150619 p893 unicef investment case collated v3

7/25/2019 150619 P893 UNICEF Investment Case Collated v3

1/44

The Case for Investmentin Nutrition in Sudan

November 2014


2/44

World Food Programme (WFP) and

United Nations Childrens Fund (UNICEF)

The Case for Investment in Nutrition in Sudan

Edited by

UNICEF Sudan

Gereif west [Manshiya]

Tel. +249 156553670

www.unicef.org/Sudan

Authors

Flora Sibanda-Mulder

Davide De Beni

Collaborators

MarcAndre PROST, World Food Programme (WFP), Sudan

Mueni Mutunga, UNICEF, SudanNational Nutrition Programme, Federal Ministry of Health, Sudan

The authors grateful for inputs from

UNICEF Nutrition, WASH and Health sections; WFP Nutrition section; Eric Keneck WFP Sudan;

Margot Vandervelden WFP Sudan; Shaya Asindua UNICEF Sudan; Nana Garbrah-Aidoo UNICEF Sudan; and

Eman Mahmoud WHO Sudan

Financed by

Government of Denmark

Design and layout

Scriptoria Sustainable Development Communications(www.scriptoria.co.uk)

All the content of this report is copyrighted. Permission is granted to reproduce any part of this publication (total or

partial) as long as the source is correctly cited.

November 2014


3/44

Thecase

forinvestmentinnutritioninSudanContents

Acronyms................................................................................................................. 1

Executive Summary................................................................................................. 2

1 Introduction ...................................................................................................... 3

2 Investment Case: The Problem and How it Can Be Addressed ...................... 5

3 Some Key Contributing Factors to High Malnutrition Rates in Sudan ........... 10

4 Why Invest in Nutrition in Sudan? ................................................................. 15

5 Results and Impact Analysis ......................................................................... 24

6 Funding Gap .................................................................................................. 34

7 Implementation .............................................................................................. 36

8 Conclusion ..................................................................................................... 38

Further Reading..................................................................................................... 39

Appendix 1............................................................................................................. 39


4/44

Thecaseforinvestmentinnutritio

ninSudan

1

AcronymsCMAM Community-based management of acute malnutrition

FAO Food and Agriculture Organization of the United NationsGAM Global acute malnutrition

GDP Gross domestic product

IFAD International Fund for Agricultural Development

LiST Lives saved tool

MAM Moderate acute malnutrition

MDG Millennium Development Goals

MoU Memorandum of Understanding

OCHA Ofce for the Coordination of Humanitarian Affairs

OHT OneHealth tool

SAM Severe acute malnutrition

SHHS Sudan household survey

SUN Scaling up nutrition

WASH Water, sanitation and hygiene

WFP World Food Programme

WHO World Health Organization


5/44


ninSudan

2

Executive SummaryThis paper presents the case for substantial investment to reduce

undernutrition in Sudan.Undernutrition is one of the countrys most serious, but least addressed, socioeconomic and healthproblems. Yet efforts to address the problem barely scratch the surface. Peoples health suffersfrom a lack of awareness about the consequences of and solutions to undernutrition. In addition,the countrys operational and nancial capacity to develop and implement a comprehensive nutritionpolicy is extremely limited. Expenditure on nutrition is often too low to get sustainable results. Most ofthe donor funding for nutrition in Sudan is for short-term support of humanitarian action with limitedlonger-term outcomes. The result of insufcient investment in nutrition over the past 30 years is thatthe country has missed opportunities for development and economic progress. Surprisingly, giventhe stage of the countrys economic development, the nutritional status of children is particularly poor.

This paper explains how to scale up high impact, cost-effective nutrition interventions within the

National Nutrition Strategic Plan 20142018 to reduce the very high undernutrition burden ofSudanese children, adolescents and women. The paper analyses what could happen under fourscenarios:

n Business as usual (maintaining the status quo)n Implementing a UNICEF/WFP plan to scale up investment in reducing undernutrition, initially in

ve statesn Scaling up investment in reducing undernutrition to cover 50 per cent of Sudann Scaling up investment in reducing undernutrition to cover 90 per cent of Sudan.

The analysis of the four scenarios with the lives saved tool (LiST) an evidence-based modellingsoftware shows that scaling up a package of selected nutrition-specic and nutrition-sensitive

interventions to cover 90 per cent of Sudan, would be the most cost-effective investment forreducing undernutrition and under-ve mortality in Sudan. An investment package that covers 90 percent of Sudan would result in more lives saved and would avert more cases of stunting compared tothe other packages.

Over the period 2015 to 2019, scaling up a package of selected nutrition-specic and nutrition-sensitive interventions to cover 90 per cent of Sudan would:

n Reduce the under-ve mortality rateto 49/1,000 live birthsn Reduce the prevalence of stunting to 25 per centn Reduce the prevalence of wasting(global acute malnutrition GAM) to 6 per centn Increase exclusive breastfeedingto 63 per centn Reduce iron deciency anaemia among pregnant womento 26 per cent.

The total cost of reaching 90 per cent of Sudan with a package of selected nutrition-specic andnutrition-sensitive interventions would be US$524 million a year an increase of US$443 million onthe US$81 million currently spent.

Studies show that investment in improving nutrition can raise a countrys gross domestic product(GDP) by 3 per cent a year. On the basis of Sudans 2013 GDP of US$66.55 billion, this wouldtranslate into a gain for Sudan of US$2 billion a year.The value of the benet would be substantiallymore than the cost and would represent a fourfold return on investment.

The estimate of the benets to Sudan from the investment of US$524 million a yearare extremelyconservative as the lives saved tool does not take into account the impact of all the nutrition-sensitive

interventions that would be included in the package to reduce undernutrition to cover 90 per cent ofSudan.


6/44


ninSudan

3

1. Introduction

1.1 Background

Sudan has a land area of 1,861,484 km2 and itshares borders with seven countries Egypt,Eritrea, Ethiopia, South Sudan, Central AfricanRepublic, Chad and Libya as well as the RedSea. The country is generally at, with mountainsin the northeast and west, while the desertdominates the north. The Nile River divides thecountry into eastern and western halves1.

Sudan comprises 18 states. Each state is dividedinto localities, the total number of localities is1842. The climate ranges from tropical in the

south to arid desert in the north. Natural disastershave had adverse effects in many states. About18 per cent of the population is severely affectedby oods every year during the rainy season(June to September). Drought also constitutesa real hazard for food security in certain states,like West and South Darfur, affecting about 10 percent of the population. Some parts of the countryexperience heat waves while others have duststorms, earthquakes and landslides.

1 Collins, R.O.,A History of Modern Sudan, Cambridge University Press, Cambridge, 2008.2 Federal Ministry of Health, Mapping of PHC Services in Sudan, 2010.

Epidemics constitute a threat to the healthand wellbeing of the population. Meningitis is

the most common epidemic as the country issituated in the meningitis belt. The geographyand ecology contribute to the prevailing health,nutrition and population situations. The vastgeographic areas, coupled with inadequate roadand transport infrastructure, affect coverageand access to health services. Despite someimprovements in recent years, Sudan ranksamong the top 10 countries in the EasternMediterranean Region with the highest childand maternal mortality rates.

1.2 Demography

Using the 2008 census data and an annualgrowth rate of 2.8 per cent, the total populationby 2014 is projected to be about 37.4 million.Of these, 88 per cent are settled (with about 33per cent of these located in urban areas) and8 per cent are nomads. Almost 7 per cent ofthe population is internally displaced. Naturaldisasters, civil conicts and poor conditions in


7/44


ninSudan

4

rural areas have contributed to displacementand increased urbanisation.The average household size is 6 persons, andthe total fertility rate is 5.7 per woman. Almosthalf (45 per cent) of the population is under 15

years old, including 16.4 per cent under 5 yearsold. Over 50 per cent are in the age group 15 to64 years and 3.9 per cent are 65 or more yearsold3. The average life expectancy at birth is59 years (58 years for males and 61 years forfemales). About 89 out of every 1,000 childrenborn alive do not live to celebrate their fthbirthday4.

1.3 Conicts

Sudan has a long history of conicts and crises

that continues to this day. As the country startedto recover from the long war with the South,new internal conicts started in Darfur, BlueNile and Nuba Mountains. These new conictshave aggravated the situation in the countryand contributed negatively to the problemof displacement. While the secession of theSouth initially brought relative peace to theborder areas, conict in the border states ofBlue Nile and South Kordofan re-erupted in2011 and continues to cause displacement,destruction and death. The conict in Darfur

reached a peak in 2004. However, a subsequentwave of violence across Darfur during 2013and 2014 has caused an estimated 320,383new displacements to date; of these, 188,760persons remain displaced5. This is in addition tothe 2 million people who have faced longer-termdisplacement since 20032005. In addition, atthe end of 2013 a civil war broke out in SouthSudan causing refugees to move to Sudan andthe surrounding countries. These crises havecontinued to cause multiple shocks both sociallyand economically.

