Nutrition for Growth

October 2014CIFF Nutrition StrategyNutrition for Growth

Supporting the transformation of how maternal and child undernutrition is prioritised, planned, resourced and delivered globally to reach the 2020 Nutrition for Growth & 2025 World Health Assembly targets

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Contents

1. Nutrition: current situation

2. Theory of change

3. CIFF objectives

4. CIFF “star” approach: transformational country programmes and global influence

5. Conclusion

• Focussing on interventions with the highest likelihood of impact• Country investment approach: achieving our 30% stunting reduction target by

working with governments, businesses and civil society • Global work: complementing country investments, drawing from them and

magnifying their impact• Country selection• Operating principles

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Undernutrition continues to be one of the most significant issues preventing children and societies from reaching their full potential

The double burden of over and undernutrition is a global issue of huge proportions. CIFF is prioritising the burden of undernutrition, which remains unacceptably large, and two of its manifestations are particularly alarming:

Stunting, a societal issue resulting in poorer education outcomes and limiting future wage earning ability, as well as increasing risk of disease and death:

• 1 in 4 children, or 162m under-5 children

• In 2012 >90% stunted children concentrated in Africa and Asia

Severe wasting has very high risk of death: 17m children suffer from Severe Acute Malnutrition*


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Eliminating undernutrition in young children can provide tremendous benefits


Growing Economies Policy Brief : IDS (Lawrence Haddad)- CIFF*http://www.who.int/nutgrowthdb/jme_2012_summary_note_v2.pdf?ua=1

Source:

Boost GNP even further by taking full advantage of the demographic dividend

Prevent 45% of child mortality

Reduce burden of disability for children under 4 by more than half

Increase school attainment by at least one year

Boost wage rates by 5-50%

Make children 33% more likely to escape poverty as adults

Make women 10% more likely to own their own business when they become adults

Break intergenerational poverty cycle: stunted mothers 3x as likely to have malnourished infants

Boost Gross National Product (GNP) by 11% in Africa and Asia

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Momentum is building: knowledge, political commitment, global trends and number of success stories are all on the rise

• Increased knowledge on what works (e.g., Lancet 2008, 2013)

• Increasing momentum (e.g. Scaling Up Nutrition movement, Nutrition for Growth) and funding

• Global reduction in stunting prevalence from 40% to 26% between 1990 and 2010, with a large share attributable to China

• Significant reductions in countries of every region:

Source: World Health Organisation

*in at least one inter-survey period (range: 3-5y)


Prevalence has dropped by more than

2.0%/year at least once

Prevalence dropped by more than 1.5%/

year at least once

Prevalence not dropping by more than 1.5%

any year

No data

Over the last two decades, prevalence has dropped at least once* by over 1.5 percentage points per year in every region

2 percentage points per year Absolute reduction achieved by top performers

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Both Nutrition for Growth, and the World Health Assembly, set ambitions to change the state of the world

*Lancet 2013, based on UN estimates of future stunting prevalence; reduction rate inferred from prevalence reduction 26%-20% over 15 years. Several countries, particularly in Africa are not on this current average trajectory and will require an even greater change in pace for World Health Assembly targets to be met**Lancet 2013: annual cost of scaling-up a package of 10 essential nutrition-specific interventions to 90% coverage in the 34 countries where 90% of the world’s stunted children live.

Nutrition for Growth (N4G) targets require increasing the pace of stunting reduction by a factor of 2-3

World Health Assembly target of a 40% reduction in the number of children who are stunted by 2025


Evolution of stunting burden over the next 15 years

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103

125

148

170

2010 2015 2020 2025

Glo

bal s

tunt

ing

burd

en (m

illio

ns)

Trajectory to reach both N4G target (2020) and World Health Assembly target (2025) for stunting

Nutrition for Growth target of reducing stunting by 20 million by 2020

World Health Assembly target of a 40% reduction in the number of children who are stunted by 2025

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Estimated current trajectory

2. Theory of change

Nutrition for Growth and WHA targets met

Societal recognition that solving malnutrition is a feasible and affordable political goal, with huge economic and social benefit

Enabling environment for planning, resourcing and

delivery of nutrition

Government leaders lobby for resources & cross-sectoral action

Business leaders make economic case for nutrition, ensure product availability and demand change

