Costed Plan for Scaling Up Nutrition (SUN)

Mali

Meera Shekar, Christine McDonald, Patrick Hoang-Vu Eozenou, and Ali Subandoro

World BankOctober 2013

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Agenda

• Country context

• Costing the scale-up of nutrition in Mali

• Methodology for costing

• Next steps

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Prevalence of Child Undernutrition

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Prevalence of Child Undernutrition

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Prevalence of Child Undernutrition

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Prevalence of Child Undernutrition

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Prevalence of Child Undernutrition

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Severity of Child Undernutrition

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Agenda

• Country context

• Costing the scale-up of nutrition in Mali

• Methodology for costing

• Next steps

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Starting point: Global SUN Costing36 priority & 32 small countries

Data Source: Horton, Shekar, et al, World Bank 2009

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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

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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.

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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.

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Agenda

• Country contextual situation

• Costing the scale-up of nutrition in Mali

• Methodology for costing

• Next steps

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Steps in Developing Costed Scale-Up Plans

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 2014-2016.

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Steps in Developing Costed Scale-Up Plans

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

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Potential Costing of Proven Nutrition-Specific Interventions

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

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Explore Costing of Nutrition-Sensitive Interventions In Mali

• 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

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Agenda

• Country context

• Costing the scale-up of nutrition in Mali

• Methodology for costing

• Next steps

Next Steps

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Start from the strategic interventions in the Plan d’Action Multisectoriel

Agreement on the scope of work, methodology and timelineCoordination 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)

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Annex

ANNEX SLIDES

Unit Costs and Delivery Platforms

Intervention Unit Cost (US$ per beneficiary per year)

Costed Delivery Platform

Community nutrition programs for growth promotion (breastfeeding, CF, hygiene)

$5.00 Community nutrition programs

Vitamin A Supplementation $0.44 MNCH weeks

Therapeutic Zinc Supplementation $0.86 MNCH weeks

Micronutrient powders $3.60 Community nutrition programs

Deworming $0.44 MNCH weeks

IFA Supplementation for Pregnant women

$1.79 (MNCH weeks)$2.00 (CNPs)

40% via MNCH weeks60% via Community nutrition programs

Iron Fortification of Staples $0.20 Market-based delivery system

Salt Iodization $0.05 Market-based delivery systemComplementary Food for Prevention of Moderate Malnutrition

$51.10 Community 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

Intervention Cost (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 Options Annual Public Investment

(US$ million)

DALYs saved

Projected number of

lives saved*

Cost/ DALYs saved

Option 1: by region $240.2 4,125,185 125,387 $58.2

Option 2: by intervention $332.1 9,726,581 264,774 $34.1

Option 3: by state $384.1 6,559,548 200,597 $58.6

Option 4: by intervention & by state

$224.9 7,433,897 202,363 $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.

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• 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:

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Consider different individual observations each with a different z-score

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

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

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

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BiofortificationAccording 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

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Aflatoxin Control

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