Costed Plan for Scaling Up Nutrition (SUN) Mali Meera Shekar, Christine McDonald, Patrick Hoang-Vu Eozenou, and Ali Subandoro World Bank October 2013

Agenda 2 Country context Costing the scale-up of nutrition in Mali Methodology for costing Next steps

Prevalence of Child Undernutrition 3

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5

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Severity of Child Undernutrition 8

Agenda 9 Country context Costing the scale-up of nutrition in Mali Methodology for costing Next steps

Starting point: Global SUN Costing 36 priority & 32 small countries 10 Data Source: Horton, Shekar, et al, World Bank 2009

Phase II: Country Level Focus on selected countries Tailored to specific country context Sustainability & ownership Nigeria, Zambia, Togo, Uganda, Burundi, DRC, Mali, Madagascar, Kenya Changing burden of disease National priorities Existing coverage of interventions Delivery platforms Phasing of interventions based on ‒Geographic targeting/scale-up ‒Cost-effectiveness considerations ‒Capacity & commitment considerations Strong collaboration with all sectors and partners using a consensus-building approach Build in-country capacities to do costing and develop scale-up plans 11

Mali: What is new?  Customized costed scale up plan to country context and needs  Conduct cost effectiveness analysis to assess different scaling up options for nutrition-specific interventions – provides solid evidence on what the government can “buy” given available resources  Explore costing for potential “nutrition-sensitive” interventions in Agriculture, Social Protection, and Education schemes. 12

Plan d’Action Multisectoriel (2013) A multi-sectoral National Nutrition Policy has been established. The NNP was adopted by the government in January 2013 and will serve as the policy framework for coordinating action on scaling up nutrition. The NNP outlines a process for forming the National Nutrition Council and the Intersectoral Technical Committee for Nutrition Mali has developed a national road map that will guide them through the process of establishing a costed multi-sectoral nutrition action plan to ensure effective implementation of the NNP. The Ministry of Health is in charge of several nutrition-specific programs including the management of acute malnutrition, vitamin A, and IYCF. 13

Agenda 14 Country contextual situation Costing the scale-up of nutrition in Mali Methodology for costing Next steps

Steps in Developing Costed Scale-Up Plans 15 Set the framework for the analysis Outline all the interventions by sector Determine activities per intervention Identify and categorize costs Calculate all costs and expected benefits Propose options for scaling up Consultations with all sectors and partners to gather costing data and seek input on the optimal costing strategy; Conduct the cost calculations, cost-effectiveness analysis, propose scaling up options and review findings with all parties involved; Consultation with donors and government to draft a roadmap to increase national resources for nutrition over the period

Steps in Developing Costed Scale-Up Plans 16 Steps in developing costed scale up plan 1  Determine and estimate the size of the targeted population, which can be categorised in three groups: ‒Pregnant women ‒Lactating women ‒Children <5 years old 2  Determine the coverage rate for intervention 3  Specify all inputs for each intervention 4  Specify price/cost for each input 5  Calculate a unit cost per beneficiary for each intervention from program experience in Mali 6  Calculate additional cost of scaling up to full coverage for each intervention by multiplying the unit cost for each intervention with the size of “uncovered” target population 7  Sum up all the costs per intervention to calculate the cost per sector and the overall cost 8  Propose the rolling out of scaling up nutrition in several phases by type of interventions, by regions and a combination of both 9  Estimate the benefits and cost effectiveness of the intervention

Potential Costing of Proven Nutrition- Specific Interventions 17 Three broad intervention groups Complementary & Therapeutic Feeding Micronutrients & Deworming Behavior Change Breastfeeding and complementary feeding Growth monitoring and promotion Handwashing Micronutrients for children: ‒Vitamin A ‒Therapeutic zinc as part of diarrhea treatment ‒Multiple micronutrient powders ‒Deworming Supplements for pregnant women: ‒Iron-folic acid ‒Iodized oil capsules Fortification for general population: ‒Salt iodization ‒Iron fortification of staple foods Treatment of severe acute malnutrition Prevention/treatment of moderate malnutrition

Explore Costing of Nutrition-Sensitive Interventions In Mali 18 Biofortification Agricultural technologies to reduce women’s workloads Zinc fertilizers (improve both agriculture productivity and child growth) Aflatoxin control through biocontrol Incorporating nutritional considerations in to agriculture extension (training, job descriptions, etc.) CCTs (incremental cost of the nutrition conditions) School-based deworming Promotion of good hygiene behaviors Some possible interventions

