Budget Analysis Workshop Guatemala

1. The Investment Case for Nutrition:
What Works?
Harold Alderman
International Food Policy Research Institute
April 28, 2015

2. Evidence Based Interventions for Improving
Maternal and Child Nutrition:
What Can be Done and at What Cost?
A team of international nutrition experts reviewed the
global evidence for a 2013 Lancet Nutrition Series and
estimated the impact and cost of scaling up 10 proven
effective nutrition specific interventions to cover 90% of
the at-risk population.
These core interventions are across the life-cycle, assisting
women of reproductive age, neonates and young
children.
They also use a range of delivery platforms including
community programs for nutrition education, integrated
management of child illnesses and food fortification.

3. Potential Impact of Scaling Up
10 Proven Interventions
Continued investment in nutrition-specific
interventions and delivery strategies to reach the
population at greatest risk can make a significant
difference
If these 10 proven nutrition-specific interventions
were scaled-up from current population coverage to
90%, we could:
• Save an estimated 900,000 lives in 34 high
burden countries (where 90% of the world’s
stunted children live)
• Reduce the number of children with stunted
growth and development by 33 million
Added to existing trends, the World Health Assembly
targets for 2025 are reachable
3

4. Effect of Scaled-up Interventions on Deaths in
Children Younger than 5 Years
4

5. Total Additional Annual Cost of Achieving 90%
Coverage with Nutrition Interventions
Nutrition interventions Cost
Salt iodisation $68
Multiple micronutrient supplementation in pregnancy (includes
iron-folate)
$472
Calcium supplementation in pregnancy $1914
Energy-protein supplementation in pregnancy $972
Vitamin A supplementation in childhood $106
Zinc supplementation in childhood $1182
Breastfeeding promotion $653
Complementary feeding education $269
Complementary feeding supplementation $1359
SAM management $2563
Total $9559
Data are 2010 international dollars, millions.
5

6. Intervention based on Bhutta et al (2008) and
Horton et al (2010)
Cost per
child
Intervention based on Bhutta et
al 2013
Universal salt iodization $0.05 Universal salt iodization
Iron fortification of staples $0.80
Iron-folic acid supplementation for mothers
during pregnancy
$2.00 Multiple micro-nutrient
supplements
Community based nutrition programs
providing information on breastfeeding,
complementary feeding, handwashing;
distribution of micronutrient powders, iron-
folate supplements
$15.00 Community based nutrition
programs that provide
information on breastfeeding
($14.32); complementary
feeding education ($5.27)
Providing complementary foods $50.001 Provision of complementary
foods
Community based management of severe
acute malnutrition
$8.13 Community based management
of severe acute malnutrition
Vitamin A supplementation $4.80 Vitamin A supplementation
Multiple micronutrient powders $10.80 Multiple micronutrients
Therapeutic zinc supplementation for
management of diarrhea
$4.00 Zinc supplementation
Deworming $1.00
TOTAL $96.58 TOTAL
Per child costs of interventions to reduce stunting in children under 24 months

7. Intervention d=3%
DALY=
$1000
d=6%
DALY=
$1000
d=3%
DALY=
$5000
D=6%
DALY=
$5000
1. Micronutrient supp. 17.3 10:1 86.5 52.1
2. Micronutrient fortif.
-Iron
-Iodine
8.0
30.0
7.0
12.1
8.0
30.0
7.0
12.0
3. Biofortification 16.7 10.0 33.5 50.0
4. Deworming (preschool) 6.0 2.4 6.0 2.4
5. Nutrition education 12.5 7.5 62.5 37.5
These interventions have individually high
Benefit:Cost Ratios, under a wide range of
assumptions

8. Why does improved nutrition of children
affect adult earnings?
• Height (curiously) affects wages even in white
collar jobs
• Malnourished children start school later (which
in itself reduces earnings through delayed entry
to labor force)
• Malnourished children attend fewer classes
• And they learn less per year of schooling