Planning for scale and sustainability, with improved institutions and monitoring & evaluation

Innovation of services, products & delivery systems

New interventions & products that increase expected impact of the nutrition toolkit

Aggressive cost reduction of interventions, products & essential platforms such as community nutrition promoters

Creation of ‘safe space’ for innovation in government and private companies

ImprovedData and Knowledge

Increased transparency & accountability on country & donor commitments and spend

Transformational nutrition programmes at

scale

Strengthened platforms for delivery at scale of nutrition specific and nutrition sensitive interventions

Strengthened management of multisectoral nutrition interventions, coupled with appropriate incentives and accountability mechanisms

National scale-up of high impact interventions within multiple platforms

Coverage of stunting and severe acute malnutrition interventions measured

Documentation and dissemination of individual and collective success stories

New business models to increase the penetration of nutritious products and interventions in base-of-the-pyramid markets

Nutrition budgets and ODA increased

Traditional / community leaders & civil society organise behaviour change & programme implementation

Increased private spend on high-impact nutrition products

Nutritional status indicators measured regularly in country surveys

Research and documentation on delivery science and cost-effectiveness

What the world needs to do: create a sense of urgency at national and global levels, and a clear path to tackle undernutrition…

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Conducive environment: gross national income, infrastructure level, trade policies, etc.

… and strengthened platforms for delivery at scale, harnessing the agency of individuals, communities and civil society to

promote, enable and sustain behaviour change

2. Theory of change

Small retailers enable access to affordable products for the community

Individuals

Households and caretakers demand adequate products and services, influence their neighbours, and change mothers’ and children’s daily feeding and hygiene practices

Civil society

CSOs can empower communities with knowledge, help shape social norms, and improve access to services

Frontline health and agricultural workers are the most credible source of information and the most cost effective delivery channel

Community leaders influence and organize to turn healthy practices into social norms

Community

Society recognizes good nutrition as a key contributor to health and productivity

Improved nutrition of mothers and children

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Support the transformation of how

maternal and child undernutrition

is prioritised, planned, resourced and delivered globally to reach the 2020 Nutrition for Growth

& 2025 World Health Assembly targets

Our objective

3. CIFF objective

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CIFF’s strategy will target indicators of comprehensive impact, focussing on stunting and severe wasting as these impact people’s whole life course

Wasting is the most acute form of undernutrition, most closely linked to death

Stunting Is the measure most strongly linked to human capital (education, future income). Fighting stunting answers societal needs

NB: these indicators will be the ones we will measure success against © 2012 Emiliano Albensi/Albefotografiche.net, Courtesy of Photoshare

3. CIFF objective

Picking a battle: faces of malnutrition

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To achieve our objectives, we will prioritise support to the next generation of country success stories, combined with targeted global actions

* See slide 15 for country selection criteria

3. CIFF objective

5 Transformational country programmes at scale to support and document the next generation of success stories that will fuel the momentum and build evidence and knowledge about what works

Global targeted actions focused on: - data and knowledge, - innovation and - advocacy and accountability

Priority Geographies:BangladeshEthiopia, Indian State (TBD) + 2 African countries (TBD)*

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Our ambitious impact target is a 30% relative reduction in stunting in five priority countries

*The WHO standard indicator for stunting measuring prevalence in <5 year olds will be used but most of the interventions to prevent stunting will target the first 1,000 days of life as this is the “critical window of opportunity” after which limited catch-up growth is possible. (Lancet series, 2013)**Assuming an initial 40 % prevalence level***Starting from baseline of $1000GDP/cap

50% greater relative reduction than the projected impact of the Lancet 2013 package of interventions

What a doubling of per capita GDP might be expected to deliver***

3. CIFF objective

30% relative reduction in under-5 prevalence*

in 5 years, i.e.12 percentage points or 2.4 percentage points per year**

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…and one million additional Severe Acute Malnutrition cases successfully treated per year globally by 2020

• UNICEF reported recovery numbers in 2012 of 1.7 million • © 2012 Emiliano Albensi/Albefotografiche.net, Courtesy of Photoshare

• 60% more children successfully treated for Severe Acute Malnutrition than in 2012*

• Increase coverage of Community Management of Acute Malnutrition (CMAM) by 50% and ensure recovery rates above 75% (SPHERE standard minimum)

