Mali
Costed Plan for
Scaling Up Nutrition
(SUN)
Meera Shekar, Christine McDonald, Patrick Hoang-Vu
Eozenou, and Ali Subandoro
World Bank
October 2013
Agenda
• Country context
• Costing the scale-up of nutrition in Mali
• Methodology for costing
• Next steps
2
Prevalence of Child Undernutrition
40
DHS
30
35
DHS
MICS
25
Stunting prevalence among children under 5 (%)
45
Stunting prevalence in Mali
2001
2006
2010
2012
Years
Source: DHS 2001, 2006, 2012 (prelim.), MICS 2010, SMART 2012.
3
Prevalence of Child Undernutrition
40
DHS
30
35
DHS
MICS
Trend
25
Stunting prevalence among children under 5 (%)
45
Stunting prevalence in Mali
2001
2006
2010
2012
Years
Source: DHS 2001, 2006, 2012 (prelim.), MICS 2010, SMART 2012.
4
Prevalence of Child Undernutrition
40
DHS
30
35
DHS
SMART
MICS
Trend
25
Stunting prevalence among children under 5 (%)
45
Stunting prevalence in Mali
2001
2006
2010
2012
Years
Source: DHS 2001, 2006, 2012 (prelim.), MICS 2010, SMART 2012.
5
Prevalence of Child Undernutrition
40
DHS
DHS
30
35
DHS
SMART
MICS
Trend
25
Stunting prevalence among children under 5 (%)
45
Stunting prevalence in Mali
2001
2006
2010
2012
Years
Source: DHS 2001, 2006, 2012 (prelim.), MICS 2010, SMART 2012.
6
Prevalence of Child Undernutrition
Undernutrition Prevalence
40
30
20
10
Prevalence among under 5 children (%)
50
Children under 5, Mali
2000
2005
Stunting
2010
Wasting
2015
Underweight
Source: DHS 2001, DHS 2006, MICS 2010, DHS 2012
7
Severity of Child Undernutrition
20
10
0
Prevalence among under 5 children (%)
30
Undernutrition gaps in Mali
2001
2006
2010
Years
Stunting gap
Wasting gap
Underweight gap
Source: DHS 2001, DHS 2006, MICS 2012 (author’s calculations).
8
Agenda
• Country context
• Costing the scale-up of nutrition in Mali
• Methodology for costing
• Next steps
9
Starting point: Global SUN Costing
36 priority & 32 small countries
Data Source: Horton, Shekar, et al, World Bank 2009
10
Phase II: Country Level
Focus on selected
countries
• Nigeria, Zambia, Togo,
Uganda, Burundi, DRC,
Mali, Madagascar, Kenya
Tailored to specific
country context
• 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
Sustainability &
ownership
• 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
• Country contextual situation
• Costing the scale-up of nutrition in Mali
• Methodology for costing
• Next steps
14
Steps in Developing Costed Scale-Up
Plans
• 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.
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
15
Steps in Developing Costed Scale-Up
Plans
Steps in developing costed scale up plan
1

2

Determine and estimate the size of the targeted population, which can be categorised in
three groups:
‒ Pregnant women
‒ Lactating women
‒ Children <5 years old
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

7

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
Sum up all the costs per intervention to calculate the cost per sector and the overall cost
8

9

Propose the rolling out of scaling up nutrition in several phases by type of interventions, by
regions and a combination of both
Estimate the benefits and cost effectiveness of the intervention
16
Potential Costing of Proven NutritionSpecific Interventions
Three broad intervention
groups
Behavior Change
• Breastfeeding and
complementary feeding
• Growth monitoring and
promotion
• Handwashing
Micronutrients &
Deworming
• Micronutrients for children:
‒ Vitamin A
‒ Therapeutic zinc as part of
diarrhea treatment
‒ Multiple micronutrient
powders
‒ Deworming
Complementary &
Therapeutic Feeding
• Treatment of severe acute
malnutrition
• Prevention/treatment of
moderate malnutrition
• Supplements for pregnant
women:
‒ Iron-folic acid
‒ Iodized oil capsules
• Fortification for general
population:
‒ Salt iodization
‒ Iron fortification of staple
foods
17
Explore Costing of Nutrition-Sensitive
Interventions In Mali
Some possible interventions
• 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
18
Agenda
• Country context
• Costing the scale-up of nutrition in Mali
• Methodology for costing
• Next steps
19
Next Steps
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)
20
Annex
ANNEX SLIDES
21
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
$1.79 (MNCH weeks)
$2.00 (CNPs)
40% via MNCH weeks
60% via Community nutrition
programs
Iron Fortification of Staples
$0.20
Market-based delivery system
Salt Iodization
$0.05
Market-based delivery system
Complementary Food for
Prevention of Moderate
Malnutrition
$51.10
Community nutrition programs
$80
Primary health care and
Community nutrition programs
IFA Supplementation for Pregnant
women
CMAM for Severe Malnutrition
Source: Nigeria local unit cost and delivery cost estimates, when feasible, otherwise from WB SUNWWIC, 2009
Option 4: Scaling Up by Intervention
and by State
Intervention
Step 1:
CNP for BCC, all
micronutrient and
deworming, 30% of
CMA for SAM
Step 2:
50% of CMAM for
SAM
Step 3:
Comp. food for
prevention of MAM
Cost (US$
million)
Total public
investment
required
Total public
investment
required
Total public
investment
required
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, CrossRiver, Oyo
Step 3 states:
FCT Abuja, Abia,
Anambra, Enugu,
Imo, Akwa-Ibom,
Bayelsa, Delta,
Edo, Rivers, Ekiti,
Lagos, Ogun, Osun
$132.7
$45.2
$89.1
$37.2
$9.8
$18.3
$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 $224.9 million
Example Nigeria: Comparing Cost-Effectiveness
of Different Scale-up Options
Scale-up Options
Annual Public
Investment
(US$ 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
$224.9
7,433,897
202,363
$30.3
Option 4: by intervention
& by state
* Using LIST tool, based on 5 years projection
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.
Annex
•
•
•
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:
1 æ ( sd - zi ) ö
FGTa = å ç
N i=1 è sd ÷ø
U
a
25
Annex
U
a = 0 Þ FGTa =
N
1 U æ ( sd - zi ) ö
a = 1 Þ FGTa = å ç
N i=1 è sd ÷ø
26
Annex
Consider different individual observations each with a different z-score
27
Annex
The prevalence measure will count the red dots, irrespective of their distance to the
reference line.
28
Annex
The undernutrition gap takes into account the distance between the undernourished and the
reference line.
29
Annex
30
Annex
Concentration indices
Inequalities in undernutrition (both prevalence and severity) have decreased
between 2001 and 2006, but then increased again between 2006 and 2010
31
Annex
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
32
Annex
Aflatoxin Control
33