1.4 Economy

Sudan occupies the 171st place in the 2013Human Development Index, indicating that thecountry still has one of the lowest levels of humandevelopment in the world6. Poverty remainswidespread with 46.5 per cent7of the populationliving below the poverty line, according to the

3 Central Bureau of Statistics, Sudan Population Census, Khartoum, 2008.4 Ibid.5

OCHA, update report, .6 The 2013 Human Development Report, The Rise of the South: Human Progress in a Diverse World,Human Development Report Ofce,UNDP, New York, NY, pp. 144-147.

7 UNDP, Explanatory note on the 2014 Human Development Report composite indices, hdr.undp.org/sites/all/themes/hdr_theme/country-notes/SDN.pdf.

8 World Bank and Ministry of Finance data, 2010.

national denition of poverty (less than SDG3.8/person/day). Those who are most affectedby poverty are the rural dwellers, particularlywomen and internally displaced persons.Despite sanctions, in 2010 Sudan was rated as

the 17th fastest growing economy in the world.This rapid development of the country resultedlargely from oil prots8. With the secession ofthe South in July 2011, the new governmenttook with it 75 per cent of the oil output. This hassignicantly affected government revenues asoil contributed about 30 per cent of the nationalbudget. Undoubtedly, this will affect the nearfuture economic forecast and the resourcesavailable for social services including health.Agriculture remains important as it employs80 per cent of the workforce and contributes to

one-third of GDP.


8/44

Thecase

forinvestmentinnutritioninSudan

5

2. Investment Case: The Problem andHow it Can Be Addressed

2.1 Why an Investment Case?

No nation can afford to waste its greatestnational resource the intellectual power of itspeople. But that is precisely what is happening inSudan where low birth weight is common, wherechildren fail to achieve their full potential growth,where micronutrient deciencies permanentlydamage the brain and where anaemia andshort-term hunger limit childrens performance atschool. Globally, people are healthier, wealthierand live longer today than they did in 1990,the year of the Millennium Development Goals(MDGs) baseline. Progress has, however, beenunequal, and Sudans burden of malnutrition isdisproportionate to its population size. Althoughsome improvement in health outcomes hasbeen achieved, progress in investing in nutritionin Sudan is still very limited. Many factorscontribute to the lack of progress political

instability, natural disasters, protracted conicts,underdeveloped infrastructure, health system

weaknesses and lack of harmonisation andalignment of aid.

Investing in nutrition in Sudan providesan opportunity to accelerate economicdevelopment and growth, contribute to savingchildrens lives and prevent disabilities. Theinvestment case for nutrition is designed to

enhance the implementation of the NationalNutrition Strategic Plan 201420189. The goalof the Plan is to improve peoples nutritionalstatus throughout their lives by encouragingSudan to make nutrition central to itsdevelopment agenda. The Plan encouragesthe country to establish and implement nutritioninterventions according to the local situationand resources. In this way it will protect andpromote healthy child and maternal nutritionand prevent acute, chronic and micronutrientmalnutrition. Purposeful, stepped up, targeted

and coordinated interventions are needed toprevent the deaths of a large number of people,

9 Federal Ministry of Health Department of Nutrition, National Nutrition Strategic Plan 2014-2018, 2014.


9/44

Thecase


6

to achieve MDG 1 and make a contribution toachieving MDGs 2, 3, 4, 5 and 6. Not only willthe Plan help save the lives of mothers andtheir children, but it also makes the case for aninvestment that will yield measurable nancial

and economic returns to the government, thehealth sector, employers and individuals.

An investment package involving scaled upexpenditure is required because a lack of moneyand nance sits at the heart of many of the poornutritional outcomes. That is particularly so inSudan because:

n Undernutrition is one of the countrys mostserious, but least addressed, socioeconomicand health problems. Peoples health suffers

from: n A lack of awareness of theconsequences of and solutions toundernutrition

n The weak commitment from politicalleaders

n Limited resources for public investment. In general, the government lacks the

political commitment and operational andnancial capacity to develop and implementa comprehensive nutrition policy.

n Expenditure in the nutrition and health

sectors is often too low to get results. Thisunderfunding is the cause of several of themajor bottlenecks found in Sudan. It is worthnoting that only 40 per cent of the populationis covered by the National Health InsuranceSystem. Despite treatment for childrenunder ve and pregnant women beingfree of charge, less than 2 per cent of thepopulation receive free care and 92 per centpay for medicines10.

n Ofcial Development Assistance (ODA)

for nutrition is low. Most of the donorfunding for nutrition in Sudan is to supporthumanitarian nutrition. Since the funds aremeant for emergency response, they areshort-term and unpredictable. In addition,some of the donor funds are earmarkedfor lifesaving interventions, such as themanagement of acute malnutrition, and willnot support high impact interventions, suchas promoting optimal strategies for feedinginfants and young children.

n The Hunger and Nutrition CommitmentIndex11, launched in April 2013, measuresthe political commitment to tackle hungerand undernutrition in 45 developingcountries, including Sudan. This index

compares and ranks countries forgovernment inputs and outputs, and thenassesses these within the context of theirwealth, administrative capacity andprevalence of hunger and undernutrition.The results show that Sudan is languishingat the bottom of the league table, beingranked 45thout of 45 countries and beingclassied as having a very low commitment.

2.2 What Is the Scale of

Undernutrition in Sudan?The nutrition situation in Sudan is characterisedby persistently high levels of acute malnutritionand stunting. Both trends have continued sincerecord keeping began in 1987. In absoluteterms, the nutrition situation of children isworsening and underscores the urgent need forpolicy and programme action for the preventionand treatment of child malnutrition. The risingprevalence of malnutrition and populationgrowth explain why the absolute numbers ofwasted, stunted and underweight children under

ve years of age have risen signicantly. Today,there are more wasted and stunted children inSudan than there were 20 years ago.

Table 1 shows the proportions of stunted, wastedand underweight children in Sudan and the WHOclassication of the public health signicance.

10 Federal Ministry of Health, Review of Free Care for Mothers and Children in Sudan, 2010.11 te Lintelo D, et al., The Hunger and Nutrition Commitment Index (HANC 2012): Measuring the Political Commitment to Reduce Hunger and

Undernutrition in Developing Countries, Institute of Developing Studies, UK, 2013.


10/44

Thecase


7

12 World Health Organization, Physical Status: The Use and Interpretation of Anthropometry, WHO, Geneva, 1995.13 Central Bureau of Statistics, Sudan Household Health SurveyRound 2 2010, 2012.14 UNICEF, Improving Child Nutrition: The achievable imperative for global progress, New York, NY, 2013.15 FSNAU/FAO, et al., Micronutrient and Anthropometric Nutrition Survey: Somalia, 2009.

Table 1. Public health signicance of child undernutrition in Sudan12

Form of undernutrition

WHO classication

Stunting

Wasting

Underweight

Sudan (2010)13

Stunting

Wasting

Low

< 20

< 5

< 10

Medium

2029

59

1019

High

3039

10-14

20-29

35

Very high

40

15

30

16.5

32

Proportion (%)

Stunting is widespread and occurs frequentlyStunting is a reduced growth rate in humandevelopment. It reects the failure to reachlinear growth potential as a result of long-termundernutrition or illness, or a combination ofboth. In Sudan, 2.2 million children less than veyears of age are stunted just over one in everythree children. It is no wonder that Sudan is one ofthe 14 countries where 80 per cent of the worldsstunted children live14. A stunted child faces ahigher risk of dying from infectious disease (1.9to 6.5 times more likely to die) and the child is

likely to perform less well in school (equivalentto two to three years loss of education). Stuntingis associated with impaired brain development,meaning lasting, impaired mental functioning.This, in turn, leads to signicantly reducedlearning. Adults stunted as children earn a lowerincome in life (on average, 22 per cent less),which further exacerbates deprivation. For acountry as a whole, stunting may result in a lossto GDP of 2 to 3 per centper year.

Acute malnutrition levels in Sudan are among

the highest in the worldSudan has a huge burden of acute malnutritionaccording to the WHO threshold for assessingseverity of undernutrition. The nationalprevalence rate places Sudan in the criticalcategory with a global acute malnutrition levelof 16.5 per cent. About one out of every sixchildren weighs too little for her/his height. Fourstates have acute malnutrition levels above theWHO threshold for a critical situation and canbe characterised as being in crisis(Figure 4).

These are North Darfur (28 per cent), Red Sea(20 per cent), Blue Nile (19 per cent) and SouthDarfur (18 per cent). Figure 4 also shows thatacute malnutrition is a widespread public healthproblem affecting every state. These levels arefar worse than those in the Horn of Africa. Forexample, in Somalia the prevalence of acutemalnutrition is 14 per cent15. It is important tonote that the majority (52 per cent) of the acutelymalnourished children live in nine non-conictaffected states (Red Sea, Kassala, Gezira,Khartoum, Northern, River Nile, Gedaref, Sennar

and White Nile).


