Social and Economic Impact of Child
Undernutrition
in Burkina Faso, Chad, DRC, Ghana, Lesotho, Madagascar, Malawi and Rwanda
Abridged Report
THE COST HUNGER
IN AFRICA
Implications for the Social and Economic Transformation of Africa
Supported by:
African Union
OF
The Cost of Hunger in Africa (COHA) study highlights the social and economic impacts of undernutrition. The results from the second phase countries – Burkina Faso, Chad, DRC, Ghana, Lesotho, Madagascar, Malawi and Rwanda – once more revealed the staggering impacts of child undernutrition on the continent.
Conversely, however, the study suggest that there is a significant economic savings to be made should governments take decisive actions to address child undernutrition.
Prioritizing investment for nutrition security is crucial to foster inclusive, equitable and sustainable development. Through aggressive actions backed by strong leadership and sustained commitment, Africa can reap the full potential of its human capital.
By investing in nutrition today, we set the pace for The Africa We Want!
Printed in Addis Ababa by the ECA Printing and Publishing Unit. ISO 14001:2004 certified.
Printed on chlorine free paper.
PHASE 2
Acknowledgement
This report, “The Cost of Hunger in Africa: The Economic and Social Impact of Child Undernutri- tion”, was prepared within the framework of the Memorandum of Understanding between the UN Economic Commission for Africa (ECA) and the World Food Programme (WFP). The work on this report took place under the institutional leadership provided to this project by H.E Mr. Mous- sa Faki, Chairperson, African Union Commission (AUC); Dr. Vera Songwe, Executive Secretary, ECA; and Mr David Beasley, Executive Director, WFP. The implementation of the agreement was coordinated by H.E. Mrs Amira El Fadil, Commissioner for Social Affairs at the AUC; and Ms Thokozile Ruzvidzo, Director of the Social Development and Policy Division at UNECA and Ms Angelline Rudakubana, Director of the WFP Addis Ababa Office and Representative to the Afri- can Union and UNECA. The design and implementation of the study was directed by a Steering Committee jointly led by Dr. Margaret K.Y. Agama-Anyetei Head of the Health, Nutrition and Population Division of the Social Affairs Department at the AUC, Dr. Saurabh Sinha of UNECA, Ms Wanja Kaaria of the WFP Africa Office.
Special recognition goes to the National Implementation Teams (NIT) of Burkina Faso, Chad, Democratic Republic of Congo, Ghana, Lesotho, Madagascar, Malawi and Rwanda which were re- sponsible for collecting, processing and presenting results. The Scaling Up Nutrition (SUN) team, the Renewed Efforts against Child Hunger (REACH) team and UN agencies provided support to the study. Acknowledgment also goes to development partners, various academics and nutrition champions.
The core team comprised of Jack Jones Zulu (Social Affairs Officer), Iris Macculi (Economic Affairs Officer), Kalkidan Assefa (Research assistant), Melat Getachew (Research assistant) from UNECA. Priscilla Wanjiru (Programme Policy Officer), Beza Berhanu (Research Assistant) and Addisu Bekele (Research Assistant) from the WFP Africa Office. Additional technical guidance was provided by Rodrigo Martínez Andres Fernandez and Amalia Palma from of the Social Devel- opment Division of ECLAC.
A special mention goes to the Publications Section of ECA for coordinating the editing and for the printing of the report.
The designations used and the presentation of material in this publication do not imply the expression of any opinion whatsoever on the part of the African Union, NEPAD, World Food Programme, Economic Commission for America and the Caribbean and Economic Commission for Africa concerning the legal status of any country, territory, city or area, or of its authorities, or concerning the delimitation of its frontiers or boundaries.
When a child is undernourished, the negative consequences follow that child for his or her entire life.
These negative consequences
also have grave effects on the
economies where he or she lives,
learns and works.
2
Foreword
While economies in Africa have grown at an average rate of 5 percent per annum between 2000 and 2013, the decline in poverty, inequality and child under-nutrition has been slow. According to an assessment carried out by the Economic Commission of Africa (ECA) in 2013, an estimated 389 million people were in extreme poverty in Africa. Furthermore, the continent’s food and nutrition security remains precarious especially in the Horn of Africa and Sahel region. Indeed, according to the report on the State of the Food and Nutrition Security (SOFI Report 2017), world hunger is on the rise with the estimated numbers of undernourished people increasing from 777 million in 2015 to 815 million in 2016, with Africa’s stunting rates (31.2%) among children remaining significantly higher than the rest of the world (22.9%).
While Africa has made significant progress over the past decade in reducing stunting and other forms of malnutrition, there is still much left to be done.
Efforts to address child undernutrition, in particular allocating adequate budgetary resources should be a priority for national governments.
The challenge for Africa however, is to diversify the drivers of growth for structural transformation and ensure the translation and complementarity of economic performance with social development.
More fundamentally, structural transformation must be accompanied by a significant demographic transition from high births and deaths to low births and deaths. This will ensure low dependency ratios that will ultimately allow households to make savings for investments.
Needless to say that there cannot be structural transformation without a social transformation agenda that targets human capital growth through improved health and education access. Indeed, there is a strong correlation between a healthy, educated workforce and improved productivity and structural transformation. This reinforces the need to match economic performance with improved social outcomes through improved access to health and education services between urban and rural areas, and between men and women. This is now affirmed by the 2030 Agenda for Sustainable Development, which calls for articulating economic, social and environmental dimensions, and leaving no one behind.
Child under-nutrition is one of the key factors contributing to high morbidity and mortality and is the cause of more than half the deaths of children in developing countries across Africa. For the
children that survive, damage from under-nutrition, especially in the first 1,000 days post conception, poses a serious threat to their physical and cognitive development with irreversible and cumulative damaging effects that persist during their entire life- cycle. The school performance of undernourished children is below potential and they have lower work capacity and productivity as adults. Such damaging impacts of under-nutrition have severe consequences for entire economies, dampening economic growth and poverty reduction.
