well as
nutrition-sensitive interventions that would need to be
implemented as part of a multi-sectoral response.

28. How can a multisectoral
strategy to reduce
stunting produce the
desired results?

29. Is a Mutlisectoral
Approach
Effective to
Prevent and
Reduce
Stunting?

30. A recent 2019
World Bank
report offers
new insights on
how to
strengthen
multisectoral
efforts aimed at
reducing
stunting
 Little evidence that involving
multiple sectors in the effort to
reduce undernutrition will
produce the desired outcomes.
 Multisectoral nutrition planning
was favored by the international
development community in the
1970s, however, overly ambitious
and too dependent on other
sectors that were reluctant to be
coordinated

31. One successful
strategy is to
implement
interventions that
combine the three
driversof nutrition –
agriculture (food
security), healthcare,
andWASH – and
target them to
geographic areas (or
populations within
theseareas)with a
high prevalence of
stunting
.There are two useful guidelines for sequencing
interventions to the target areas or populations
 First, if available resources allow for investment in
only one sector, this sector should be health.
 Second, if a target area is already covered by the
health sector, the decision about whether to cover
the same target area with either food security or
WASH interventions should be based on costs
rather than on benefits because their benefits in
terms of reductions in stunting appear to be
similar.

32. Preventing and Reducing
Stunting in Sudan – An
Incremental-Based
Approach

33. What are the
optimized
interventions to
minimize the
prevalence of
stunting in
Sudan
To reduce stunting prevalence within an
affordable and feasible budget envelope,
policymakers in Sudan will need to
implement a package of a highly cost-
effective nutrition interventions that
could be implemented in the medium
term.

34. Seven specific
and sensitive
interventions
are being
proposed

35. The selection of
interventions, their
cost and benefits
are presented in
three incremental
scenarios to
minimize both
prevalence of
stunting and the
number of stunted
children

36. Scenario 1:
Prioritizing
nutrition-
specific
interventions
• Prioritizing and selecting those five high-impact cost-effective
nutrition specific interventions would require Sudan to allocate a
lesser amount of US$53.6 million annually at 95 percent coverage
from the current baseline.
• The full list of nutrition-specific interventions listed in SNIC2014 that
would address malnutrition problems in Sudan would cost Sudan the
amount of US$230 million annually at 90 percent coverage.

37. Scenario 1: Prioritizing
and selectingthose
five high-impact cost-
effectivenutrition
specific interventions
would requireSudan
to allocate a lesser
amount ofUS$53.6
million annually at 95
percent coverage
from the current
baseline.
Scaling up the optimized package of nutrition-specific
interventions (Scenario 1) would ensure a 4 percent reduction
in prevalence of stunting over the period 2019 to 2024 (from
38% to 34%) and 402,471 cases of stunting averted in children
turning 5 years of age at a cost of US$569.97 per additional
case of stunted averted.

38. Scenario 2 -
Adding family
planning
services to the
mix of the
nutrition-specific
interventions
 The provision of family planning services was selected
given it is relevance to the reduction of the number of
stunted children and low birth weight, a key driver of
stunting, given the strong association between a
mother’s young age and smaller children.
 In 2014, only 12 percent of Sudanese women of
reproductive age (15 to 49 years old) use
contraception, and only a mere 10 percent use modern
contraceptives.
 If implemented nationally, family planning alone has
the potential to reduce the number of stunted children
by about 2,157,483 children by 2050.

39. Scenario 2 -
Adding family
planning
services to the
mix of the
nutrition-specific
interventions
Adopting policies aimed at achieving a low fertility
scenario, a reduction of the number of stunted children
could be achieved to 2,797,010 instead of the current
projection of 4,954,493 by 2050, representing a
reduction of almost half (2,157,483 stunted cases
averted), as a result of encouraging the use of family
planning methods as well as educating girls,
empowering and employing women

40. Scenario 2 -
Adding family
planning
services to the
mix of the
nutrition-specific
interventions
The investment required to provide 95 percent coverage of
family planning services by 2024 would be US$2 million per
year totaling to US$55.6 million adding this to the cost of
Scenario 1.
Scenario 2 would ensure a 4 percent reduction in prevalence of
stunting over the period 2019 to 2024 (from 38% to 34%),
430,619 cases of stunting averted in children turning 5 years of
age at a cost of US$513.20 per additional case of stunted
averted.

41. Scenario 3 -
Adding
handwashing to
the mix of the
nutrition-specific
interventions
and family
planning
 Our analysis of the determinants of stunting in Sudan
revealed that hand washing with soap and water
decreased the odds of being stunted by 32 percent in
households with children aged 6 to 23 months old.
 Studies have found that poor water and sanitation is
associate with a greater incidence of diarrheal diseases,
which are a risk factor for stunting.
 Evidence shows that a community’s coverage of
sanitation is more important than any one household:
in other words, a child living in a household with
improved sanitation can expect to benefit from a
cleaner home environment, but she benefits further if
she lives in a household in a community where others
also use improved sanitation.

