Progress Toward Meeting Nutrition Targets in Africa Presented by M. Ag Bendech, 19 October 2016, Accra (Ghana )

The scale of the problem of malnutrition in Africa (GNR 2016) 163.6 million children and women of reproductive age are anemic 58 million children under age five are too short for their age (stunting) 13.9 million under 5’s weigh too little for their height (wasting) 10.3 million under 5’s are overweight 8 percent of adults over 20 years are obese.

The Multiple Burdens of Malnutrition in African Countries the nutrition problems Africa is facing are multiple and overlapping. The Figure shows that 8 of the 54 African countries (Botswana, Egypt, Equatorial Guinea, Lesotho, Libya, Namibia, South Africa and Swaziland) are facing serious public health issues on 3 key dimensions stunting, women’s anemia and overweight/obesity—a triple burden. Thirteen countries are facing a double burden of undernutrition and overweight/obesity. Only four countries are facing serious single burdens of stunting (Ethiopia and Rwanda) and women’s anemia (Ghana and Senegal).

The annual cost of undernutrition in 7 African countries (www The annual cost of undernutrition in 7 African countries (www.costofhungerafrica.com) The burdens in terms of human suffering, mortality and disease are large (IFPRI 2015), but so too are the economic burdens. The African Union and the World Food Programme Cost of Hunger estimates are summarized in this Figure.

Investing in nutrition: a wise investment

Meeting the Malabo stunting target : the status (countries ranked on stunting prevalence in %) To assess whether a country will attain the Malabo stunting target by 2025 we calculate the average annual rate of reduction (AARR) required for a country to get to 10% stunting from where it currently stands. We then compare the required AARR to the country’s recent performance in reducing rates (the current AARR as determined by the Joint Child Malnutrition Estimates from UNICEF/WHO/WB: JME 2015). If the current AARR ≥ the required AARR then the country is “on course”. If the current AARR is > 0 but < the required AARR then the country if designated as “off course but making progress” and if the current AARR is ≤0 (i.e. stunting rates are static or increasing) then the country is designated as “off course, no progress”.   The table lists the countries by their latest stunting estimate and the colours designate if they are on or off course. 49 countries have sufficient data to make the comparison while 5 do not. Of the 49 with data, only 4 are on course to meet the Malabo declaration target, 39 are off course but making some progress and only 6 are making no progress.

Countries ranked according to stunting (%), lowest to highest prevalence, and assessment of progress towards WHA Global Nutrition 2025 target (stunting)   Rank Country Stuntinggg % Stunting % 1 Seychelles 7.9 19 Togo 27.5 37 Tanzania 34.7 2 Tunisia 10.1 20 Zimbabwe 27.6 38 Sierra Leone 37.9 3 Algeria 11.7 21 Guinea-Bissau 39 Rwanda 4 Morocco 14.9 22 Angola 29.2 40 Sudan 38.2 5 Gabon 17.5 23 Cote d'Ivoire 29.6 41 Mali 38.5 6 Ghana 18.8 24 South Sudan 31.1 42 Chad 38.7 7 Senegal 19.4 25 Guinea 31.3 43 Zambia 8 Libya 26 Botswana 31.4 44 Ethiopia 40.4 9 Mauritania 27 Sao Tome and Principe 31.6 45 Central African Republic 40.7 10 Egypt 22.3 28 Comoros 32.1 46 Malawi 42.4 11 Namibia 23.1 29 Liberia 47 DRC 42.6 12 South Africa 23.9 30 Cameroon 32.6 48 Niger 13 Gambia 24.5 31 Burkina Faso 32.9 49 Mozambique 43.1 14 Congo 32 Nigeria 50 Madagascar 49.2 15 Swaziland 25.5 33 Lesotho 33.2 51 Eritrea 50.3 16 Somalia 25.9 34 Djibouti 33.5 52 Burundi 57.5 17 Kenya 35 Benin   Cape Verde No data 18 Equatorial Guinea 26.2 36 Uganda 34.2 Mauritius The table undertakes the same exercise, but instead the aim is to meet the more modest WHA target of a 40% reduction in the number of stunted children by 2025 applied to each country. The results show that 9 countries are on course, the same 6 are making no progress and that 34 are off course but making some progress.   On course, good progress   Off course, some progress Off course, no progress Insufficient data to make assessment