To respond to these challenges, the African Union developed the Africa Regional Nutritional Strategy (ARNS, 2016 -2025), as part of the African Agenda 2063 which sets out strategies and actions for nutrition for the next decade. In addition, within the Malabo declaration, the AU set continental nutrition targets to reduce stunting to 10 percent and underweight to 5 percent by 2025.
It is within this framework that the African Union has continued to implement the Cost of Hunger in Africa (COHA) studies, which provide a compelling case for increasing both investments and suitable policy interventions in child undernutrition for African Member States. More specifically, COHA studies have empirically estimated the cost to Member States of inaction on addressing hunger and child undernutrition that manifests through the child’s reduced cognitive development, poor educational performance, increased child morbidity and mortality, and reduced economic productivity later in life in labour markets.
Against this background, appropriate nutrition interventions need to be prioritized in Africa if the continent is to meet the global nutrition target of
Abridged Report
3
Foreword
“ending by 2030 all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under five years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women and older persons” (SDG Goal 2 Target 2.2).
In order to increase awareness of the seriousness of the problem and address the challenge of child undernutrition in selected Member States, the African Union Commission and its NEPAD Planning and Coordinating Agency partnered with the World Food Programme, the United Nations Economic Commission for Africa, to estimate the economic and social costs of child undernutrition.
This has been implemented through South-South cooperation with the United Nations Economic Commission for Latin America and the Caribbean (ECLAC), to share experiences developed in LAC countries.
In this report, the results of eight countries studied are presented (Burkina Faso, Chad, DRC, Ghana, Lesotho, Madagascar, Malawi, and Rwanda).
It highlights the significant negative effects of undernourished children on health, school performance and labour productivity. This report provides evidence to assist Member States to devise targeted nutrition policy measures within their specific national contexts and priorities.
In going forward, we intend to support Member States to design suitable policies to reduce child stunting. We hope the best practices and lessons learnt from the current evidence can be replicated at national and subnational levels. This report provides that firm foundation and building blocks for this.
4 About the Study
Conceptual Framework
The Cost of Hunger Study in Africa (COHA) is a project led by the African Union Commis- sion (AUC) and the NEPAD Planning and Coordinating Agency, and supported by the UN Economic Commission for Africa (ECA), Economic Commission for Latin America and the Caribbean and the UN World Food Programme(WFP). COHA is a multi-country study aimed at estimating the economic and social impacts of child undernutrition in Africa.
This continent-wide initiative is being led by the African Union Commission Department of Social Affairs, within the framework of the Revised African Regional Nutrition Strategy (2005-2025), the objectives of the African Task Force on Food and Nutrition Development (ATFFND) and the principles of the AU/NEPAD’s CAADP Pillar 3.
In March 2012, the COHA Study was presented to African Ministers of Finance, Planning and Economic Development, who met in Addis Ababa, Ethiopia. The ministers issued Resolution 898 confirming the impor- tance of the study and recommending it continue beyond the initial stage.
The core implementers of the study are national teams organized in each participating country, drawn from relevant governmental institutions such as the Ministry of Health, Ministry of Education, Ministry of Social Development, Ministry of Planning, Ministry of Finance, and the National Statistics Institution.
The COHA study is being carried out in 12 countries, namely: Burkina Faso, Chad, DRC, Egypt, Ethiopia, Ghana, Lesotho, Madagascar, Malawi, Rwanda, Swaziland and Uganda. The data in this document are the results collected from the COHA initiative in the eight second-phase countries, Burkina Faso, Chad, DRC, Ghana, Lesotho, Madagascar, Malawi, Rwanda.
In order to estimate social impacts for a single year, the model focuses on the current population, identifies the proportion of that population who were undernour- ished before the age of 5, and then estimates the asso- ciated negative impacts experienced by the population in the current year.
Estimates on health, education and productivity are based on the concept of the relative (or differential) risk experienced by individuals who suffer from undernu- trition.
Using these risk factor, alongside with economic, de- mographic, nutritional, health, and educational data provided by each country team, the model then esti- mates the associated economic losses incurred by the economy in health, education, and potential produc- tivity in a single year.
The COHA model is used to estimate the additional cases of morbidities, mortalities, school repetitions, school dropouts, and reduced physical capacity that can be directly associated to a person’s undernutrition before the age of 5.
years0-5
years6-18
15-64 years
Undernourished children are at higher risk for anaemia, di- arrhoea, fever and respiratory infections. These addition- al cases of illness are costly to the health system and fam- ilies. Undernourished children are at higher risk of dying.
Stunted children are at higher risk for repeating grades in school and dropping out of school. Additional instances of grade repetitions are costly to the education system and families.
If a child dropped out of school early and is working in he or she may be less productive, particularly in the non-manual labour market. If he or she is engaged in manual labour he/she has re- duced physical capacity and tends to be less productive. People who are absent from the workforce due to undernutrition-re- lated child mortalities represent lost economic productivity
About the Study
5
Abridged Report
A Methodology for Africa
With the support of experts and representatives from the National Implementation Teams (NITs) of the participating countries, a conceptual framework was adapted to the context of Africa. This framework es- tablishes clear linkages in the direct consequences associated with undernutrition, considering the par- ticular structures of the labour market in the continent, as well as the limitations in data availability. The result allows the model to clearly define boundaries in the cost analysis both from a public and individu- al perspective, as well as define a clear differentiation with direct cost and opportunity costs in the results.
The COHA model utilizes a two-dimension- al analysis to estimate the costs arising from the consequences of child undernutrition in health, education and productivity. The inci- dental retrospective dimension analyses the history of child undernutrition in the coun- try in order to estimate the current econom- ic and social consequences. To complement this analysis, a prospective dimension is used to project and generate scenarios for analysis.
COHA is based on a model originally de- veloped in Latin America by the Econom- ic Commission for Latin America and the Caribbean (ECLAC). The process of adap- tation was carried out in partnership with ECLAC, and endorsed by the African Task Force for Food and Nutrition Development.
Modified from Rodrigo Martínez and Andrés Fernández, Model for analysing the social and economic impact of child undernutrition in Latin America, based on consultations carried out by authors.
Key Terms and Concepts
Chronic Hunger: The status of people whose food intake regularly provides less than their minimum energy re- quirements leading to undernutrition.