11/44

Thecase


8

Figure 1. Prevalence of stunting by state

Figure 2. Prevalence of wasting by state

Source: S3M Survey in Sudan, 2013



12/44

Thecase


9

So far, the response to acute malnutritionhas been insufcientFor example, in 2013, of 555,203 severelyacutely malnourished children, just 122,919received treatment. Thus 432,284 (78 per cent)

of the children in need were not treated.

Micronutrient deciencies the hiddenhungerDeciencies in vitamin A, iodine and iron arethought to be widespread. There has not been amicronutrient survey carried out since the 1990s.Proxy indicators from the 2012 simple spatialsurvey method (S3M) national nutrition survey,include:

n Low coverage with iron and folic acid

supplements during the second and thirdtrimesters of pregnancyn Low postpartum coverage with vitamin A

supplementsn Very high prevalence of night blindness

during the last pregnancy suggest that thematernal micronutrient status is poor.

Night blindness caused by vitamin A deciency during the last pregnancy was reported by upto 90 per cent of mothers in one locality in SouthDarfur16. In only 29 of 184 localities did less than5 per cent of mothers experience night blindness

during their last pregnancy. The WHO cut-offvalues classify a prevalence of 5 per cent assevere17.

16 Federal Ministry of Health/UNICEF, S3M Survey Report, 2014.17 WHO, Global Prevalence of Vitamin A Deciency in Populations at Risk 19952005. WHO Global Database on Vitamin A Deciency,WHO,

Geneva, p. 8 Table 4, 2009.18 Worldwide Prevalence of Anaemia 19912005, Global Database on Anaemia, with additional data from Demographic and Health Surveysand WHO global database on Anaemia.

19 WHO, Worldwide Prevalence of Anaemia 19932005, in WHO Global Database on Anaemia, edited by B. de Benoist, E. McLean, I. Egliand M. Cogswell, WHO, Geneva, 2008.

20 Central Bureau of Statistics, SHHS Round 2, 2010, 2012.

Anaemia in children is associated with reducedcognitive development (as much as 9 IQpoints may be lost), lack of concentration andlistlessness. Studies in some African countriesdemonstrate that anaemia is most prevalent

in the rst 2 years of life. This is particularlyworrisome as this is the age during whichbrain development takes place. In women ofreproductive age, anaemia is a major cause ofmaternal mortality. WHO recently estimated therates of anaemia in Sudan to be extraordinarilyhigh in preschool-aged children (88 per cent),pregnant women (58 per cent) and non-pregnantwomen (43 per cent)18. Also the contribution ofmicronutrient deciencies to the disease burdenis likely to be substantial.

Iodine deciency is the leading preventablecause of brain damage worldwide and it cansignicantly lower the IQ of whole populations by10 to 15 points. The most severe effects of iodinedeciency occur during foetal development andin the rst few years of life. The SHHS 2010showed that only 9.5 per cent of householdsconsumed iodized salt20, which meant that over1 million infants remained unprotected from

iodine deciency disorders.

Table 2. Prevalence of anaemia among preschool-aged children andpregnant women and the WHO categories of public health signicance

WHO classication19

Prevalence of anaemia

Prevalence of anaemia in Sudan

Preschool-aged children

Pregnant women

Non-pregnant women

Nopublic health

problem

4.9

Mildpublic health

problem

5.019.9

Moderatepublic health

problem

2039.9

Severepublic health

problem

40

Category of public health signicance

88

58

43


13/44

Thecase


10

3. Some Key Contributing Factors toHigh Malnutrition Rates in Sudan

3.1 Sub-Optimum Infant andYoung Child Feeding Practices

Improving infant and young child feeding (IYCF)practices, especially exclusive breastfeedingand complementary feeding, has been identiedas the single most important intervention in a

package of essential child survival interventionsrecommended for low-income countries with highlevels of child undernutrition and mortality rates.Promoting breastfeeding and complementaryfeeding are, therefore, integral interventionsfor child survival; they have the potential tosubstantially reduce child mortality21.

Figure 3 shows that exclusive breastfeedingand the timely introduction of age-appropriate,quality complementary foods lag behind early

initiation and continued breastfeeding up to oneyear of age. The low exclusive breastfeedingand complementary feeding levels reect sub-optimal infant feeding practices which are amajor cause of undernutrition among youngchildren. This, in part, explains the very highacute malnutrition and stunting levels in childrenunder two years old.

In 2011, a causal analysis of severe acutemalnutrition (SAM) in Kassala state found thatearly (before the age of 6 months) introductionof uids other than breast milk was associatedwith the risk of SAM; not introducing other uidswas found to be protective against SAM22(oddsratio = 0.7). Early introduction of other uids is amarker of poor IYCF practices.

21

The Lancet 2003 Child Survival Seriesestimates that with 90 per cent coverage of exclusive breastfeeding for the rst six months and90 per cent coverage of continued breastfeeding to 12 months, child mortality could be reduced by 13 per cent. It also estimates that timelyand appropriate complementary feeding could avert 6 per cent of the under-ve deaths. The Lancet 2008 Nutrition Seriesestimates thatoptimal breastfeeding practices up to 2 years could potentially save 1.4 million lives annually.

22 Federal Ministry of Health/State Ministry of Health/UNICEF/GOAL, Report on Rural Kassala CMAM program coverage survey and trainingusing SQUEAC tools and SAM causal analysis, 2011.


14/44

Figure 3. Exclusive breastfeeding and good infant and young child feedingpractices


ninSudan

11

3.2 Water and Sanitation NeedsAre Great

Unsafe drinking water and poor hygiene frequentlylead to increases in diarrhoeal diseases, oftenrendering the use of nutritional supplementsand other nutrition efforts ineffective. In Sudan,20 per cent of the population uses unimprovedwater sources23. In addition, national nutritionsurvey results in 2013 showed that almost halfthe children surveyed had had an episode ofdiarrhoeal disease in the two weeks preceding

the survey.

Open defecation, improper sanitation facilitiesand waste disposal often contaminate foodproduction. Provision of improved sanitationfacilities is low across the country. In KhartoumState less than 50 per cent of people use improvedsanitation facilities. This is compounded by thenon-sanitary disposal of childrens faeces.Good hand washing practices are poor withonly four of the 18 states having a mean above2.5 for the ve critical hand washing times.

23 Central Bureau of Statistics, Sudan Household Health Survey Round 2, 2010, National Report, 2012.24 Ibid.

In Sudan, there is a recognised associationbetween increased access to improvedsanitation facilities and water sources and thereduction of stunting levels in children. Thereis a general reducing trend in the stunting rateassociated with the populations increasedaccess to improved water (see Figure 9).

The child stunting rate also increases withan increased rate of open defecation (seeFigure 10)24.

Source: Sudan household survey Round 2, 2010


15/44


ninSudan

12

Figure 4. Improved water and stunting prevalence

Source: Sudan household health survey Round 2

Figure 5. Open defecation status and stunting prevalence by state



16/44

Thecase


13

Food insecurity is widespreadHousehold food insecurity is one of the primaryunderlying causes of malnutrition in Sudan. Oneout of three Sudanese suffers food deprivationand over 46 per cent are classied as poor. In

2014, the number of food insecure persons wentfrom 4.2 million in July to 5.7 million in August.Inadequate food intake and poor dietary diversityin many households are linked to the high pricesof food and basic commodities, poor harvestsand limited knowledge of nutrition. Food pricesare at an all-time high estimated at 150 percent higher than the average of the last veyears. Additionally, Sudan is the fth most foodinsecure country in the world ranking 74thoutof 78 countries in the 2013 Global Hunger Index.

Maternal nutrition the missing linkThe high levels of maternal undernutritionacross the country are contributing to the highlevels of child stunting. The nutritional status

Figure 6. Prevalence of maternal undernutrition (as measured by mid-upperarm circumference less than 230 mm) by state

25 Mid-upper arm circumference < 23 cm, > 50 per cent classied as extreme, Food Security Nutrition Assessment Unit Somalia,.

of the mother has intergenerational effects,not only affecting her pregnancy and birthoutcomes, but also the growth and developmentof her child. Micronutrient deciencies during thecritical window of opportunity the rst 1,000

days, starting from pregnancy through to achilds second birthday can have long-lastingimplications for the growth and development ofa child.