• Leverage combined service delivery, advocacy and cost reduction strategy to enable scale up in high burden Severe Acute Malnutrition countries

3. CIFF objective

1 million

Additional Severe Acute Malnutrition cases treated successfully per year globally by 2020

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CIFF’s STAR approach: making nutrition a top economic and development priority, supported by transformational programmes at scale in priority countries

Resource mobilisation& budgets

Institutions and

community

Data & Knowledge

Innovative products, services &

tools

Transformational programmes at scale

for a 30% stunting reduction and SAM treatment in priority

countries

Global actions

Leaders and

champions

4. CIFF’s “star”approach

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4. Country selection

Rationale for the selection of countries where CIFF will support transformational programmes at scale ($10-30m per year per country for 5-7 years to reach 2020 targets)

Significant burden: We excluded countries:

• With a too small burden

• Already well advanced in stunting reduction (prevalence <25%, annual reduction rate >2 percentage points)

A potential to become leaders in the nutrition space:

• At the country level: We analyzed the country leaders’ history on nutrition, the history of these countries in pioneering health sector innovations, and their likely regional influence

Ability to deliver : We analyzed:

• The country context (limited corruption index, high spending on health, percentage progress in health and sanitation making success more likely, political stability both in terms of people and institutions, potential for in-country scale up in terms of access and public health infrastructure at community level)

Role for CIFF: We analyzed:

• CIFF existing relationships (facilitating the rapid launch of collaborative initiatives)

• We only selected countries where CIFF would contribute significantly to a change in undernutrition as one of the lead donor, yet also leave sufficient “financial space” for other donors to follow

To maximise the impact of CIFF’s support, selected priority countries combine:

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At the centre of CIFF STAR’s approach, transformational programmes at scale will be country-tailored portfolio of projects, sharing common principles

• CIFF as one of the leading donors in the country, with funding of $10m-30/year for the next 5 years

• Aspiration to work with government and partners towards a 30% reduction in stunting by 2020• Focus on sustainability with a clear exit strategy for 2020. Programmes will be designed with

eventual scale up in mind in a cost-effective sustainable way with financing taken over by government, communities and businesses

• Prioritising high impact interventions for scale up, where these intersect with country priorities• Focus on a portfolio of projects for synergistic impact

• Focus on reducing costs and testing innovations• Working with partners using a diagonal approach and seeking to leverage government and

private resources • Focus on households as key agents for change and economic actors of nutrition

4. Country approach

• Working with government directly (supporting their programmes) or • in support of national priorities through other partners such as key

members of civil society• Working with businesses to support commercial solutions• Supporting R&D (by private or public actors)

at country levelInfluence on

entire country

Direct support to ~30% under-5 coverage by

CIFF

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Note: 1. This classification of interventions will be reviewed regularly as new evidence of impact come to light2. The need for specific interventions will vary depending on local epidemiology3. Gender will be considered during the intervention design, implementation and M&ESource: Lancet series 2013 and CIFF internal nutrition evidence assessment

*Not including health interventions

4. CIFF’s “star” approach - stunting

We need to make choices about interventions. We will focus on those with largest potential for impact in terms of under 5 stunting reduction (plus CMAM for SAM) based on local epidemiology and plans

Zinc for diarreah

Birth spacing

Vit. A suppl. childrenIron suppl. of children

Handwashing promotion

Homestead food production (dietary diversity)

Interventions to increase girls’

secondary schooling

Homestead food production

(animal sources)

Calcium suppl. in pregnancy

Antibiotics for pregnant ♀with bacteria in their

urineTobacco cessation in

pregnancy

Preventive zinc for children

Nutrient-dense complementary foods

Micronutrient suppl. in pregnancy (including

iron and folic acid)Appropriate

complementary feeding promotion

Antenatal care package

Platform type:

Community promoter package

Market transacted package

Campaigns

Breastfeeding promotion

Promotion of delayed age at first birth

Deworming

Psychosocial stimulation

Water quality interventions

Measles immunisation

Optional synergies given implementation platforms

Operational R&D

Malaria prevention In pregnancy

Balanced energy-protein

suppl. in pregnancy

Feasibility

Potential for impact on stunting reduction

Proven high impact

interventions

Proven low impact on

stunting

Proven effective

for a sub-group

“Must have” interventions for transformational programmes

Prevention of mother to child HIV transmission

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• In our review of interventions to reduce the burden of stunting, we could not identify evidence that immediate, exclusive, or continued breastfeeding positively impacts the prevalence of stunting