Child Undernutrition: The result of prolonged low levels of food intake (hunger) and/or low absorption of food consumed. It is generally applied to energy or protein deficiency, but it may also relate to vitamin and mineral defi- ciencies. Anthropometric measurements (stunting, underweight and wasting) are the most widely used indicators of undernutrition.
Intrauterine growth restriction (IUGR): An infant suffering from IUGR is defined as being below the 10% per- centile of the recommended gender-specific birthweight for gestational age reference curves.
Low birth weight (LBW): A new-born is considered to have low birth weight when he or she weighs less than 2,500 grams.
Malnutrition: A broad term for a range of conditions that hinder good health caused by inadequate or unbalanced food intake or by poor absorption of the food consumed. It refers to both undernutrition (food deprivation) and obesity (excessive food intake in relation to energy requirements)
Stunting: Reflects shortness-for-age; an indicator of chronic malnutrition, calculated by comparing the height-for- age of a child with a reference population of well-nourished and healthy children. The model uses it as the indica- tor to analyse the impact on educational performance and productivity.
Underweight: Measured by comparing the weight-for-age of a child with a reference population of well-nourished and healthy children. The model utilizes it to analyse the impact of child undernutrition on health.
Abridged Report 7
8 Country Results
Country Results:
Burkina Faso, Chad, DRC, Ghana, Lesotho, Madagascar, Malawi and Rwanda
The following sections provide summaries of the results from the second-phase countries in the Cost of Hunger in Africa Study, as well as summaries of the conclusions and recommendations developed
by each country’s national implementation team.
“Cutting hunger and thereby achieving food and nutrition security in Africa is not only one of the most urgent means of reducing the vulnerability and enhancing the resilience of national economies, but also one of those which produces the highest returns for broader social and economic development.”
- 5th AU Conference of Ministers of Finance, Planning and Economic Development Resolution 898
Burkina Faso 7.7% GDP US$ 802 million
Ghana 6.4% GDP US$ 2,588 billion
Chad 9.5% GDP US$ 1,162 million
Malawi 10.3% GDP US$ 597 million
Madagascar 14.5% GDP US$ 1,461 million
Lesotho 7.1% GDP US$ 200.3 million
Rwanda 11.5% GDP US$ 820 million 4.6% GDPDRC
US$ 1,771 million
Abridged Report 9
Country Results: Burkina Faso
10
1. Introduction
Burkina Faso is a West African country with a gross domestic product (GDP) estimated at 5,322 billion FCFA in 2012 and a gross national income per capita (GNI) of about 670 dollars. According to the latest available information, rates of inequality and extreme poverty remained high with a Gini index of 39.8 and 44% of the population living on less than US$ 1.25 a day. The incidence of poverty is higher in rural areas where about 52.8% of the population lives below the poverty line, compared to 25.2% in urban areas.
Burkina Faso has made progress in reducing stunting in children. According to the 2010 Demographic and Health Survey (DHS), about 34% of children under five years of age in Burkina Faso suffered from stunting (low in size for their age), a significant reduc- tion from 42, 4% estimated in 2006. The prevalence of underweight children also improved from 37% to 25% over the same period.
Nevertheless, these two indicators remain below the “high” threshold based on the categorization of levels of undernutrition in the WHO child. For the same period, the prevalence of low birth weight among children remained stable at about 13.9%.
Current child undernutrition rates illustrate the continuing challenges of eliminating child hunger. It is estimated that about one in three children, more than one million children under the age of five, suffered stunting. 806,769 children were underweight in Burkina Faso in 2012. This situation is particularly alarming for children aged 24-59 months, who are affected by stunting by 41%.
During the process, all data from the study were collected from the National Institute of Statistics and Demography (INSD) and other structures such as the Ministry of Economy and Finance, the Ministry of National Education and Literacy, ICF International 2012, and the United Nations Population Division. The main statistical reports used are the 2010 Demographic and Health Survey (DHS), the 2012 World Health and Education Statistical Yearbook and the World Bank’s World Development Indicators database.
In addition, primary data collection was carried out, particularly at the health sector level.
2. Effects and Costs in Health
Undernutrition is mainly characterized by wasting (low weight- for-height), stunting (low height- for-age), and underweight (low weight-for-age). Undernutrition during early childhood translates into life-long adverse consequences and intergenerational seque- lae; undernourished children are more likely to require medical care as a result of illnesses linked to undernutrition and deficiencies.
This increases the burden on government social services and health care spending by government and affected families. Without appropriate care, underweight and emaciation expose children to a higher risk of mortality. During the years of schooling, children are more likely to repeat classes and drop out of school, thus reducing their ability to earn income later in life. In addition, those who have experienced growth retardation in childhood have reduced physical and cognitive abilities in adulthood, which would affect their productivity.
The study estimated that in Burkina Faso in 2012, there were 332,532 incremental episodes of illness related to diseases associated with being underweight.
Country Results: Burkina Faso
Abridged Report 11
In Burkina Faso, over the past five years, there were an esti- mated 197,014 child deaths directly associated with under- nutrition. These deaths account for 40.1% of all infant deaths during this period
3. Effects and Costs in Education
There is no single cause for repetition and dropout;
however, there is substantive research that shows that students who were stunted before the age of 5 are more likely to underperform in school.
According to official data provided by the Ministry of Education and Literacy, more than 229,002 children (10.5 per cent) repeated classes in 2012. Based on the high risk of repetition among stunted children, the mod- el estimates that the repetition rate for these children was 11.5 per cent, while the repetition rate for non- stunted children was 8.5 per cent. Based on these rates and the proportion of stunted students, the model estimates that 13,201 students, or 5.8 per cent of all repetitions in 2012, wereassociated with undernutrition.
40.1%
of child deaths associated with undernutritionThe model estimates that among the working-age population, aged between 20 and 64, 6.2 per cent of non-stunted children completed pri- mary school, compared to only 1.9per cent of children with growth retarda- tion. With regard to the completion of their education, the gap between stunted and non-stunted children would be reduced to less than 1 per cent, given other factors unrelated to the nutritional situation.