9. Undernutrition is a risk factor for overall
cognitive development

10. Neglect of undernutrition can cost an
economy millions of dollars
According to ECLAC underweight in 2004 cost
 Guatemala $3 Billion (11.4% of GDP)
 El Salvador $1Billion (7.4% of GDP)
 Honduras $780 Million (10.6% of GDP)
 Costa Rica $318 million (1.7% of GDP)
These estimates are based on the lost potential
education of the current labor force. Projections for
cost of undernutrition of today’s children under 5
(fewer and often healthier) range from 0.5% of GDP
for Guatemala to virtually nothing for Costa Rica

11. There is a need to complement Nutrition
Specific investments with Nutrition
Sensitive Programs
The 2013 Lancet Nutrition Series estimated that
scaling 10 nutrition specific interventions would
reduce stunting globally by 20 percent.
While this would be a major improvement in the
health and development of children, it does not go
far enough.
Thus, there is also a need for programs that address
the core determinants of undernutrition
This is the role of nutrition sensitive interventions
11

12. Definition: Nutrition-sensitive Interventions
These are interventions or programs that address the underlying
determinants of fetal and child nutrition — food security; adequate
caregiving resources at the maternal, household and community
levels; and access to health services and a safe and hygienic
environment—and incorporate specific nutrition goals and
actions.
Nutrition-sensitive programs can serve as delivery platforms for
nutrition-specific interventions, potentially increasing their scale,
coverage and effectiveness
12
Examples
:
Agriculture and food security Social safety nets
Early child development Maternal mental health
Women’s empowerment Child protection
Schooling Water, sanitation and hygiene
Health and family planning services

13. Why Nutrition Sensitive Programs are also
Important Instruments to Reduce
Undernutrition
The potential for nutrition sensitivity in sectors such as
agriculture and social protection comes in part from their
scale; most governments devote substantial resources to
programs in these sectors.
In addition, these programs are generally intrinsically targeted
to the poor
They often contain design features that can empower women
These programs can also serve as delivery platforms for
nutrition-specific interventions, potentially increasing their
scale, coverage and effectiveness
Moreover, by improving nutrition they increase overall
economic growth 13

14. Nutrition-sensitive programs have enormous potential, yet to be fully
unleashed it is important to strengthen nutrition goals in the design
and to use programs as delivery platforms for health and nutrition
services.
It is also important to focus on women’s time availability and their
physical and mental health and empowerment
Targeted agricultural programs and social safety nets play a key
role in mitigating negative effects of shocks as well as supporting
livelihoods, food security, diet quality, and women’s empowerment.
Safety nets can be linked to nutrition services via conditions and by
social marketing.
Incorporating nutrition in early child development programs and in
school curricula can benefit both nutrition and child development
and have long-lasting impacts into adulthood
Enhancing the Nutrition-sensitivity of
Programs
14

15. Obesity and related non-communicable diseases are a rising
concern in many countries.
Part of the problem is that obesity increases faster with
income growth than stunting declines. Transfers, such a
PROGRESA, help on one front but hurt on another
But the double burden is not only a concern for high income
settings; even low and middle income countries are seeing
rising levels of obesity. Mexico has one of the highest rates of
obesity in the world.
It is not uncommon to find an individual with a high body mass
index in the same household with a stunted child.
The double burden of obesity presents a
challenge for nutrition sensitive programs
15

16. Linking cash support to nutrition education has been shown to
improve the impact on undernutrition; plausibly the linkage can
also address obesity
School meals are being redesigned in much of Latin America
to address obesity among students and to provide an entry
into nutrition education
Mexico introduced taxes on sugary soft drinks. They have also
introduced regulations on advertising such drinks and also
high calorie snacks
However, it is too soon to know whether any of these
approaches work at large scale
Nutrition Sensitive approaches to addressing
obesity are being explored
16

17. Some concluding points for knowledge
generation
The knowledge base on what can work (efficacy) is extensive;
much more is needed to go from this knowledge to a national
scale.
Some questions still to be answered include:
 What behavioral change communication can augment food security
measures to encourage diet diversity and improved mother-child
interaction?
 How can schools be a vehicle for practical nutrition education?
 What are the most feasible means to achieve an institutional
continuity from nutrition in the first 1,000 days through preschool?
 Can this institutional framework link health care with social
protection as well as with education ministries?