Figure 6 shows the distribution of maternalundernutrition. The highest level of maternalundernutrition is in Red Sea State, where onein every three mothers is malnourished. This isfollowed by North Darfur (26 per cent). In Haialocality (Red Sea State) up to 62 per cent ofmothers are undernourished. A prevalence of

maternal undernutrition greater than 50 per centis classied as extreme25. Yet, interventions toimprove maternal nutrition are not to be seen inSudan.

class boundaries are 5% and 15%



17/44

Thecase


14

The uptake of antenatal care (ANC) services iscorrespondingly low. At the state level, only threestates reported four or more ANC visits to morethan 50 per cent of pregnant women. The lowestcoverage reported was in two localities in Red

Sea State (with 0 and 2 per cent coverage)26.

Furthermore, 10 per cent of Sudanese girls aremarried before reaching the age of 15, and38 per cent are married before the age of 1827,which has detrimental consequences for healthand nutrition. Maximum adult height can bereached as early as 16 years or particularlyfor populations such as Sudan with high ratesof undernutrition as late as 23 years28. Thus

26

Federal Ministry of Health/UNICEF, S3M Survey Report, 2014.27 Central Bureau of Statistics, SHHS Round 2, 2010, 2012.28 Roche, A.F., et al., Late adolescent growth in stature, Paediatrics, 50, pp. 874880, 1972.29 UNICEF, State of the Worlds Children, New York, NY, 2009.30 Allen. L. and Gillespie, S., What works? A review of the efcacy and effectiveness of nutrition interventions, ACC/SCN Nutrition Policy

Paper no. 19 and ADB Nutrition and Development Series no. 5, Manila: ADB in collaboration with ACC/SCN, 2001.

undernourished adolescent girls may not havenished growing before their rst pregnancy,predisposing them to deliver low birth weight(LBW) babies. In Sudan, the prevalence of LBWbabies is 31 per cent29. This is probably a result

of the competition for nutrients between thegrowing adolescent and the growing foetus. Thisresults in poorer placental function, which in turnincreases the risk of LBW babies and neonatalmortality. The calcium status of mothers is ofparticular concern as the bones of adolescentsstill require calcium for growth at a time whenfoetal needs for bone growth are also high30.


18/44

4. Why Invest in Nutrition in Sudan?

4.1 Investing in Nutrition WillProduce Real Benets inEconomic Growth

Good nutrition outcomes have been associatedwith accelerated national economic growth ratesand are considered essential for achieving themajority of the MDGs. Undernutrition has higheconomic and welfare costs, which fall roughly

into four categories. Inadequate nutrition:

n Increases child and maternal mortalityn Increases susceptibility to diseasen Reduces school performancen Lowers human capital development and

labour productivity.

In short, undernutrition undermines all aspects ofdevelopment. Delaying the investment to improvethe nutrition status of the population imposes realnancial costs on individuals, households, thehealth system and the next generation. What is

at the core of the challenges of undernutritionin Sudan are the countless lives that can be

saved and improved, the suffering that can bealleviated and the human potential that can berealised.

In Asia, there have been good examples ofhow improvements in nutrition contributed toeconomic growth through enhanced humancapital development. In the early 1980s Thailandimplemented a nationwide community-basednutrition programme. As a result, Thailand

reduced child undernutrition by half from50 per cent to 25 per cent in less than a decade(1982 to 1986). Needless to say, Thailand isnow an upper middle income country. Chinareduced child undernutrition by more thanhalf from 25 per cent to 8 per cent (1990 to2002). Not surprisingly, China became a middleincome country in 2009. Vietnam implementedan integrated community nutrition programmeand reduced child undernutrition by 40 per cent from 45 per cent to 27 per cent (1990 to 2006).Vietnam became a middle income country in

2010.

THECASEFOR

INVE

STMENTIN

NUTRITION

IN

SUDAN

7


ninSudan

15


19/44

THECASEFOR

INVE

STMENTIN

NUTRITION

IN

SUDAN

8

Improved nutrition will reduce highmaternal, infant and child mortalityAlthough there is no Sudan-specic data on

child mortality attributable to undernutrition,globally it is estimated that 45 per cent of childdeaths are due to undernutrition, mostly fromincreased severity of disease. It is conceivablethat the proportion is higher in Sudan. Giventhe alarming levels of malnutrition, underweightbabies are almost four times more likely to dieduring the rst month of life than are babies ofnormal weight. For those who survive, 20 percent of them are more likely to be stunted at12 months of age. A child who is severely acutelymalnourished is 11.6 times more likely to die thana well-nourished one. Malnutrition also affectsmaternal mortality. Iron deciency anaemia isassociated with 22 per cent of maternal deathsand 24 per cent of neonatal deaths. In Sudan,58 per cent of pregnant women are anaemic.

Undernutrition decreases educationalperformanceIn Egypt and Ethiopia, Cost of Hunger inAfrica (COHA) showed that stunted childrensachievements are 1.2 schooling years lowerthan those of well-nourished ones. In Ethiopia,it was estimated that the repetition rate in primary

school among stunted children was 15 per cent,while among non-stunted children it was 11 percent31.

As shown in Table 3, nutrition disorders canpermanently lower IQ by up to 15 points.

Sudan is not on track to achieve MDG 1Figure 7 shows that underweight and stuntinglevels in Sudan progressively increased between1990 (when the MDGs were introduced)

Table 3: Prevalence of common nutritional disorders in Sudan andassociated loss in IQ

Indicator

Iron deciency anaemia (< 5 years old)

Sub-optimal breastfeeding in rst 6 months

Stunting (< 5 years old)

Low birth weight

Iodine deciency disorders

Prevalence (%)

85

59

35

31

22

IQ loss (points)

9

4

5 to 10

5

10 to 15

31 African Union Commission/NEPAD/UNECA/WFP, The Cost of Hunger in Africa: Social and Economic Impact of Child Undernutrition inEgypt, Ethiopia, Swaziland and Uganda, UNECA, Addis Ababa, 2014.

and 2000. Although there was a signicantreduction in the two indicators of undernutrition(underweight and stunting) between 2000 and

2006, the trend has stagnated. MDG 1 focusesspecically on reducing hunger, measured usingthe proxy indicator of underweight.

MDG 1 is linked through cause and effect to veother MDGs. Achievement of MDG 1 will improveschool performance (MDG 2), improve maternalnutrition (MDG 3), reduce child mortality (MDG4), improve maternal health (MDG 5) and reducethe burden of disease (MDG 6). Investing inchildrens nutrition results in healthier, bettereducated and more productive adults withimportant gains to individuals and the economy,which would improve the income poverty aspectof MDG 1. Improving the nutrition of Sudanesechildren will reduce inequity, lessening the

risk of social and political instability.

Undernutrition decreases labourproductivityUndernutrition robs people of their earningpotential and stands in the way of a countryseconomic development. Undernutrition in the1,000 days between pregnancy and a childssecond birthday carries lifelong consequences.

It affects a childs survival, growth anddevelopment, ability to learn and lifelong healthand productivity. This is exacerbated by highlevels of maternal undernutrition in the country.Investing in nutrition in Sudan provides anopportunity to accelerate economic developmentand growth, contribute to saving thousandsof lives and preventing lifelong disabilities,and moves the country closer to achieving theobjectives of the national poverty reductionstrategies and the MDGs.


ninSudan

16


20/44


ninSudan

17

Figure 7. Sudan is not on track to achieve the MDG 1 target

Improved nutrition will reduce the nancialcosts of health careImproved nutrition will reduce the nancial costsof health care for the family, the community, theprivate sector and the government. There areseveral potential consequences for householdsrelated to the costs of health care. First, costscould be prohibitively expensive, which maymean that parents have to forego treatment for

their children. Second, to pay for health care,households may have to sell their assets orincur debts. Third, health care costs can have acatastrophic impact and push households into,or more deeply into, poverty. These challengesare especially relevant in Sudan where theavailability of risk pooling mechanisms, suchas health insurance, is low. At the macro level,society as a whole would benet from a healthypopulation. The costs to the government andthe private sector for health care provision, lostproductivity, high turnover and unemploymentbenets would be reduced.

4.2 Does Sudan Have anEnabling Environment forInvesting in Nutrition?

There is some support and commitment from thegovernment to address the underlying and basiccauses of undernutrition. In 2014, the governmentof Sudan released the S3M national nutrition

survey results acknowledging the huge problemof malnutrition. Consequently, the governmenthas worked with UNICEF to develop a nationalscale up plan to treat acute malnutrition. TheNational Nutrition Directorates, with support fromUNICEF, World Food Programme (WFP) andpartners, developed the four-year Multi-sectorStrategy to Address Malnutrition 20142018.

In addition, the Federal Ministries of Healthand Agriculture are currently developing acomprehensive food security and nutrition policy.

SERISS 86/87 Sudan emergency and recovery information and surveillance system tapes 1986 and 1987SMCHS 93/94 Sudanese maternal and child health survey 1993MICS 2000 Multiple indicator cluster survey 2000SHHS Sudan household survey



21/44


ninSudan

18

The establishment of a Food Security andNutrition Council to oversee the implementationof the plan is under discussion. This presents anunprecedented opportunity to redouble efforts toprevent and treat undernutrition in Sudan.