Country Results: Burkina Faso
12
4. Effects and Costs in Productivity
The model estimates that 51.7 per cent of the working-age population in Burkina Faso had stunted growth during childhood. Research shows that adults who have suffered from stunting in childhood are less pro- ductive than those who have not suffered from stunting and are less able to contribute to the economy. This represents more than 4.7 million people in Burkina Faso suffering losses on the potential income associated with undernutrition.
According to data from the Household In- come, Expenditure and Consumption Sur- vey, that the education gap between stunted and non-stunted population is 0.3 years. It is important to note that over time, there has been an improvement in the average years of schooling of the labor force. The cohort aged 60 to 64 has an average years of school- ing of 0.3 years and the cohort aged 20 to 24 has an average year of schooling of 1.8 years.
The poor academic performance of those who have suffered from stunting has an impact on the lev- el of income that these individuals might earn as adults. The model estimates that 938,127 of the pop- ulation engaged in non-manual activities suffered from stunting in childhood. This is equivalent to 10 per cent of the country’s labor force, which is currently less productive due to poor academic performance associated with stunting. The estimated annual losses on the potential income of this group are FCFA 20,516 million (USD $40.8 million) which is equivalent to 0.39 per cent of the Country’s GDP in 2012.
Research shows that stunted workers engaged in manual activities tend to have less lean body mass and are more likely to be less productive in manual activities than those who were never affect- ed by growth retardation. The model estimated that 7.3 million Burkinabe are engaged in manual ac- tivities, of whom 4.2 million were stunted as children. This represented an annual loss that surpass- es 37.2billion, equivalent to 0.7 percent of the GDP in potential income lost due to lower productivity.
An estimated 51.7% of the working age population, or 4.7 million people, were stunted as children.
1.3
1.0 -
1.0 2.0
Average Schooling of the Non-
Sunted Population Average Schooling of the Sunted Population
Average Schooling Years by Nutritional Status
The poor academic performance of those who have suffered from stunting has an impact on the level of income that these individuals might earn as adults. The model estimates that 938,127 of the population engaged in non-manual activities suffered from stunting in childhood. This is equivalent to 10 per cent of the country's labor force, which is currently less productive due to poor academic performance associated with stunting. The estimated annual losses on the potential income of this group are FCFA 20,516 million (USD $40.8 million) which is equivalent to 0.39 per cent of the Country’s GDP in 2012.
Research shows that stunted workers engaged in manual activities tend to have less lean body mass and are more likely to be less productive in manual activities than those who were never affected by growth retardation. The model estimated that 7.3 million Burkinabe are engaged in manual activities, of whom 4.2 million were stunted as children. This represented an annual loss that surpasses 37.2billion, equivalent to 0.7 percent of the GDP in potential income lost due to lower productivity.
As indicated in the section on health, there is an increased risk of infant mortality associated with undernutrition. The model estimates that 1,247,212 of the working-age population were absent from the Burkina Faso workforce in 2012 due to infant mortality associated with undernutrition. This represents a 13.6 per cent reduction in the current working-age population.
The value of hours of work lost due to the absence of this labor force represents a cost to national productivity. To reach this value, estimates were made of the current productive level of the population, taking into account the type of activity carried out, the age and the level of education. Combining these elements, the model estimated that in 2012 economic losses (measured by hours lost due to undernutrition- related child mortality) amounted to FCFA 318,595 million which represented 6.0 per cent of the country's GDP.
Reduced income in manual and non-manual activities due to stunting, 2012
Age in
2012 Population working in non-manual sectors who were stunted as
children
Income losses in non-
manual labour Population working in manual
sectors who were stunted as children
Income losses in manual labour
Millions of
FCFA Millions of
Dollars Millions of
FCFA Millions of Dollars
15-24 1,698,660 13,697 27 335,128 3,606 7
25-34 1,077,279 11,038 22 356,945 6,410 13
35-44 720,696 6531 13 214,496 5,152 10
45-54 454,611 3835 8 114,086 3,578 7
55-64 279,010 2,103 4 44,695 2,070 4
Total 4,230,255 37,205 73 1,065,351 20,816 41
% GDP 0.7 0.39
An estimated 51.7% of the working age population, or 4.7 million people, were stunted as children.
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5. Summary of Costs
For Burkina Faso, the total losses asso- ciated with undernutrition are estimat- ed at FCFA 409 billion (USD 802 mil- lion) for the year 2012. These losses are equivalent to 7.7 per cent of GDP for that year. The highest element in these costs is the loss in the potential produc- tivity as a result of undernutrition relat- ed mortalities.
6. Analysis of Scenarios
The previous section showed that the social and economic costs that affect Burkina Faso in 2012 are due to the strong trends in child undernutrition. Most of these costs are already embedded in society and policies need to be put in place to improve the lives of those already affected by undernutrition during childhood. Nevertheless, there is room to avoid these costs in the future. Currently, one in three Burkinabe children under 5 years of age are stunted.
The model generates a baseline for various scenarios, based on nutritional goals established in each country.
Scenarios are constructed based on the estimated costs of the children born in each year, from 2012 to 2025.
While the previous section calculated the costs incurred in a single year by historical trends of undernutrition, these costs represent the present values and savings generated by children born between 2012 to 2025.
Burkina Faso 409billionCFA 802 millionUSD
7.7% GDP
As indicated in the section on health, there is an increased risk of infant mortality associated with under- nutrition. The model estimates that 1,247,212 of the working-age population were absent from the Burkina Faso workforce in 2012 due to infant mortality associated with undernutrition. This represents a 13.6 per cent reduction in the current working-age population.
The value of hours of work lost due to the absence of this labor force represents a cost to national productivity.
To reach this value, estimates were made of the current productive level of the population, taking into account the type of activity carried out, the age and the level of education. Combining these elements, the model es- timated that in 2012 economic losses (measured by hours lost due to undernutrition-related child mortality) amounted to FCFA 318,595 million which represented 6.0 per cent of the country's GDP.
Country Results: Burkina Faso
14
The scenarios developed for this report are as follows:
Baseline: The Cost of Inaction. Progress towards reducing the prevalence of stunting and under- weight children remains at the level achieved in 2012
Scenario #1: Cutting by half the prevalence of child under nutrition by 2025.