Countries ranked according to exclusive breastfeeding (EBF) of infants <6 months (%), highest to lowest prevalence, and assessment of progress towards WHA EBF target Rank Country EBF 1 Rwanda 87 19 DRC 47.6 36 Algeria 25.7 2 Sao Tome & Principe 73.8 20 Gambia 46.8 37 Niger 23.3 3 Zambia 72.5 21 South Sudan 45.1 38 Mauritius 4 Malawi 70.2 22 Swaziland 44.1 39 Guinea 20.5 5 Burundi 69.3 23 Madagascar 41.9 40 Botswana 20.3 6 Eritrea 68.7 24 Benin 41.4 41 Nigeria 17.4 7 Lesotho 66.9 25 Tanzania 41.1 42 Comoros 12.1 8 Uganda 63.2 26 Mozambique Cote d'Ivoire 9 Kenya 61.4 Zimbabwe 43 Tunisia 8.5 10 Cape Verde 59.6 27 Egypt 39.7 44 South Africa 8.3 11 Togo 57.5 28 Mali 37.8 45 Equatorial Guinea 7.4 12 Sudan 55.4 29 Central African Republic 34 46 Gabon 13 Liberia 55.2 30 Senegal 33 47 Somalia 5.3 14 Guinea-Bissau 52.5 31 Congo 32.9 48 Djibouti 1.3 15 Ghana 52.3 32 Sierra Leone 49 Chad 0.3 16 Ethiopia 52 Cameroon 28.2   Angola  No data 17 Burkina Faso 50.1 Morocco 27.8 Libya 18 Namibia 48.5 35 Mauritania 26.9 Seychelles Finally for exclusive breastfeeding (infants <6 months), so important for getting infants off to the best possible start in life, Table 5 shows that 23 countries are on course, 3 are off course but making some progress, while 12 are off course making no progress (and one of these 12, Egypt, is actually showing a worsening rate of exclusive breastfeeding rates). 16 countries do not have sufficient data to make an assessment. On course   Off course, some progress Off course, no progress Insufficient data to make assessment

Countries ranked according to wasting (%), lowest to highest prevalence, and assessment of progress towards WHA target Rank Country Wasting % 1 Swaziland 2 19 Senegal 5.8 37 Egypt 9.5 Rwanda 2.2 20 Cameroon 38 Guinea 9.9 3 Morocco 2.3 21 Congo 5.9 39 Burkina Faso 10.9 4 Tunisia 2.8 22 Bissau 6 40 Comoros 11.1 5 Lesotho 23 Mozambique 6.1 41 Sao Tome and Principe 11.2 Equatorial Guinea 3.1 24 Burundi 42 Gambia 11.5 7 Zimbabwe 3.3 25 Zambia 6.3 43 Mauritania 11.6 8 Gabon 3.4 26 Libya 6.5 44 Somalia 14.9 9 Tanzania 3.8 27 Togo 6.7 45 Eritrea 15.3 10 Malawi 28 Namibia 7.1 46 Mali 11 Kenya 29 Botswana 7.2 47 Chad 15.7 12 Algeria 4.1 30 Central African Republic 7.4 48 Sudan 16.3 13 Seychelles 4.3 31 Cote d'Ivoire 7.6 49 Niger 18.7 14 Uganda 32 Nigeria 7.9 50 Djibouti 21.5 15 Benin 4.5 33 DRC 8.1 51 South Sudan 22.7 16 Ghana 4.7 34 Angola 8.2   Cape Verde No data 17 South Africa 35 Ethiopia 8.7 Madagascar 18 Liberia 5.6 36 Sierra Leone 9.4 Mauritius The table summarises the country rankings and progress status for wasting. Here the WHA 2025 target is to be less than 5%. As the Table shows of 51 countries with data, 17 are on course and 34 are off course. On course Off course   Insufficient data to make assessment

Countries ranked according to anaemia (%), lowest to highest prevalence, and assessment of progress towards WHA target The table summarises the rankings and progress for anaemia in women of reproductive age (15-49 years). Only one country, Burundi, is on track to meet this WHA target.