A signicant change in nutrition outcomes inSudan requires high coverage with, and equitableuse of, an integrated multi-sector package ofinterventions, which comprises both nutrition-specic and nutrition-sensitive interventions.These nutrition actions have been endorsed bythe scaling up nutrition (SUN) movement andalready form the basis of the overall strategy fornutrition of many development partners. Someof the interventions are being implementedin Sudan at this time, albeit on a limited scale

and with limited resources that render themineffective. The rst phase of the investment casewill be implemented in line with the governmentsNational Nutrition Strategic Plan 20142018, theSudan National Acceleration Plan for Maternaland Child Health 20132015 and the roll-outof the community-based management of acutemalnutrition (CMAM) scale up plan.

4.3 Why Are UNICEF and WFPJoining Forces?

WFP and UNICEF work together at the globaland national levels to address undernutrition.WFP is mandated to ght hunger in all its formswhile UNICEF works towards the protection ofchildrens rights to help meet their basic needsand to expand their opportunities to reach their fullpotential. Food insecurity causes undernutrition,which in turn predominantly affects children.If undernutrition is not addressed, it is likelythat these children will grow up to becomeless productive adults, turning the probleminto an intergenerational cycle of hunger and

undernutrition.

The collaboration between WFP and UNICEFin the nutrition sector is sanctioned at the globallevel through a Memorandum of Understanding(MoU) that denes their complementary rolesand responsibilities. The two UN agencies havestrong eld presences and work complementarily.In Sudan, this collaboration was formalised in2013 through a Letter of Understanding, whichcommits both organisations, together withWorld Health Organization (WHO), Food andAgriculture Organization of the United Nations

(FAO), United Nations Population Fund andInternational Fund for Agricultural Development(IFAD), to join forces in ghting undernutrition,

one of the main impediments to a healthy andproductive Sudan. The rst initiative under theMoU is a three-year project to link resilience andnutrition in Kassala state. This is supported byUNICEF, WFP and FAO with funding from the

United Kingdoms Department for InternationalDevelopment.

Together, WFP and UNICEF contribute over75 per cent of the nutrition response in SudansStrategic Response Plan 2014. The overallnancial needs stand at US$81 million. Thismoney is used mostly for the core pipeline ofnutrition products required to prevent and treatacute malnutrition, capacity development andsocial and behaviour change interventions. Thesimple spatial surveying method (S3M) nutrition

survey provides a solid foundation for a commonunderstanding of the magnitude and geographiclocation of needs and where investment ofresources can be targeted for maximum impact.

On that basis, UNICEF and WFP havecollaborated with the Federal Ministry of Healthto design a joint scaling up plan for the CMAMframework. CMAM is collaboratively supportedin 9 out of 18 states; it is hoped to expand theframework to 13 states in the near future.

4.4 Proposed Investment toScaling Up of Nutrition in Sudan

To reduce undernutrition, four scenarios forscaling up investment in nutrition in Sudan havebeen considered:

n Scenario 1: Business as usual (maintainingthe status quo)

n Scenario 2: UNICEF/WFP initial scale upplan (starting in ve states)

n Scenario 3: Medium coverage (50 per cent

coverage nationwide)n Scenario 4: High coverage (90 per cent

coverage nationwide).

Within each scenario the level of target coverage,the geographic focus and technical support willbe adjusted to suit the location.

In Scenario 1 the country maintains the baselinelevel of coverage throughout the period withoutscaling up interventions.

Scenario 2 is based on the coverage levels

proposed in an integrated package of interventionsby UNICEF and the WFP to scale up nutrition inSudan. In this plan CMAM, home fortication


22/44

of food with micronutrients, iron-folate andvitamin A supplements, use of iodized salt andimmunisation are implemented nationwide. Therest of the interventions are rolled out initially inve states (Red Sea, Gedaref, Gezira, Central

Darfur and Kassala) to test what would workin the Sudanese context. Eventually they willcover all 18 states. The ve states were selectednot only on the basis of the magnitude of bothacute malnutrition and stunting, but also on thelevel of some other indicators, such as health,water, sanitation and hygiene (WASH) and foodinsecurity.

Scenarios 3 and 4 are based on a generalnationwide scaling up of the coverage of thepackage of interventions listed above. Scenario

3 looks at providing coverage up to 50 per cent(medium coverage) and Scenario 4 considers90 per cent coverage (high coverage for themaximum effect on child undernutrition andmortality reduction).

InterventionsThe interventions included in the four scenariosare a selection of highly effective direct nutritionactions and nutrition-sensitive interventionsthat can contribute signicantly to large-scalereductions in undernutrition as describedelsewhere in this document. These nutrition

interventions span a variety of sectors andaddress underlying and basic determinants ofthe nutrition outcomes.

4.5 What Will it Cost and WhatReturns Can Be Expected?

Costing methodologyA detailed costing exercise to establish thecosts of implementing the activities necessaryto support the scaling up of direct nutrition

actions and nutrition-sensitive interventionswas undertaken. The costing was performedapplying the ingredients approach based on theUN OneHealth tool (OHT) and using Scenario 2(UNICEF/WFP initial scale up plan) as a base.

The ingredients approach embodies a bottom-upmethod of costing. We rst isolated the activitiesdening each intervention and then identied,

Thecase


19

quantied and costed all of the inputs neededto produce the target outputs. In addition to thedirect costs per input (medical supplies, medicalpersonnel costs, etc.), we estimated indirectprogramme costs (programme personnel,

technical support, monitoring and evaluation,supervision, advocacy, etc.) and other sharedhealth system costs, such us infrastructure andlogistics. Input costs were calculated as follow:

n Direct input costs were obtained from theUNICEF International Drug Price Indicatorsdatabase

n Direct medical personnel costs, includingsalaries for nurses, midwives andcommunity health workers, were calculatedin terms of the number of full-time equivalent

personnel required for each intervention andservice delivery channel (community,outreach, clinic/health centre and hospital)

n Indirect programme costs were obtainedfrom the UNICEF and WFP estimatedsector-specic programme costs requiredto scale up activities to the targets dened inScenario 2

n Other shared health system costs wereestimated to be a mark-up of 7 per cent onall other costs.

Estimation of costs

The additional cost of achieving 90 percent national coverage for the full package ofdirect nutrition actions and nutrition-sensitiveinterventions would be US$443 million per year.This equates to a total cost of US$524 milliongiven that the cost of maintaining the existingcoverage level is estimated at approximatelyUS$81 million annually.

If the programme is scaled up to provide 50 percent coverage nationally, the same package ofinterventions would cost Sudan an additional

US$255 million per year (total cost US$336million).

The UNICEF/WFP initial scale up plan(Scenario 2), with some interventions initiallyimplemented in ve states only, would cost anadditional US$99 million per year (total costUS$180 million). See Figure 8 for the totalcosts over ve years.

32 World Bank, Scaling Up Nutrition. What Will It Cost?International Bank for Reconstruction and Development/The World Bank,Washington, DC, 2010; Horton, S. and Steckel, R., Global economic losses attributable to malnutrition 19002000 and projections to 2050,in The Economics of Human Challenges, edited by B. Lomborg, Cambridge University Press, Cambridge, UK, 2013.


23/44

Thecase


20

Table 4. Proposed nutrition, health, livelihood/food security and socialprotection interventions and their target recipients

Sector

Nutrition

Daily iron and folic acid supplements

Breastfeeding counselling and support

Complementary feeding counselling and support

Micronutrient fortication of foods at home

Vitamin A supplements

Management of SAM

Treatment of moderate acute malnutrition (MAM)

Food-based prevention of MAM

Iodized saltHealth

Antenatal care (ANC)

Postpartum care

Tetanus toxoid

De-worming

Kangaroo care

Oral rehydration therapy

Zinc (diarrhoea treatment)

Pneumonia treatment

Malaria treatment

Measles vaccine

Rotavirus

WASH

Use of an improved water source

Improved excreta disposal

(improved latrines/toilets)

Hand washing with soap

Hygienic disposal of childrens stools

Livelihood/food security

Labour intensive asset creation (food for assets)

Nutrition value chain of food products

Small business skills, literacy (food for training)

Social protection

Conditional cash transfer (CCT)

Target population

Pregnant women

Postpartum and pregnant women

Children 623 months

Children 623 months

Children 659 months

Children 659 months

Children 659 and pregnant and lactating women

Children 623 and pregnant and lactating women

Total population

Pregnant women

Mothers and newborns

Pregnant women

Pregnant women and children 1259 months

Newborn

Children 059 months

Children 059 months

Children 059 months

Children 059 months

9 months

2 and 4 months

Households

Households

Households

Households

Households

Households

Households

Pregnant and lactating women


24/44


25/44

Two studies (World Bank, 2010; Horton andSteckel, 2013) estimated that investing innutrition can increase a countrys GDP by atleast 3 per cent annually32. For Sudan, with a2013 GDP33of US$66.55 billion, this amounts

to a gain of approximately US$2 billion peryear. This is signicantly above the annualcost of the high coverage scenario presentedin this investment case (US$524 million).