Scenario #2: The ‘Goal’ Scenario. Reducing stunting to 10% and underweight to 5% by 2025.
This section will analyze the impact that a reduction in child malnutrition can have on the socio-economic context of the country. The results presented in this section outline the additional costs in the areas of health and education as well as the income losses that Burkinabe children will experience in the future. The model could generate a baseline for various scenarios, based on nutritional goals established in each country. The scenarios, which were designed with the endorsement of the Burkinabe national team, can then serve as a springboard to advocate for increased investments in the nutrition interventions tested.
The scenarios were designed according to the estimate of the net present value of the costs of children born each year between 2012 and 2025. While the previous section calculates the costs of historical patterns of mal- nutrition incurred in a single year, these costs represent the current values and savings generated by children born during this period.
As evidenced by the gradual reduction of child malnutrition generates a similar reduction in associated costs.
The distances between the trend lines indicate the potential savings in each scenario. In the case of the refer- ence scenario, where the reduction in the prevalence of undernutrition stops at the level reached in 2012, the cost in 2025 could reach 328,557 million CFA francs (or 644 million dollars).
For the baseline scenario, the progress in reducing the prevalence of undernutrition stops at the level reached in 2012.
This also assumes that population growth would maintain the pace of the year of analysis, and thus, the number of undernourished children and the estimated cost would increase. Although highly unlikely, this assumption serves as a baseline against which any improvement in nutritional status is compared to assess potential cost savings.
This scenario predicts that the prevalence of underweight and stunting among children will be halved compared to baseline values for 2012. In the case of Burkina Faso, this would mean a steady reduction of 1.3 per cent of the stunting rate per year, a reduction from 34.6 per cent (estimated for 2012) to 17.3 per cent in 2025. With an appropriate com- bination of proven interventions, this scenario would be achievable because the average reduction in stunting between 2006 and 2010 is estimated at 1.95 per cent, which is stronger than the rate of progress needed to achieve this scenario.
In this scenario, the prevalence of stunted children would be reduced to 10 per cent and the prevalence of underweight children under the age of five, to 5 per cent. Currently, the global stunting rate is estimated at 26 per cent, with Africa having the highest prevalence at 36 per cent. This Goal Scenario would require a true call for action and would repre- sent an important regional challenge, in which countries of the region could collaborate jointly in its achievement. The progress rate required to achieve this scenario would be 1.9 per cent annual reduction for a period of 13 years, from 2012 to 2025.
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7. Conclusions and recommendations
The Government of Burkina Faso put forward its Strategy for Accelerated Growth and Sustainable Develop- ment (SCADD) 2011-2015, which aims to make Burkina Faso a “productive economy that accelerates growth, raises the standard of living, improves and preserves the living environment and the living environment through wise and efficient governance “. This vision, which was developed through a broad participatory pro- cess, identified four pillars and defined key indicators and targets to guide the country’s economic and social growth. “The cost of hunger in Burkina Faso” provides an opportunity to better understand the role that child nutrition can play as a catalyst for achieving the goals of the SCADD.
Some of the main results of the study indicate the need to strengthen current prevention interventions and the development of innovative and multi-sectoral solutions to combat under-nutrition of children in Burkina Faso. In this regard, it is recommended that Burkina Faso set ambitious targets to reduce the stunting which goes beyond a relative reduction to establish an absolute target of 10% as set by the Africa region. To this end, it is essential that the Government of Burkina Faso promote access to and use of essential health services, promote public awareness of the adoption of good hygiene and nutrition practices, increase the fortification of food for children who go to school and children over six months; strengthens the system for collecting specific data and health surveys in order to improve the monitoring and evaluation of nutrition policies and programs in place; and, finally, tackles the bottlenecks that undermine the effectiveness of existing interventions, maxi- mizing the results achieved through these interventions.
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Country results: Chad
1. Introduction
Chad is a Central African country with an estimated gross domestic product (GDP) of US$ 13.5 billion in 2012 and a per capita gross national income (GNI) of about US$1030. According to the latest available information, rates of inequality and extreme poverty remained high with a Gini index of 43.3 and 36.5 per cent of the popu- lation living on less than US$ 1.25 a day. The incidence of poverty is higher in rural areas where about 52.5 per cent of the population lives below the poverty line, compared with 20.9 per cent in urban areas.
Chad has made progress in reducing stunting among children. According to national data, about 38.7% of chil- dren under 5 in Chad were stunted in 2010 (low for their age), which is a reduction from the estimated 44.8 per cent for 2004.The prevalence of underweight children has also improved from 34 per cent to 30.3 per cent over the same period. Nevertheless, these two indicators remain below the “high” threshold if we take as a reference the categorization of levels of undernutrition in WHO. For the same year (2010), the prevalence of low birth weight among children remained high at around 19.9 per cent.
Public investment in the social sector in Chad remains low compared to the average for sub-Saharan Africa.
From an education point of view, public spending on education is also below the average for sub-Saharan Af- rican countries. Total spending on education fell from 13.8 per cent to 10.1 per cent of total expenditure and, relative to GDP, spending remained at almost the same level (2.3%).
During the process, all data from the study were collected from national institutions, and from the United Nations system. The main statistical reports used are: Demographic and Health Surveys (DHS), Surveys on Consumption and the Informal Sector (ECOSIT3), Multiple Indicator Cluster Surveys (MICS), Health and Education Statistical Yearbooks and the Database World Bank Development Indicators. In addition, primary data collection has been carried out, particularly at the level of the health sector. The data and documents of the National Institute of Statistics, Economic and Demographic Studies (INSEED) were also used for this study.
2. Effects and Costs in Health
Undernutrition is mainly characterized by wasting (low weight- for-height), stunting (low height- for-age) and underweight (low weight-for-age). Undernutrition during early childhood has negative consequenc- es throughout life and intergenerational sequelae. Indeed, undernourished children are more vulnerable to diseases related to malnutrition and deficiencies, and therefore more likely to require medical care. This phenomenon increases the burden on the public social services and the health expenses incurred by the Government and the families concerned. Without proper care, underweight and wasting expose children to a higher risk of death. During the school years, children are more likely to repeat grades and drop out of school, reducing their physical and cognitive abilities as adults and thus affecting their productivity and income.