• However, we fully recognise that immediate, exclusive, and continued breastfeeding are essential nutrition actions to save lives and to accelerate cognitive and emotional development

• We will support efforts to improve breastfeeding practices as part of integrated Infant and Young Child Feeding programmes which also have a strong focus on complementary feeding

• We condemn violations of the International Code of Marketing of Breast-milk Substitutes. We would like to see better monitoring of the Code at country level

• We will continue to dialogue with all partners in an effort to reduce violations of the Code

CIFF strongly supports efforts to increase recommended breastfeeding practices

4. CIFF’s “star” approach - stunting

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CIFF will prioritise interventions with largest potential impact in terms of under-5 stunting and wasting*

*Prioritization of interventions will vary depending on local epidemiology.

Stunting

Wasting

4. Country approach

Antenatal care for women in pregnancy: Must-have interventions: Micronutrient supplementation (including iron and folic acid), malaria prevention, balanced energy-protein supplementation Operational R&D: Antibiotics for women with bacteria in their urine, calcium supplementation, tobacco cessationOptional synergistic programmes: Prevention of mother to child HIV transmission

Household behaviour change through community-based agentsMust-have interventions: appropriate complementary feeding promotion, birth spacing, interventions to increase girls’ secondary schooling (in partnership with education programmes), promotion of delayed age of first pregnancyOperational R&D: Homestead food production (animal sources)Optional synergistic programmes: Breastfeeding promotion, handwashing promotion

Business approaches for fortified infant and mother foodsMust-have interventions: nutrient-dense complementary foods

Health campaignsMust-have interventions: Measles immunisation Optional synergistic programmes: Deworming of pre-school children

Scale up of CMAM programs or set up of new programs

KPIsReduction of stunting burden in 5 years in whole country (CIFF zones of action + leverage)

Number of Severe Acute Malnutrition cases successfully treated per year by 2020

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CIFF will continue to invest in the scale-up of community management of acute malnutrition (CMAM)

• Treating children with deadly, yet curable, conditions like SAM alongside longer term preventative efforts will avert millions of deaths

• CIFF shares the longer term aspiration that no child fall into a SAM state in the first instance. We will seek opportunities to integrate SAM treatment into programmes that focus on prevention of undernutrition e.g. comprehensive stunting prevention programmes

• As a life threatening condition for which an effective cure is readily available at reasonable cost, SAM treatment should be provided by governments as an essential service on a long term basis

4. CIFF’s “star” approach - SAM

• 17 million children under-five suffer from severe acute malnutrition, but less than 10% are treated successfully and an estimated 1 million die each year

• Limited number of donors and funding

• Strong evidence on the effectiveness of SAM treatment within a community based management programme with high cost effectiveness – community management of acute malnutrition (CMAM)

• Integrating CMAM into an Integrated Community Case Management (ICCM) approach may be even more cost effective

There remains a significant need to save lives

There is strong evidence of effective treatment

There is a need to integrate treatment as essential public service

Treatment is needed alongside prevention

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To achieve our target of an additional 1 million children treated successfully for SAM every year by 2020, the number of admissions into CMAM programmes needs to increase by almost 60%. To do this our SAM strategy focuses on three key objectives designed to increase coverage of CMAM:

Increasing coverage of SAM treatment by mainstreaming CMAM as an essential health service must be included in our priority country approach and in the intervention package supported through the Catalytic Financing Facility.

A country approach in itself will not be sufficient to meet our ambitious target and we must also support efforts to scale up CMAM outside of these countries through cost reduction strategies. Although CMAM is cost effective, continued work on alternative formulations of ready-to-use therapeutic food, research and innovation on treatment regimen are needed

Where CMAM treatment is not currently acceptable, efforts will focus on supporting the development of an acceptable approach combined with targeted advocacy to support policy change and enable treatment scale up

4. CIFF’s “star” approach - SAM

Cost reduction will be the strongest single contributor to additional children treated successfully by our SAM strategy

CIFF’s SAM strategy:

Additional children successfully treated



Mainstreaming of CMAM as an essential health service

CMAM introduction in high burden countries

Cost Reduction

350,000

250,000

400,000

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Directly invest significant resources in interventions that do not impact stunting or SAM.