42. Scenario 3 -
Adding
handwashing to
the mix of the
nutrition-specific
interventions
and family
planning
 Adding the promotion of handwashing to the package
would require an additional US$9.5 million per year for
95 percent coverage totaling to US$65 million.
 Scenario 3 would ensure a 5 percent reduction in
prevalence of stunting over the period 2019 to 2024
(from 38% to 33%) and 539,489 cases of stunting averted
in children turning 5 years of age at a cost of US$477.59
per additional case of stunted averted.

43. What are the
benefits of
implementing
the three
scenarios as one
package
Scenario 3 presents itself as the most-cost effective set
of nutrition specific and sensitive interventions to
recommend for Sudan in the medium term.
When comparing the benefits of all three scenarios
included in this analysis, scaling up the optimized
package of nutrition-specific interventions including
family planning and handwashing would ensure the
following:
 the highest reduction of 5 percent in prevalence of
stunting over the period 2019 to 2024 (from 38% to
33%),
 the most significant number of cases of stunting
averted in children turning 5 years of age, 539,489
cases averted,
 the lowest cost US$ 477.59 per additional case averted.

44. What are the
benefits of
implementing
the three
scenarios as one
package

45. Preventing and Reducing
Stunting in Sudan – A
Regional-Phased
Approach

46. How can
geographic areas
best be
prioritized to
reduce stunting
in Sudan?
 Given fiscal and capacity constraints, there is need to prioritize
and optimize investments geographically.
 SNIC2014 recommended targeting five states with a high
prevalence of stunting: Al Gezira, Kassala, Gedaref, Central
Darfur, and Red Sea.
 Combining stunting prevalence with the number of stunted
children in each state, other states should be considered as
potential targets to reach highest number of people in need.

47. How can
geographic areas
best be
prioritized to
reduce stunting
in Sudan?
Combining
Prevalence and
Numbers
 Phase 1: Stunting prevalence more than 40 percent
and high stunting burden (more than 150,000
stunted children)
 Phase 2: Stunting prevalence less than 40 percent
and medium stunting burden (fewer than 150,000
but more than 100,000 stunted children)
 Phase 3: Stunting prevalence more than 40 percent
or medium stunting burden (fewer than 150,000
but more than 100,000 stunted children)
 Phase 4: Stunting prevalence more than 40 percent
and low stunting burden (fewer than 100,000
stunted children)
 Phase 5: Stunting prevalence less than 40 percent
and low stunting burden (fewer than 100,000
stunted children).

48. How many
women and
children can we
cover and in
how many
places?
Optimal Allocation Scenario -
Phase 1
(Al Gezira,West Kordofan,
North Kordofan, Kassala, North
Darfur)
Estimate
d annual
spending
(US$ mil)
Outcome Cost per
addition
al cases
of
stunting
averted
(US$)
Additiona
l cases of
stunting
averted
(2019-
2024)
Baseline
stunting
prevalen
ce (2019)
Stunting
prevalen
ce (2024)
Reductio
n in
stunting
prevalen
ce
Al Gezira 7.27 58,028 42% 37% -5% 642
Kassala 3.61 27,142 46% 41% -5% 838
North Darfur 3.68 31,285 42% 37% -5% 923
North Kordofan 5.07 40,269 40% 35% -5% 705
West Kordofan 5.44 39,873 46% 42% -4% 708
Total 25.08 196,598 43% 38% -5% 763

49. How much
would it cost?
States Optimal allocation (US$ mil)
Phase 1
Al Gezira, West Kordofan, North Kordofan, Kassala, North
Darfur
25.08
Phase 2 South Darfur, White Nile, Khartoum 17.18
Phase 3 Gedaref, South Kordofan, East Darfur 11.17
Phase 4 Blue Nile, Central Darfur, Red Sea 4.16
Phase 5 Sennar, River Nile, West Darfur, Northern 7.55
Total 65.14

50. The Cost-Benefit Analysis
of the Different Scale Up
Scenarios

51. Benefits, costs
and benefit-cost
ratios
Scenario
Discoun
t rate
Present
value
benefits
(US$, mil)
Present
value cost
(US$, mil)
Benefit
-cost
ratio
IRR
(discounte
d costs and
benefits)
1. Optimized Nutrition specific interventions 3% 1,332 457 2.91 4%
2. Optimized Nutrition specific + family planning 3% 3,963 475 8.35 8%
3. Optimized Nutrition specific + family planning +
hand washing
3% 6,093 556 10.97 9%
4. Optimal allocation in five priority states of
Optimized Nutrition specific + family planning +
handwashing
3% 2,622 214 12.26 10%