The study estimated that as a consequence of this incremental risk, in 2012 there were 262,016 incremental episodes of illness from diseases associated with underweight in Chad. In addition, pathologies related to calorie and protein deficiencies and low birth weight associated with intrauterine growth restriction (IUGR), totalled 1,185,876 episodes in 2012. As a consequence, Chad had to address 1,447,892 illnesses in children that required medical attention and generated costs both to families and to the health sector.
Country Results: Chad
18
The model estimates that the equiv- alent of 13.1 per cent of the current labor force has been lost due to the incidence of undernutrition associ- ated with high infant mortality rates.
This represents 798,226 population aged between 15 and 64 years and could have been part of the country’s labor force.
There is no single cause for repetition and dropout;
however, there is substantive research that shows that students who were stunted before the age of 5 are more likely to underperform in school.
According to official information provided by the Ministry of Education, 748,139 students (26.4 per cent) repeated grades in 2012. Based on the high repetition risk of stunted students, the model esti- mates that the repetition rate of these students was 29.9 per cent, while the repetition rate of students with stunted growth was 22.2 per cent. Based on these rates and the proportion of stunted students, the model estimates that 105,732 students, or 14.1 per cent of all repeaters in 2012, were associated- with undernutrition.
43 %
of child deaths associated with undernutritionAbridged Report 19
Research shows that students who were stunted as children are more likely to drop out of school.
According to available data and taking into ac- count the risks associated with the consequences of stunting in the field of education, it is estimat- ed that 47.3 per cent of non-stunted population (working age) in Chad completed their education.
compared to only 23 per cent of stunted popula- tion.
4.
Effects and Costs in Productivity
As described in the health section of the report, the model estimates that 56.4 per cent of the labor force in Chad experienced stunted growth during childhood. Research shows that adults who have suffered from stunting during childhood are less productive compared to non-stunted workers and less able to contribute to the economy. This represents more than 3.4 million people suffering losses on potential incomes associated withundernutrition.
According to data from the Household Income, Expenditure and Consumption Survey, it is esti- mated that the education gap between stunted and non-stunted people is 1.9 years. It is important to note that over time there has not been a substantial improvement in the average years of schooling of the working-age population. The cohort aged 60 to 64 has average yearsof schooling of 4.2 years while that of 20 to 24 shows an average years of schooling bare- ly higher (4.9 years).
The poor academic performance of those who have suffered from stunting have an impact on the level of income that these people might have adults. The model estimates that 1.6 million of the population engaged in non-manual activities suffered from stunting during childhood. This is 25.71per centof the country’s labor force, which is currently less productive due to poor academic performance associated with stunting. The an- nual losses on the potential income of this group are 29,671 million CFA, which is equivalent to 0.49 per cent of thecountry’s GDP in 2012
w.Research shows that stunted workers engaged in manual activities tend to have less lean body mass and are more likely to be less productive in manual activities than those who were never affected by growth retardation.
The model estimated that 3.6 million Chadians are engaged in manual activities, of whom 2.2 million were stunted as children. This represented an annual loss that surpasses CFA 37 billion, equivalent to 0.56 percent of the GDP in potential income lost due to lower productivity.
Country Results: Chad
20
An estimated 56.4% of the work- ing age population, or 3.4 million people, were stunted as children infants.
As indicated in the health section of this report, there is an increased risk of infant mortality associated with undernutrition. The model estimates that 798, 266 of the working age population were absent from the labor force of Chad in 2012 due to infant mortality associated withundernutrition. This represents a 13 per cent re- duction in the current workforce.
Given the levels of productivity of the population, according to age and the labor sector, the model estimates that in 2012, economic losses (as measured by working hours lost due to child malnutrition mortality) were raised to FCFA 334.556 million, which is equivalent to 5.5 per cent of the country’s GDP.
Losses in potential productivity due to mortality associated with undernutrition, 2012
Losses in potential productivity due to mortality associated with undernutrition, 2012
Abridged Report 21
5. Summary of Costs
For Chad, total losses associated with child under- nutrition are estimated at FCFA 575.5 million or US1,162 million for 2012. These losses correspond to 9.5 per cent of GDP for the same year. The high- est cost element in these costs is the potential rev- enue losses from manual activities associated with stunting.
6. Analysis of Scenarios
The previous section showed that the social and economic costs that affect Chad in 2012 are due to the strong trends of child malnutrition. Most of these costs are already embedded in society and policies need to be put in place to improve the lives of those already affected by malnutrition in childhood. Nevertheless, there is room to avoid these costs in the future. Currently, two out of five Chadian children under 5 years of age have stunted.
The model generates a baseline for various scenarios, based on nutritional goals established in each country.
Scenarios are constructed based on the estimated costs of the children born in each year, from 2012 to 2025.
While the previous section calculated the costs incurred in a single year by historical trends of undernutrition, these costs represent the present values and savings generated by children born between 2012 to 2025.
The scenarios developed for this report are as follows:
Baseline: The Cost of Inaction. Progress towards reducing the prevalence of stunting and underweight children remains at the level achieved in 2012
Scenario #1: Cutting by half the prevalence of child under nutrition by 2025.
Scenario #2: The ‘Goal’ Scenario. Reducing stunting to 10% and underweight to 5% by 2025.
Chad575,500 million CFA 1,162 million USD 9,5% GDP
For the baseline scenario, progress in reducing the prevalence of malnutrition stops at the level reached in 2012. This also implies that population growth would maintain the pace of the year of analysis, the number of undernourished children and the estimated cost would increase. Although highly unlikely, this assumption serves as a baseline against which any improvement in the nutritional situation is compared to assess potential cost savings.
This scenario predicts that the prevalence of underweight and stunting in children will be reduced by half compared to the baseline values for 2012. In the case of Chad, this would mean a steady reduction of 1.49 % of the stunting rate per year, i.e.
a reduction of 38.7% (estimate for 2012) to 19.35% in 2025. With an appropriate mix of interventions, this scenario would be feasible if appropriate measures are taken to exceed the average rate of reduction of stunting estimated at 1,025% per year between 2006 and 2010.