Agenda 19 Country context Costing the scale-up of nutrition in Mali Methodology for costing Next steps

Next Steps 20 Start from the strategic interventions in the Plan d’Action Multisectoriel Agreement on the scope of work, methodology and timeline Coordination with ICF costing exercise Obtain data from program implementation: (1) cost by interventions, delivery platform, region (2) coverage by region, target population (3) Nutritional outcomes Calculate induced benefits from costed scaled-up plans (lives saved and DALYs)

Annex 21 ANNEX SLIDES

Unit Costs and Delivery Platforms InterventionUnit Cost (US$ per beneficiary per year) Costed Delivery Platform Community nutrition programs for growth promotion (breastfeeding, CF, hygiene) $5.00Community nutrition programs Vitamin A Supplementation$0.44MNCH weeks Therapeutic Zinc Supplementation$0.86MNCH weeks Micronutrient powders$3.60Community nutrition programs Deworming$0.44MNCH weeks IFA Supplementation for Pregnant women $1.79 (MNCH weeks) $2.00 (CNPs) 40% via MNCH weeks 60% via Community nutrition programs Iron Fortification of Staples$0.20Market-based delivery system Salt Iodization$0.05Market-based delivery system Complementary Food for Prevention of Moderate Malnutrition $51.10Community nutrition programs CMAM for Severe Malnutrition$80 Primary health care and Community nutrition programs Source: Nigeria local unit cost and delivery cost estimates, when feasible, otherwise from WB SUNWWIC, 2009

Option 4: Scaling Up by Intervention and by State InterventionCost (US$ million) Step 1 states: Niger, Adamawa, Bauchi, Borno, Gombe, Taraba, Yobe, Jigawa, Kadung, Kano, Katsina, Kebbi, Sokoto, Zamfara, Ondo< Nasarawa Step 2 states: Benue, Kogi, Kwara, Plateua, Ebonyi, Cross- River, Oyo Step 3 states: FCT Abuja, Abia, Anambra, Enugu, Imo, Akwa-Ibom, Bayelsa, Delta, Edo, Rivers, Ekiti, Lagos, Ogun, Osun Step 1: CNP for BCC, all micronutrient and deworming, 30% of CMA for SAM Total public investment required $132.7$45.2$89.1 Step 2: 50% of CMAM for SAM Total public investment required $37.2$9.8$18.3 Step 3: Comp. food for prevention of MAM Total public investment required $208.4$29.5$29.9 The proposed option is to scale up step 1 and step 2 interventions in states where stunting rates is higher than 25% (Step 1 and step 2 states) which amounts to $224.9 million

Example Nigeria: Comparing Cost-Effectiveness of Different Scale-up Options * Using LIST tool, based on 5 years projection Scale-up OptionsAnnual Public Investment (US$ million) DALYs saved Projected number of lives saved* Cost/ DALYs saved Option 1: by region$240.24,125,185125,387$58.2 Option 2: by intervention$332.19,726,581264,774$34.1 Option 3: by state$384.16,559,548200,597$58.6 Option 4: by intervention & by state $224.97,433,897202,363$30.3 Recommendation: Comparing across all four options, option 4 is the most cost-effective and feasible option, with an annual investment of US$224 million, a cost/DALYs saved of $30.3, more than 7.4 million DALYs saved, and a very conservative estimate of over 200,000 lives saved over five years.

Trends and maps in stunting, wasting and underweight prevalence using DHS 2001, DHS 2006 and DHS 2010 (moderate and severe). Trends and maps in stunting, wasting and underweight gap using DHS 2001, DHS 2006 and DHS 2010 (moderate only). Both the prevalence and the gap are Foster-Greer-Thorbecke indices and can be written as:Foster-Greer-Thorbecke 25 Annex

26 Annex

27 Consider different individual observations each with a different z-score Annex

28 The prevalence measure will count the red dots, irrespective of their distance to the reference line. Annex

29 The undernutrition gap takes into account the distance between the undernourished and the reference line. Annex

30 Annex

31 Concentration indices Inequalities in undernutrition (both prevalence and severity) have decreased between 2001 and 2006, but then increased again between 2006 and 2010 Annex

32 Biofortification According to a recent Biofortification prioritization tool developed by IFPRI, Mali could be considered a top priority country for vitamin A maize, vitamin A sweet potato, and zinc rice Annex

33 Aflatoxin Control Annex