The high coverage Scenario 4, although the mostexpensive, gives the most cost-effective returnsin terms of reducing undernutrition and mortalityin Sudan, coupled with the highest number oflives saved and cases of stunting averted. Thus,efforts to address undernutrition in Sudan shouldbe directed at achieving high national coverage,

which is the most cost-effective way of SUN forboth child mortality reduction and prevention ofstunting.

When these costs are broken down byintervention package (Table 6), prevention ofundernutrition is the most expensive packageacross the four scenarios. The investmentin improving the maternal nutrition packageinterventions also increases signicantly fromScenario 1 to Scenario 4, relative to the otherpackages. This cost surges from US$12 millionto US$532 million over the ve years of the plan.

This package is the least developed componentat the moment and contains a majority of theinterventions currently not implemented in

33 .

Thecase


22

Table 6. Estimates of cost by scenario 20152019 (US$ million)

Scenario

1. Business

as usual

2. UNICEF/

WFP initial

scale up plan

3. Medium

coverage (50 per

cent nationwide)

4. High

coverage (90 per

cent nationwide)

Prevent

undernutrition

219

389

923

1,473

Reduce

child

mortality

172

313

406

615

Improve

maternal

nutrition

12

195

349

532

Total

cost

403

897

1,678

2,620

Annual

average

cost

81

179

336

524

Annual

incremental

cost

99

255

443

Sudan, including livelihood, food security andsocial protection interventions. The estimatedtotal investment over the ve years of the planfor the prevention of undernutrition is US$1,473million for Scenario 4. It is important to note

that the cost of this package is relatively highbecause stunting reduction requires substantialcross-sector coordination and investment withthe WASH and health sectors.

A detailed list of costs by intervention and scaleup scenario is contained in Appendix 1.

The cost of each package over the ve years isshown in Figure 8.


26/44

Thecase


23


Figure 8. Projected cost estimates by scenario over ve years (US$ million)


27/44

Thecase


24

5. Results and Impact Analysis

An analysis of the impact of the four nutritionintervention scenarios on the prevalence ofstunting, wasting, under-ve mortality rate,exclusive breastfeeding prevalence and anaemiain pregnant women in Sudan was undertaken.

The scale of the benets estimated in this modelhave to be considered as highly conservative asthey do not account for some of those nutrition-sensitive interventions that currently are notincluded in the model used in this impact analysis(LiST).

5.1 Methodology

To analyse the results of investing in nutrition inSudan, four different scaling up scenarios weredeveloped with the OHT using the LiST model.We assessed the effects of the different scenarioson under-ve mortality, stunting, wasting, anaemiain pregnant women and exclusive breastfeedingrates.

To calculate the cost-effectiveness of the fourscenarios we looked at the number of deaths

prevented in children under ve years of age (lives

saved) and the number of cases of stuntingaverted in children 659 months of age34. Theseprojected indicators were also obtained usingLiST. To calculate the cost-effectiveness ratioswe combined this information with the costs perpackage of interventions.

5.2. Overview of the LivesSaved Tool (LiST)

LiST is a computerised module integratedwithin the OHT and used to estimate theeffects of nutrition-specic and nutrition-

sensitive interventions on undernutritionand child mortality. LiST is based on a linearmathematical model linking the coverage ofinterventions to outputs, such as level of riskfactors (like stunting and wasting) or cause-specic mortality (child mortality 159 months).The relationship between the changes in theintervention coverage with one or more outputsis specied in terms of the effectiveness of theinterventions in reducing the probability of thatoutcome. The coefcients of effectiveness perintervention and the demographic data are

already populated in LiST from a Sudan-specic

34 The number of cases of stunting averted is the difference between the estimated stunting prevalence in the target year with the prevalencein the base year. This percentage change is then multiplied by the total population of children 659 months of age.


28/44

database. Baseline data for each interventionand prevalence were taken from the 2010 Sudanhousehold survey (SHHS).

We excluded from the cost-effectiveness

analysis those interventions that are notmodelled in LiST the use of iodized salt andthe livelihood/food security and social protectionrelated interventions. While recognising that theimpacts of these interventions on undernutritionand child mortality have no conclusive scienticbasis, several studies have demonstratedsignicant positive effects on nutritional status35.For this reason our estimates are likelyto underestimate the number of deathsprevented (lives saved), cases of stuntingaverted and, in general, the overall benets

of all the scenarios presented.

The linkages between risk factors, interventionsand mortality in LiST are outlined by Figure 9.

5.3. Expected Results WhatCan Be Achieved?

Scaling up the three packages of direct nutritionactions and nutrition-sensitive interventionsto 90 per cent national coverage would givethe most cost-effective returns in terms of


ninSudan

25

35 For a study of the impacts of agriculture interventions on nutrition see Food and Agriculture Organization of the United Nations (2013).Synthesis of Guiding Principles on Agriculture Programming for Nutrition, FAO, Rome, Italy. p. 13. (http://www.fao.org/docrep/017/aq194e/aq194e.pdf). For cash transfer and other non-nutrition sectors see WHO e-Library of Evidence for Nutrition Actions (eLENA)(http://www.who.int/elena/titles/en/).

Figure 9. Linkages between risk factors, interventions and mortality in LiST

reducing undernutrition and mortality in Sudan.This would be coupled with the highest numberof lives saved and cases of stunting averted.

The expected benets from achieving 90 per

cent coverage nationwide for the package ofdirect nutrition actions and nutrition-sensitiveinterventions modelled in LiST would beremarkable:

n Under-ve mortality rate would be reducedfrom 73/1,000 live births to 49/1,000 livebirths; over 100,000 additional lives ofchildren under ve years of age would besaved during the period 20152019

n Stunting prevalence would be reduced from35 per cent to 25 per cent over the ve year

period; more than 0.5 million additionalcases of stunting among children 659months would be averted

n Wasting(GAM prevalence) would bereduced from 16.5 per cent to 6 per centbetween 2015 and 2019; 1.9 million children659 months would be treated for SAMusing the community-based managementapproach; 5 million children aged 659months and pregnant and lactating womenwould receive complementary food for thetreatment of moderate malnutrition


29/44


ninSudan

26

n Exclusive breastfeeding would beincreased from 41 per cent to 63 percent; 7 million pregnant women and motherswith children 06 months would be reachedby breastfeeding counselling and support

programmesn Iron deciency anaemia among pregnant

womenwould be reduced from 58 per centto 26 per cent; 6 million pregnant womenwould receive iron-folic acid supplements aspart of their antenatal care.

It is important to note, once again, that theseresults are to be considered highly conservativeand an underestimate of the real benets ofscaling up the plans, as some of the nutrition-sensitive interventions included in the four

scaling up scenarios are currently not modelledin LiST.

Figure 10. Projected reduction in under-ve mortality rate (death per 1,000live births)


Under-ve mortality rate (deaths per 1,000live births)With an under-ve mortality rate of 73/1,000 livebirths (SHHS 2010), Sudan will not meet its MDGtarget (42/1,000 live births). However, scaling up

interventions to provide 90 per cent coveragenationwide, will result in a reduction in mortalityof 24/1,000 live births, bringing the rate in 2019to 49/1,000 live births (Figure 10). The mediumcoverage scenario (50 per cent nationwide)would ensure a reduction of under-ve mortalityto 59/1,000 live births, while the UNICEF/WFPinitial scale up plan will lead to a reduction to68/1,000 live births. It is worth noting that themortality rate will remain unchanged if the statusquo (business as usual scenario) is maintained.


30/44


ninSudan

27

The projected additional number of lives savedduring the ve year period is 101,055 for the highcoverage scenario and 56,483 for the mediumcoverage one. The additional number of deathsprevented by implementing the UNICEF/WFPinitial scale plan (Table 7) is estimated at 18,019.

An analysis of the direct nutrition actions andsensitive interventions preventing death inchildren under ve years of age (Figure 11)reveals the multi-sector nature of this investmentcase and the relevance of employing thisapproach. The top four interventions contributingto saving lives in 2019 will be from the health,nutrition and WASH sectors (oral antibioticsfor pneumonia management, kangaroo care,therapeutic feeding for severe wasting and handwashing with soap).

