Planning a national strategy

• Advocacy/initiation

• Planning

• Implementation

• (Evaluation/adjustment)

Advocacy

MDG Targets and Indicators

Goal 1. Eradicate extreme poverty and hunger

Target 1: Reduce by half the proportion of people living on less than a dollar a day

1. Proportion of Population Below $1 (PPP) per Day (World Bank)

2. Poverty Gap Ratio, $1 per day (World Bank) 3. Share of Poorest Quintile in National Income or

Consumption (World Bank)

Target 2: Reduce by half the proportion of people who suffer from hunger

4. Prevalence of Underweight Children Under Five Years of Age (UNICEF)

5. Proportion of the Population below Minimum Level of Dietary Energy Consumption (FAO)

http://www.undp.org/mdg/goallist.shtml

Concept note

“Fighting Malnutrition in Africa: lessons learned and future strategies”

Conceptual outlineJBM/MG 9 Jan 2007

Why do it?Can we do it?How do we do it?What will it take?What next?

Audiences1. W Bank: RLT, senior management2. Donors, CSOs, SCN3. Scientific community4. Media (NYT, Economist. BBC …)5. Gates etc.

1. What is the problem and why tackle it? (‘Why do it?’)- extent trends and consequences of malnutrition

- economic and - human costs

- hence benefits of success; - relation to MDGs (#1); - causes to address; - potential goals.

2. Experience of current actions – “do we think it can be done?”… [how to select to keep manageable?]- description of current programs (type,

coverage, intensity)- probable effectiveness of current programs- relevance of experience from elsewhere

(esp. CHNPs, CCTs, Asia, LAC)- current supporting policies, context, and

changes needed for more effect- institutions

3. New strategies – How do we do it?- where we need to get to in terms of programs (design, coverage, type, intensity...) hence program gaps?- what policies are needed for supporting

programs and for context?- how could the needed programs be

developed?- what new ideas could be developed and

how- CCT- communication strategies- using cell phones and web2.0- others

4. What will it take?- funds and institutions for program development- funds and institutions for program

implementation and expansion- benefit-cost estimates

5. What next?- what can the Bank do?- what do we advocate that others do?

Initiation• Survey

• International mandate (ICN/NPANs; MDGs; H rights …)

• Intersectoral bodies, institutions to plan

• External assistance

Planning

First, direct interventions

Then, context and supporting policies

RETA approach (see Annex 1)

1. Situation analysis

2. C-based programs and service delivery (including micronutrients)

3. Context and supporting policies

4. An improved nutrition strategy

5. Financing

India 62 m

Bangladesh11 m

China 17 m

Cambodia 1 m

Vietnam 5 m

Pakistan 10 m

Sri Lanka 0.6 m

Philippines 3 m

0 300

Child populationmillions

Prevalence (%)

60

Figure 1.1. Prevalences and numbers of pre-school children underweight

Notes. Children aged 0-5 years, < -2 SDs by NCHS/WHO standards.Prevalences are on the vertical axis, numbers on the horizontal, so that relative numbers

underweight are represented by the areas of the rectangles. Estimated numbers of underweight childrenare indicated, in millions (m). Dates of estimates mid-1990’s.

Source: see table 1.1

40

20

0

100 200

PNG 0.2 m

Indonesia 8 m

Myanmar 2 m

Malaysia 0.6 m

Thailand 0.6 m

Countries includedin study

2000 2020 2060

Prevalence underweight %

60

0

Figure 1.2C. Years to halve prevalences of underweight pre-schoolchildren at present rates, in Bangladesh, at present rates (0.5per-centage points/year) and at an accelerated rate expected within-vestment in local programs (2.0 pp/year)

2040

20

40

at present rate

at acceleratedrate, with localprograms

Current program analysis

• current coverage, intensity, targeting

• current content

Suggest new resources and content

Hence calculate new costs (and likely effects)

Until something better is established:

• adequate program produces acceleration of about 1 ppt/yr reduction in underweight

• adequate program costs about $5-15/child/year (including costs of screening targeting)

(Gillespie/Mason’s rule of thumb)

Community based programs: content Require:

Community ownership Adequate population coverage Targeting Central support – e.g. supplies, training,

information Adequate intensity

May include:

Ante-natal care Midwifery Maternal nutrition Breastfeeding support Complementary feeding practices Growth monitoring Health referral Immunization, deworming Micronutrient programs Water/sanitation Poverty alleviation/employment Household food security (e.g. seasonal) Local food production/supplementary feeding

In Asian study, five contextual factors seen as crucial for success

• women’s status and education

• community organization

• lack of social exclusion

• political commitment

• literacy

From: Mason, Hunt, Parker, Jonsson. ‘Investing in child nutrition in Asia’, Asian Dev Review, 17 (1,2) 1-32, 1999; ‘Improving child nutrition in Asia’, Fd Nutr Bull, 22 (3 suppl) 5-80, 2001.

Context and supporting policies

0 1 2 3 4

Vietnam

Sri Lanka

Philippines

Pakistan

India

China

Cambodia

Bangladesh

mobilizers/20 children 0 0.1 0.2 0.3 0.4

Figure 2.2 Intensity of current community-based nutrition-oriented programs in terms of mobilizers/child ratios within programs.

mobilizers/1000 population

0 5 10 15 20

Vietnam

Sri Lanka

Philippines

Pakistan

India

Cambodia

Bangladesh

$/child participant/year

Figure 2.3 Intensity of current community-based nutrition-oriented programs in terms of $/child/year within programs.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Vietnam

Sri Lanka

Philippines

Pakistan

India

China

Cambodia

Bangladesh

Now

Proposed

Figure 4.2 Proposed coverage of community-based nutrition-oriented programs

0 2 4 6 8 10

Vietnam

Sri Lanka

Philippines

Pakistan

India

China

Cambodia

Bangladesh

Now

Proposed

mobilizers/1000 population

mobilizers/20 children 0 0.2 0.4 0.6 0.8 1.0

Figure 4.3 Proposed intensity of current community-based nutrition-oriented programs in terms of mobilizers/child ratios within programs.

Figure 4.4 Proposed intensity of community-based nutrition-oriented programs in terms of $/child/year within programs.

$/child participant/year

0 5 10 15 20

Vietnam

Sri Lanka

Philippines

Pakistan

India

Cambodia

Bangladesh

Now

Proposed

Gaps (e.g. B’desh, Pakistan, Sri Lanka, Vitenam, Cambodia)

• $160-250 million/year (@ $5/ch/yr addl)

• Facilitators: 200,000

• Mobilizers: 4 million

Implementation

For CHNWs, issues of

• Training

• Supervision

• Incentives

• Remuneration

Needed for implementation• Mix of top down and horizontal/grass roots

• Effective institutions

• Sustainable finance

• Decentralized decision-making

• Adequate information/surveillance

CHNWs are observed to work at some times-and-places -- with favorable context, adequate resources, effective technology, etc.

Policy implications include:

• invest in context -- human rights, addressing destitute sick ...

• political commitment; judicious donor input

• counteract unsustainable stresses (economic, political)

• sometimes crucial to address context first, rather than throwing resources ineffectively at problem