This scenario provides for a 10% reduction in the prevalence of stunting in children and a 5% reduction in underweight in children under five. Currently, worldwide, the rate of stunting is estimated at 26%, while Africa has a very high prevalence of 36%. This scenario would require a real call for action and would constitute a major challenge on a continental scale for which African countries could build consensus and promote action to combat child malnutrition. The rate of progress needed to achieve this scenario would be an annual reduction of 2.21% for a period of 13 years, between 2012 and 2025.
Country Results: Chad
22
This section will analyze the impact that a reduction in child malnutrition may have on the socio-economic context of the country. The results presented in this section outline the additional costs in the areas of health and education as well as the lost income that children in Chad will sustain in the future. The model could gen- erate a baseline for various scenarios, based on nutritional goals established in each country. The scenarios, which were designed with the endorsement of the national implementation team, can then serve as a spring- board to advocate for increased investment in the nutrition interventions tested.
For Scenario 1, where the current prevalence is halved, the cost in 2025 would be reduced to FCFA 442.824 million ($ 894 million). For the entire period between 2012 and 2025 this would represent a total saving of FCFA 1,185.688 million ($ 2.1 billion). Although the trend in savings is not linear, as it will increase over time and as progress is made, a simple average of annual savings would be FCFA 91.206.8 million (184.1 million) per year.
In the case of the ‘target to achieve’ scenario, the cost in 2025 would be reduced to FCFA 163.857.4 million (USD 232.6 million). This would result in an increase in total savings to FCFA 2,383,241.6 million ($ 4,810.7 million), which would represent FCFA 183,326.3 million ($ 370.1 million) per year for the same period of 13 years.
The potential economic benefits of reducing malnutrition are an essential element in defending investment in nutrition. Reducing clinical episodes for the health system, reducing repetition, improving academic perfor- mance and physical capacity are factors that can contribute directly to national productivity.
7. Conclusions and recommendations
The Government of Burkina Faso put forward its Strategy for Accelerated Growth and Sustainable Development (SCADD) 2011-2015, which aims to make Burkina Faso a "productive economy that accelerates growth, raises the standard of living, improves and preserves the living environment and the living environment through wise and efficient governance ". This vision, which was developed through a broad participatory process, identified four pillars and defined key indicators and targets to guide the country's economic and social growth. "The cost of hunger in Burkina Faso" provides an opportunity to better understand the role that child nutrition can play as a catalyst for achieving the goals of the SCADD.
Some of the main results of the study indicate the need to strengthen current prevention interventions and the development of innovative and multi-sectoral solutions to combat under-nutrition of children in Burkina Faso. In this regard, it is recommended that Burkina Faso set ambitious targets to reduce the stunting which goes beyond a relative reduction to establish an absolute target of 10% as set by the Africa region. To this end, it is essential that the Government of Burkina Faso promote access to and use of essential health
Estimated savings, by scenario (in millions)
S1. Cutting
Undernutrition by Half by 2025
S2. Goal Scenario
FCFA USD FCFA USD
Total Potential Savings (2012-2025)
434,431 850,9 741,240,6 1,451,9
Average Annual Savings (2012-2025)
33,418 65,5 57,018 111,7
Annual percentage reduction of stunting necessary
(2012-2025) 1.37% 1.89%
Trends of estimated costs of child undernutrition, 2012-2025 (in millions of FCFA)
Abridged Report 23
7. Conclusions and recommendations
The study of the cost of hunger in Chad shows the magnitude of the consequences of child undernutrition on health, education and productivity of people. However, this study also shows the effects of undernutrition on the national economy and consequently the need for a multisectoral approach to counteract the short, medium and long-term effects of stunting in Chad.
Some of the main findings of the study indicate the need to reinforce current prevention interventions and the development of innovative and multisectoral solutions to combat under-nutrition of children in Chad. In this regard, it is recommended that Chad set itself ambitious targets to reduce the stunting which go beyond a rel- ative reduction to establish an absolute target of 10% as set for the Africa region. To this end, it is essential that the Government of Chad promote access to and use of essential health services; encourages public awareness of the adoption of good hygiene and nutrition practices; increases the fortification of food for children who go to school and children over six months; strengthens data collection and health surveys to improve the monitoring and evaluation of nutrition policies and programs in place; and, finally, tackles the bottlenecks that undermine the effectiveness of existing interventions, maximizing the results achieved through these interventions, both in urban and rural areas.
Country Results: Democratic Republic of Congo
24
Abridged Report 25
1. Introduction
The Democratic Republic of Congo is the second largest country in Africa, with an area of 2,345,095 square kilometers. Because of its geographical location, the country is endowed with immense natural resources: 80 million hectares of arable land, 145 million hectares of forest, a subsoil very rich in mineral resources, a sig- nificant water potential (52 per cent of freshwater resources of the continent) and energy (more than 100,000 MW), a climate favorable to agriculture and an estimated population of 77.3 million. Despite these potentiali- ties, the Congolese population is far from enjoying this “paradise”, because of a poor governance that suffers the country. In 2015, the GDP per capita is estimated at 319.5 USD and the country ranks 176th out of 188 coun- tries selected, with an HDI of 0.433 points. The level of poverty and inequality of income distribution are still very high with 63.4 per cent of the population living on less than $ 1.25 and a Gini index of 0.40 (EDS-RDC, 2013- 2014). The unemployment rate is estimated at 17.7 per cent of which 74 per cent among young people aged 15 to 24 (Survey 1-2-3, 2012).
DRC is making progress in the fight against malnutrition, even if the results remain below the political am- bitions given in view of the evolution of stunting prevalence rates (small size compared to age) and the low weight for age in children under five. According to the different Demographic and Health Surveys, stunting has been steadily decreasing since 1990, from 50.39% to 42.6% in 2014. The prevalence of underweight children has decreased from 38% in 1990 to 23% in 2014. Nevertheless, these two indicators remain above the thresh- olds considered critical. The prevalence of low birth weight also remains high and is estimated at 12% in 2014.