Table 7. Additional deaths prevented in children under ve years of age

Scenario

1. Business as usual

2. UNICEF/WFP initial scale up plan

3. Medium coverage (50 per cent nationwide)

4. High coverage (90 per cent nationwide)

Additional lives saved

-

18,019

56,483

101,055

Figure 11. Additional deaths prevented in under-ves by intervention relativeto impact year

StuntingExperience has shown that a reduction in stuntingcan be achieved at an average annual rate of 1.5per cent. Figure 12 shows the trend in stuntingprevalence among children 659 months of agefor the four scenarios. The projections show that

the current level of stunting can be reduced by1.62 per cent with the UNICEF/WFP initial scaleup plan. It can be reduced by 5.7 per cent byscaling up the interventions to medium coveragenationwide and by 9.5 per cent with high coveragescaling up. Scaling up interventions to 90 percent coverage nationwide will reduce the level ofstunting among children 659 months to 25 percent.


31/44


ninSudan

28

Again, these results are to be consideredconservative and underestimate the realreduction of stunting, as some of the keyinterventions having a signicant impact onstunting and proposed in the packages currentlyare not modelled in LiST.

Figure 12. Projected reduction in stunting in children under ve years old


Table 8. Additional stunting cases averted in children under ve years old,20152019

Scenario

1. Business as usual2. UNICEF/WFP initial scale up plan



Additional cases of stunting averted

29591,111

321,427

536,389

Table 8 shows the number of additional numberof cases of stunting averted by the four scaling upscenarios. Scenario 4 would ensure the highestnumber of cases averted 536,389 additionalcases of stunting among children 659 monthswould be averted during the period 20152019as compared with Scenario 1. Scenario 3 wouldavert 321,427 additional cases and Scenario 2,91,111.


32/44

WastingThe only experience in reducing wastingcomes from a country that was able to reducethe prevalence of SAM by 2.3 per cent in ayear through full coverage with a preventative

programme (including food supplements).Our projection takes into account the currentlow programme coverage, the weak capacity,the context, logistics, imperative for ensuringquality services and other factors. Therefore,scaling up interventions as per Scenario 2 willreduce nationwide wasting among children 659months of age (GAM) by 3.8 per cent. It would bereduced by 4.7 per cent if the interventions werescaled up to 50 per cent coverage (Scenario 3)(Figure 13).

However, by increasing the coverage to 90 percent nationwide (Scenario 4) GAM will declineby 10.5 per cent, bringing the prevalence rate to6 per cent by 2019. The prevalence of MAM will


ninSudan

29

Figure 13. Projected reduction in wasting prevalence in children under veyears old


be reduced from 11.5 per cent to 4.5 per centand SAM prevalence will be reduced from 5 percent to 1.5 per cent.

Table 9 shows the number of additional cases of

wasting averted by the four scaling up scenarios.The high coverage scenario would ensure thehighest number of cases averted 589,914additional cases of wasting among children659 months would be averted during the period20152019. The medium coverage scenariowould avert 265,598 cases and the UNICEF/WFP initial scale up plan scenario would avert211,670 cases.

Exclusive breastfeedingOur projection (Figure 14) showed a very modest

increase in the rate of exclusive breastfeedingwhen scaling up in the ve selected states only(Scenario 2). This is because the baseline forthe ve states is already reasonably high


33/44


ninSudan

30

Table 9. Additional wasting cases averted in children under ve years old,20152019

Scenario

1. Business as usual2. UNICEF/WFP initial scale up plan



Additional cases of wasting averted

108211,670

265,598

589,914

Figure 14. Projected increase in exclusive breastfeeding rates


(66 per cent) as compared to the nationalbaseline average (41 per cent).

However, a nationwide coverage of 50 per centwill increase the breastfeeding prevalence to51 per cent and a 90 per cent national coverage,to 63 per cent.

Anaemia in pregnant womenThe WHO ndings that show that 50 percent of anaemia in women is a result of iron

deciency were used as a starting point sinceiron supplements and/or multiple micronutrientsupplements will have an effect on irondeciency. Our analysis shows a remarkablereduction in anaemia in pregnant women a32 per cent decrease if the coverage is scaledup to 90 per cent nationwide. This will decreasethe prevalence of anaemia to 26 per cent by

2019. There is no difference between outcomesof Scenarios 2 and 3 as they target the samelevel of coverage (70 per cent nationwide). In


34/44

Figure 15. Projected reduction in anaemia prevalence among pregnantwomen


Thecase


31

both cases the reduction of anaemia in pregnantwomen will be 21 per cent over a ve year period(Figure 15).

In all scenarios this is a considerable reductionin anaemia which could potentially improvematernal nutrition and signicantly reduce therisk of maternal mortality. A projection for the rateof anaemia reduction in children has not beencarried out as it is not available in LiST.

5.4 Cost-effectiveness andValue for Money

To determine the most cost-effective scenarioproviding the greatest value for money the

largest gain for each dollar spent we rstlooked at which scenario would achieve thelargest reduction in the prevalence of stuntingfor the least cost. For stunting we considered

only the costs of those interventions in LiSThaving an impact on stunting reduction complementary feeding counselling and support,home fortication of food with micronutrients(including zinc), food-based prevention of MAM,use of an improved water source, improvedexcreta disposal, hand washing with soap,hygienic disposal of childrens stools, zinc fordiarrhoea treatment and daily iron and folic acidsupplements.

We then applied the same calculation to theadditional number of deaths prevented inchildren under ve years of age (lives saved), butaccounting for the cost of the complete packageof direct nutrition actions and nutrition-sensitive

interventions with the exclusion of the use ofiodized salt, labour intensive asset creation, foodfor training and conditional cash transfers, whichare not currently modelled in LiST.


35/44

Thecase


32

Table 10. Cost-effectiveness by scenario (stunting)

Scenario


2. UNICEF/WFP initial

scale up plan

3. Medium coverage

(50 per cent nationwide)

4. High coverage


Annual cost*

(US$ million)

44

76

184

286

Number of

cases of

stunting

averted

295

91,111

321,427

536,389

Annual cost

per additional

stunting case

averted (US$)

n/a

836

572

534

Number of

cases averted

per US$1 million

invested

n/a

1,196

1,748

1,873

* Includes only interventions in LiST which affect stunting.

Table 11. Cost-effectiveness by scenario (lives saved)

Scenario


2. UNICEF/WFP initial

scale up plan

3. Medium coverage


4. High coverage


Annual cost*

(US$ million)

80

143

272

427

Additional

lives saved

-

18,019

56,483

101,055

Annual cost

per additional

life saved

(US$)

n/a

7,955

4,808

4,224

Number of lives

saved per US$1

million invested

n/a

126

208

237

* Excludes use of iodized salt, labour intensive asset creation, food for training and conditional cash t ransfer.

36 WHO, Cost effectiveness and Strategic Planning: Threshold Values for Intervention Cost-effectiveness by Region, WHO-CHOICE(Choosing Interventions that are cost-effective) Programme, WHO, Geneva, Switzerland,, 2013.

Table 10 shows the cost-effectiveness of

each scenario in terms of stunting reduction.Implementing Scenario 4 would ensure thelowest annual cost of averting an additional caseof stunting (US$ 534) while at the same timeachieving the highest number of stunting casesaverted (1,873) for each US$1 million investedevery year.

Table 11 shows the cost-effectiveness in termsof lives saved (additional number of deathprevented). Scenario 4 appears to be the mostcost-effective, with the lowest annual cost of

saving an additional life (US$ 4,224) and the

greatest number of lives saved for each US$1million invested (237).

All the cost-effectiveness ratios calculated in thisanalysis (annual costs per additional stuntingcase averted and lives saved) are consideredcost-effective based on the categorization usedby WHO-CHOICE (Choosing interventions thatare cost-effective)36. An intervention is verycost-effective if the ratio is less than the GDPper capita. An intervention is cost-effective ifit is between one and three times the GDP per


36/44

Thecase


33 37 .

capita and not cost-effective if it is more thanthree times the GDP per capita (Sudans GDPper capita in 2013 was US$1,753, World Banknational accounts data, World DevelopmentIndicators37).

Although Scenario 4 is the most expensive,it is the most cost-effective way for scaling upinvestment in nutrition in Sudan. It would ensurethe most cost-effective returns in terms ofreducing malnutrition and mortality in Sudan. It

also results in the highest number of lives savedand cases of stunting averted.


37/44

Thecase


34

6. Funding Gap

In order to calculate the gap between the fundingavailable and the estimated expenditures foreach scenario, we looked at the funding availablein terms of domestic and donor nancingcommitments. In the absence of reliable data ondonors commitments and government spendingfor intervention packages, we estimated thefunding available for the period 20152019based on the following assumptions:

n Government spending estimated at 9.5 percent of the cost for the base year (2015) ofthe business as usual scenario, incrementedby 10 per cent every year until 2019

n Donor commitments calculated from theinformation provided by the sectors for theyears 2014/2015, also increased by 10 percent every year until 2019. Fundinginformation was veried against the SudanOfce for the Coordination of HumanitarianAffairs (OCHA) report on Requirements,commitments/contributions and pledges percluster report as of 30-October-201438.