Underlying drivers of improved nutrition status

Thresholds for underlying drivers Threshold corresponding to a prediction of stunting prevalence of <15% Unit Total per capita calories in food supply 2800 Kilocalories Calories from non-staples in food supply 50 Percent Access to piped water 69 Access to improved sanitation 76 Female secondary school enrollment rate 81 Ratio of female to male life expectancy 1.072 Ratio

Number of African countries by number of vulnerabilities Names of countries 0/6 1 0/14 2 4/14 Algeria, Egypt, South Africa, Tunisia 3 4 3/4 Botswana, Morocco, Sao Tome and Principe 5 6/11 Benin, CAR, Ghana, Mauritania, Namibia, Uganda 6 27/35 Angola, Burkina Faso, Cameroon, Chad, Congo, Cote d’Ivoire, Djibouti, Ethiopia, Gabon, The Gambia, Guinea, Guinea-Bissau, Kenya, DRC, Liberia, Madagascar, Malawi, Mali, Mozambique, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, Togo, Tanzania, Zimbabwe

Africa is off track to meet the nutrition targets of Malabo Declaration and Global targets but there is hope

Strong implementation Political leadership & SMART commitment Brazil Ethiopia Kenya Maharashtra Nutrition- oriented development Bangladesh Colombia Ghana Tanzania Data Systems Guatemala Indonesia Peru Strong implementation Argentina Burkina Faso Chile The ingredients for success are well known… ...and can lead to rapid improvements in nutrition. And political leadership is vital for progress in nutrition In the past 3 GNRs we have highlighted several countries experiences on moving nutrition indicators. They are listed. Many factors are responsible and we have listed 4 sets. Central to these is political commitment. Remember: Ghana & Maharashtra halved their stunting rates 12 years. When forces are aligned properly rapid change can happen. SUGGEST YOU DO NOT REMOVE THIS SLIDE

Commitment by African Countries Malabo Declaration: Bring down stunting to 10% and underweight to 5% by 2025 2nd International Conference on Nutrition: Framework for Action and the UN Decade of Action on Nutrition While the problem of food and nutrition security in Africa, and indeed the world, is one that may appear daunting, it is true that a problem can only be addressed when it is first recognized as a problem. In this regard, African countries have already recognized that food and nutrition security must be addressed and certain commitments have been made. Recognising the extent and consequences of the burdens, African leaders made this bold commitment within the Malabo Declaration of 2014: "To improve nutritional status, and in particular, the elimination of child under-nutrition in Africa with a view to bringing down stunting to 10% and underweight to 5% by 2025." In addition, African leaders have signed up to the World Health Assembly Targets to reach key targets for 6 nutrition outcomes by 2025. This is the Malabo Declaration on ”Nutrition Security for Inclusive Economic Growth and Sustainable Development”. The Decade of Action is for everybody. What will each African country, professional Nutrition Association like the African Nutrition Society do to ensure that within 10 years we change positively the face of malnutrition in Africa? Initiative for Food and Nutrition Security in Africa (IFNA), which was launched at TICAD VI in Nairobi this August by the Government of Japan. IFNA aims to work with African Governments to accelerate the implementation of their food and nutrition security policies. Initiative for Food and Nutrition Security in Africa (IFNA) The African Leaders for Nutrition (ALN)

Conclusion Make the right political choice—supported by SMART commitments for accountability Current commitments do not match the need we need a blend of nutrition specific, and nutrition sensitive actions, supported by an enabling environment Predictable and dedicated nutrition financing is essential: Invest more and allocate better Reject business as usual Invested in more and better data

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