In the health sector, total health expenditure is down relative to national wealth and was estimated at 7.62%
of GDP in 2014 compared to an average of 6.5%in Africa. Health expenditure per capita, for its part, has been increasing over the years, from US14.34 in the early 2010s to about US 20.52 in 2014, but remains well below the African average of US 96.2. These efforts in health spending are less and less supported by the public sector, which accounts for less than 20 per cent of total health expenditure compared with an average of 43.9 per cent for the African region.
The data used for the study was mainly collected from the National Institute of Statistics (INS) and other struc- tures such as the National Nutrition Program (PRONANUT), the Ministries of Economy, Planning, Budget, Finance, Public Health, and Primary and Secondary Education. The main national reports exploited are: Sur- vey 1, 2, 3 (2014); EDS (2013 - 2014); QUIBB survey (2016); MICS (2010); RESEN (2012), National Health Accounts (2014), the Statistical Yearbook (INS, 2014) and the SNSAP report (2015). Additional data were col- lected from the United Nations Population Division database, the World Bank’s World Development Indicators database, and the WHO Health Observatory. In addition, primary data collection was carried out, notably at the level of the health and education sector by the CAID.
2. Effects and Costs in Health
Undernutrition is mainly characterized by wasting (low weight- for-height), stunting (low height- for-age) and underweight (low weight-for-age). Undernutrition during early childhood has negative consequences throughout life and intergenerational sequelae. Indeed, undernourished children are more vulnerable to dis- eases related to malnutrition and deficiencies, and therefore more likely to require medical care. This phenom- enon increases the burden on public social services and health expenditure incurred by the Government andat the household level. Without proper care, underweight and wasting expose children to a higher risk of death.
During the school years, children are more likely to repeat grades and drop out of school, reducing their phys- ical and cognitive abilities as adults and thus affecting their productivity and income.
The study estimated that as a consequence of this incremental risk, in 2013 there were 1,418,923 incremen-
Country results:Democratic Republic of Congo
Country Results: Democratic Republic of Congo
26
The model estimates that equiva- lent of 7.5 per cent of the current labor force has been lost due to the incidence of undernutrition due to high infant mortality rates. There are 2,852,040 population aged between 15 and 64 who could have been part of the country’s labor force.
31.5 % of child mortality associated with under- nutrition
tal episodes of illness from diseases associated with underweight in DRC. In addition, pathologies related to calorie and protein deficiencies and low birth weight associated with intrauterine growth restriction (IUGR), totalled 3,772,593 episodes in 2013. As a consequence, DRC had to address 5,191,516 illnesses in children that required medical attention and generated costs both to families and to the health sector.
3. Effects and Costs in Education
There is no single cause for repetition and drop- out; however, there is substantive research that shows that students who were stunted before the age of 5 are more likely to underperform in school.
According to the official data provided by the Ministry of Education, the repetition rate in the DRC is estimated at 11.1 per cent for the year 2012, that is 1,849,776 of students who have been enrolled in the same class for consecu- tive years. Using the data on the increased risk of repetition among students suffering from stunting, the model estimates the repetition rate for stunted student at 15.8 per cent, com- pared to 6.5 per cent for non-stunted students.
This demonstrates an additional differential risk of 9.3 percentage points for stunted students.
Thus, given the proportion of stunted children, estimates show that 697,973 students, or 36.8 per cent of all repetitions in 2014, wereassociat- ed with stunting
Abridged Report 27
Research shows that students who were stunted during their childhood are more likely to drop out of school. Based on available data and tak- ing into account the risks associated with the consequences of stunting in education, it is es- timated that 69 per cent of non-stunted popula- tion (working age population) in the DRC com- pleted school compared with only 46 per cent of children with stunting.
Based on national education data, the model estimates that the average number of school years completed by population aged 15 to 64 is 5.1 years. Applying the differential risk of repetition associated with stunting, it appears that those who did not suffer from stunting averaged 7.8 years of schooling compared to 5.3 years of those who suffered from stunting, highlighting a gap of 2.6 years between the two categories.
4. Effects and Costs in Productivity
As described in the health section of the report, the model estimates that 49.8 per cent of the labor force in the DRC experienced stunted growth during childhood. Research shows that adults who have suffered from stunting during childhood are less productive than those who have not suffered from stunting and are less able to contribute to the economy. This represents more than 25,339,784 of the population suffering losses on potential incomes associated withundernutrition.
7.8
5.3 1.0 -
2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0
Average schooling of the non-stunted
population
Average schooling of the stunted population Average schooling years by nutritional status
Country Results: Democratic Republic of Congo
28
The poor academic performance of those who have suffered from stunting have an impact on the level of income that these people might have had as adults. The model estimates that 6,507,584 of the population working non-manual labor in DRC suffered from stunting during childhood. This is 17.1 per cent of the country’s labor force, which is currently less productive due to poor educational outcomes related to stunting. The annual losses on the potential income of this group are 181.7 bil- lion CDF, which is equivalent to 0.5 per cent of GDP in 2014.
Research shows that stunted workers engaged in manual activities tend to have less lean body mass and are more likely to be less productive in manual activities than those who were never affected by growth retardation. The model estimated that 25 million Congolese are engaged in manual activi- ties, of whom 12.4 million were stunted as children. This represented an annual loss that surpasses CDF225.6 billion, equivalent to 0.6 percent of the GDP in potential income lost due to lower pro- ductivity.
In 2014, the total losses in productivity due to undernutrition are estimated at about CDF 1,356.7 billion (US
$ 1.467 billion), the equivalent of 3.78 per cent of Congolese GDP, the largest share of the productivity losses is due to mortality associated with undernutrition, which represents 70 per cent of the total cost. The loss of productivity in non-manual activities represents 13 per cent of costs.
The income gap in manual labor, due to a lower physical and cognitive capacity of stunted people as a child, accounts for 17 per cent of total costs. This economic cost associated working hours lost is particularly high in the DRC, given the mortality associated with the historically high rates of underweight children. This mor- tality associated with undernutrition and related costs can be significantly reduced through increased efforts in programs that specifically address this issue.