Based on these assumptions, the estimatedfunding needed to invest for SUN in Sudan forthe period 20152019 is US$524 million for theve years (Table 12). This amount is signicantlybelow the amount required to implement therecommended Scenario 4 (US$2,620 millionover ve years), and can only cover Scenario 1.

The magnitude of the funding gap is also welldepicted by Figure 16, which shows how thefunding gap between the cost of Scenario 4 andthe funding available is more than US$2 billionover the ve year period. This gure may needto be revised when more accurate informationabout the governments and donors nancialcommitments is available. However, theoverwhelming view is that the resource shortfallis substantial and that additional nancialsupport will be required.

38 .


38/44

Thecase


35

Table 12. Estimated costs versus funding available 20152019 (US$ million)

Estimated expenditures:





Estimated funding available

Funding gap:





2015

80

98

187

218

80

0

19

107

139

2016

81

154

265

373

93

13

60

171

280

2017

80

188

337

523

105

24

84

233

419

2018

80

213

408

674

117

36

96

291

557

2019

82

243

481

832

129

47

114

352

703

Total

403

897

1,678

2,620

524

120

373

1,154

2,096

Figure 16. Projected estimated expenditures for different scenarios and thefunding available 20152019 (US$ million)


39/44

Thecase


36

7. Implementation

This is a national investment case, which shouldbe implemented in all 18 states at 90 per centcoverage to achieve substantial returns in reducingundernutrition and boosting human capital inSudan. As a starting point, UNICEF and WFPhave agreed to initiate the scaling up of nutrition bysupporting the roll-out of an integrated multi-sectorpackage of direct nutrition actions and nutrition-sensitive interventions in ve states (Red Sea,Gedaref, Gezira, Central Darfur and Kassala). Theinterventions are grouped into three packages:

n Preventing undernutrition (both acute andchronic)

n Reducing child mortalityn Improving maternal nutrition.

In addition to the ve states CMAM frameworks, thetwo agencies will also support the implementationof home fortication with micronutrients, iron folateand vitamin A supplements, use of iodized salt andimmunisation countrywide.

The implementation of Scenario 2 in the ve stateswith the highest levels of malnutrition in Sudan

will be a good starting point for rolling out the

proposed package of interventions. This will beparticularly useful for identifying the bottlenecksin capacity, logistics and implementation thatneed to be addressed before going to scalenationally. Additionally, it will serve as a platformfor advocacy and attract other stakeholders tojoin the efforts to address undernutrition at scalein Sudan.

The implementation will be done through threedelivery modes health system, community-based and population based. The mainstrategies suggested are:

n Capacity development and support forimplementation

n Communication for social and behaviourchanges

n Technical support at national and statelevels for advocacy, coordination andmanagement

n Supply chain and logistics managementn Operational research and knowledge

managementn Monitoring and supervision.


40/44

The two agencies recognise that the pathwaysto improved nutrition are complex and multi-faceted. Hence policies and investments in othersectors are of enormous importance to nutritionoutcomes. As much as possible, UNICEF

and WFP will strive to identify mechanisms toenhance inter-sector synergies, particularly witheducation, social protection, child protection andgender equality, in the implementation of theproposed package.

7.1 Policy Implications

Scaling up nutrition will not be achieved withoutpolitical commitment at both Federal and Statelevels, and the earmarking and mobilisationof sufcient nancial resources. Signicantly

reducing the very high levels of undernutritionin Sudan will require strong and dedicatedpublic action. Yet, without greater accountability,incentives for political leaders to act onundernutrition will remain limited. Developingpolitical commitment for nutrition is essential tocreating a policy environment where action onthe ground can actually be taken.

Investments in the governance and stewardshipfunctions of the government are also neededin order to translate policies into action on theground and to promote accountability in the

health system. Efforts should also focus onbuilding institutional capacity and governanceand promoting equity in access to services by

THECASEFOR

INVE

STMENTIN

NUTRITION

IN

SUDAN

7

decentralising health systems and empoweringstates and local authorities. New evidencesupports the notion that an equity-focusedapproach could bring vastly improved returns oninvestment by averting undernutrition, child and

maternal deaths, and by signicantly expandingthe effective coverage of nutrition interventionsand health services.

The analytical approach used to underpin thisinvestment case has a number of advantages.First, it makes assumptions about costs andeffects explicit and transparent. Second,it focuses policy attention and investmentresources on those key binding constraints andspecic system bottlenecks that are operating inthe country. Third, it enables the government andtheir development partners to estimate nancingneeds on a rational and defensible basis andthen allocate expenditures accordingly.

This investment package is nanciallysustainable. In principle, with sufcient politicalcommitment, the Sudanese economy could havea sufcient level of economic growth to createthe additional public scal space to invest inthe nutrition required for the proposed packageof interventions. But, given other competingpriorities in the countrys external development,nancing to accelerate the implementation of an

integrated package of interventions at scale willbe required.


ninSudan

37


41/44

THECASEFOR

INVE

STMENTIN

NUTRITION

IN

SUDAN

8

8. Conclusion

There is a strong case for investing in child andmaternal nutrition globally. And there is even astronger case for investing in nutrition in Sudanwhere undernutrition prevalence rates are stillunacceptably high. The analyses conductedin this report highlight the need to expand thecoverage of direct nutrition actions and nutrition-sensitive interventions to achieve signicantresults in reducing malnutrition and childmortality, and in improving maternal nutrition.It also indicates that the status quo (businessas usual) approach imposes real costs onsociety, economic productivity, households andindividuals.

The scenario recommended in this report(Scenario 4 90 per cent national coverage),although the most expensive, would ensurethe most cost-effective returns by reducingmalnutrition and mortality in Sudan. It will alsoensure signicant economic returns in the formof increased productivity of its labour force andan improved GDP.

It should be noted that the conclusions reached

as to the size of the benets estimated for thismodel are conservative and do not accountfor those nutrition-sensitive interventions notcurrently modelled in LiST.

Reaching 90 per cent coverage nationwide willrequire substantial additional expenditure bythe government and its development partners.But the additional expenditure is nancially andpolitically feasible and this analysis demonstratesthat signicant outcomes and impacts canbe achieved and measured. This additionalexpenditure is also substantially cost-effective.

The nancial and economic costs of inactionto Sudan are high. The business as usualapproach involves avoidable nancial strainson the fragile budgets of the government andindividuals. Failing to invest more now meansfurther reductions in national productivity, bothin the immediate term and in future generations.

Ultimately, the Sudan of tomorrow depends oninvestments in nutrition today. Sudanese leaderscannot afford to continue to squander Sudansmost precious natural resource its children.Great things can be achieved when the bestpossible science, sound strategies, adequateinvestment and political commitment combine.


ninSudan

38


42/44

Thecase


39

Further ReadingHoddinott, J., Rosegrant, M. and Torero, M., Investments to reduce hunger and undernutrition,Challenge paper prepared for the 2012 Copenhagen Consensus, 2012.

Hoddinott, J., et al., The economic rationale for investing in stunting reduction. Maternal and ChildNutrition, vol. 9, Suppl. 2, 15 September 2013, pp. 6982, 2013.

Horton, S. and Steckel, R., Global economic losses attributable to malnutrition 19002000 andprojections to 2050, in The Economics of Human Challenges, edited by B. Lomborg, CambridgeUniversity Press, Cambridge, UK, 2013.

World Bank, Repositioning Nutrition as Central to Development: A strategy for large-scale action,International Bank for Reconstruction and Development/The World Bank, Washington, DC, 2006.

World Bank, Scaling Up Nutrition. What Will It Cost?International Bank for Reconstruction and

Development/The World Bank, Washington, DC, 2010.

Appendix 1

Cost estimates by intervention and scenario 20152019

Prevention of

undernutrition

De-worming

(children)

Pneumonia treat-

ment (children)

Malaria treatment

(children)

Measles vaccine

Rotavirus

Complementary

feeding, couns.

and supp.Home fortication

of food with

micronutrients

Food-based pre-

vention of MAM

Universal use of

iodized salt

Use of improved

water source

Improved excreta

disposal

Hand washing

with soapHygienic

disposal of

childrens stools

Cost per

beneficiary(US$)

0.05

3.21

3.88

5.12

6.72

17.40

6.94

83.20

0.24

135.51

57.90

31.44

31.44

Baseline

coverage(%)

0

69

21

85

0

37

7

7

9

55

30

30

30

Estimated

cost (US$thousands

219,448

5,237

4,611

6,902

14,302

820

93,071

907

49,489

21,145

11,482

11,482

Geographic

focus

5 states

5 states

5 states

5 states

All

All

All

5 states

5 states

5 states

5 states

Target

coverage(%)

0

80

80

90

0

50

31

15

70

90

66

66

66

Estimated

cost (US$thousa

150619 p893 unicef investment case collated v3

Documents