4. CIFF’s “star” approach – what we will not do

CIFF will not…

The driving force behind the choice of intervention is whether there is sufficient evidence that the intervention is efficacious and feasible in achieving our goals regardless of whether it is nutrition specific or nutrition sensitive. In particular, CIFF will not invest significant resources in fighting obesity, or in nutritional interventions unrelated to growth (e.g. vitamin A, iodine, etc.)

Finance a multitude of small programmes across different countries. CIFF will rather focus on delivering a comprehensive intervention package in a limited set of countries, with the aim of maximising their chances of success and supporting these countries in becoming global trail-blazers.

Work in isolation or duplicate what is already done by others in the focus countries

Enter into service delivery commitments alone, without co-funding from other donors and/or government/partner funds.

Success at scale can only be achieved through strong partnerships. If already covered by another entity, CIFF will collaborate with government agency or donor/partner and use its own resources only for other parts of the ideal package

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Goal in priority countries:Households and governments prioritise nutrition.

Goal at global level:Nutrition central to development dialogue. CIFF could support:

Leaders & champions, Institutions, Resources

4. Global & country actions

Formulation of persuasive case for nutrition by leaders and champions

Development and implementation of advocacy campaign for additional budget allocations

Set-up and evaluation citizen accountability mechanisms

Developed, costed and validated frameworks (policies/plans/coordination mechanisms)

Producing the analysis of fiscal space and financial flows to nutrition at national and sub-national levels

Awareness raising of need for behaviour change for good nutrition in communities

Establishing the human and economic case for nutrition through leaders and champions

Activation of inter-country networks to build global constituency

Development and implementation of advocacy campaign for N4G commitments to be met and increased

Set up of Catalytic Financing Facility

Strengthening regional institutions to deliver nutrition frameworks, policies and accountability mechanisms

Development and dissemination global accountability report

KPIs

20 new signatories to Nutrition for Growth by 2016

Nutrition budget increased by the equivalent of at least 3% of

government budget on health in three priority and at least five

selected non-priority geographies by 2020.

$2bn of additional commitments for nutrition by 2020

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Goal in priority countries: Improved data and knowledge to drive nutrition results. CIFF could support:

Goal at global level:Increased knowledge on unresolved nutrition issues. CIFF could support:

Building data & knowledge

Case studies of successful transformations of countries’ nutrition environments

Modelling tools to reshape programmes, e.g. establishing optimal lowest-cost bundle of locally available foods for pregnant women and young children

Research on critical programme questions and capacity development of local research institutions

Coverage measurement of progress and cost through locally tailored surveys ensuring quality assurance of collection and analysis

National information systems on nutrition including citizen led data

KPIs:

Key nutritional indicators are included and measured in regular

country-level surveys

Population coverage of stunting intervention package, including

coverage of CMAM

Publish and disseminate 25 papers on effective implementation

science through international forums

Existing Global tracking systems of inputs (resources) and outputs (intervention coverage)

Dissemination of national data and case studies to sub-region and global audiences, including data from experiential learning

Standardised M&E methodology to support planning programme implementation including data collection and analysis of key status and coverage indicators.

Efficacy studies/Proof of concept for stunting and SAM interventions with high potential


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Goal in priority countries:Increased (cost-) effectiveness of nutrition interventions. CIFF could support:

Goal at global level:Increased (cost) effectiveness of products and delivery mechanisms. CIFF could support:

Supporting innovation in products, services & delivery strategy


Diagnostics in priority countries on consumer preferences, existing markets and business environments for complementary foods and foods for PLW.

Local food businesses in creating new improved products for both young children and their mothers

Innovative ideas that emerge from the priority country diagnostics

Design and implementation of innovative tools in national nutrition programmes including use of technology to reinforce behaviour change

KPIs

Commercial solutions developed for nutrient-dense foods for children aged 6-24m

and pregnant and lactating women

Cost of commercially available RUTF reduced by at least 50%

from 2014 prices

Proof of concept for 5 new interventions, products or

delivery modes that on average reduce stunting by 2% each

R&D programmes focused on RUTF cost reduction and volume optimization and the development of balanced protein-energy supplements for pregnant women

Operational R&D opportunities that have potential to reduce stunting e.g. maternal calcium supplementation. The evidence will be reviewed and challenges and potential opportunities identified

