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