A wholesale approach to building an innovation pipeline by investing in entities that self manages several proof of concepts/innovations

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Together, CIFF’s country and global activities will transform 5 countries and seek to accelerate global momentum for the elimination of malnutrition

5. Conclusion

CIFF Quantitative Targets

Scale up transformational nutrition programmes reaching millions of households

Reduce the prevalence of stunting by 30% (relative reduction) in five priority countries by 2020, relative to 2014

Successfully treat an additional one million children with Severe Acute Malnutrition per year by 2020, relative to 2013

Coverage increase of X key SUN interventions by [TBD]% in five selected non priority countries

Transform the political and institutional environment for nutrition

20 new signatories to Nutrition for Growth by 2016

Nutrition budget increased by the equivalent of at least 3% of government budget on health in three priority geographies and at least 5 selected non-priority countries (/geographies) by 2020, relative to 2013

$2bn of additional commitments for nutrition ( $1bn from CAFIN) by 2020, post Nutrition for Growth

Test new products and delivery strategies

Average cost of RUTF (price and/or volume) needed to treat one child with Severe Acute Malnutrition reduced by at least 50% by 2020, relative to 2013

Proof of concept established for at least 5 new interventions, products or delivery mechanisms that on average reduce stunting by an additional 2% each

Develop commercial solutions for nutrient-dense foods for children aged 6-24 months and for pregnant and lactating women leading to [TBD] million more children and [TBD] million more pregnant and lactating women consuming adequate fortified products

Document coverage, efficacy and deployment of nutrition interventions

Nutritional status indicators included and measured in regular country-level surveys, in CIFF priority countries

Coverage of stunting intervention package, plus coverage of CMAM, established and routinely measured in at least five high burden countries in addition to the five CIFF priority countries. Data from all ten countries shared publicly

Twenty five papers published and disseminated through international forums on effective implementation science and/or cost effectiveness of delivering stunting and/or SAM interventions through the platforms identified by the CIFF strategy and deriving from CIFF supported work

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Appendix: Glossary

Absolute reduction of XX percentage points

Arithmetic difference between two percentages. E.g., a reduction in prevalence from 40% to 30% equals to a reduction of 10 percentage points

Complementary feeding

“The introduction of nutritionally-adequate and safe complementary (solid) foods at 6 months together with continued breastfeeding up to two years of age or beyond”* (WHO)

Leverage

In this presentation, resource leverage means bringing new resources or shifting the use of existing resources towards better use

Micronutrient

Micronutrients are essential vitamins and minerals that every human being needs – in small quantities – for good health. These essential vitamins and minerals include vitamin A, iodine, iron, folic acid and zinc.

Nutrition-sensitive interventions

Programs that address the underlying causes of undernutrition in complementary sectors (agriculture, health, social protection, early child development, education, water and sanitation, etc…)

Psychosocial stimulation

Refers to the extent that the environment (caregiver-child bond and home) provides the child with physical (adequate sensory experiences, play materials, opportunities to practice skills) and emotional (affection, communication, child appreciation,...) stimulation to facilitate his/her development

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Appendix: Glossary

Relative reduction by XX percent

Ratio expressed as a fraction of 100. E.g., a reduction in prevalence from 40% to 30% equals to a reduction of 25 percent

Severe acute malnutrition (SAM)

Severe acute malnutrition in 6-59 month old children is defined by a weight for height z-score that’s minus 3 standard deviations below the median WHO child growth standard or by a mid-upper-arm circumference less than 115 mm, with or without nutritional oedema*

Stunting

Stunting reflects chronic undernutrition during the most critical periods of growth and development in early life. Moderate stunting is defined as height-for-age Z score (HAZ) between -2 and -3 standard deviations from the median of the WHO Child Growth Standards and severe stunting is HAZ<-3.

Wasting

Wasting reflects acute undernutrition. Moderate wasting is defined as weight-for-height Z score (WHZ) between -2 and -3 standard deviations from the median of the WHO Child Growth Standards, severe wasting is WHZ<-3

UNICEF, Micronutrient initiative, WHOPhotos from previous slide: (1) © Farrah Mateen, Courtesy of Photoshare, (2) © Dr. Steve Vosti , (3) © CIFF

Sources:

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Documents

Nutrition for Growth