Knowledge Brief Health, Nutrition and Population Global Practice AN INVESTMENT FRAMEWORK FOR NUTRITION IN KENYA Julia Dayton Eberwein, Jakub Kakietek, Davide de Beni, Grainne Moloney, Audrey Pereira, Jonathan Kweku Akuoku, Marjorie Volege, Sicily Matu, and Meera Shekar December 2016 KEY MESSAGES:  Despite recent reductions, over one-fourth of all Kenyan children under five remained chronically malnourished (stunted) in 2014.  Scaling-up 11 key nutrition-specific interventions in all counties of Kenya would cost $76 million in public and donor investments annually, and produce tremendous health benefits: 455,000 DALYs (disability-adjusted life years, or years of healthy life lost due to a health condition) averted, 5,000 lives saved, and almost 700,000 cases of stunting averted.  This investment could increase economic productivity by $458 million per year over the productive lives of the beneficiaries.  Every dollar invested in this package of interventions has the potential to result in $22 in economic returns.  This package of interventions is highly cost-effective at $207 per DALY averted.  Focusing the scale up on 10 cost-effective interventions in counties with stunting prevalence above 20 percent would require $48 million annually and would avert almost 295,000 DALYs and save more than 3,000 lives, with a cost per DALY averted of $179. Introduction Evidence from around the world shows that a number of This Knowledge Brief presents the costs of scaling up key interventions are effective in reducing malnutrition. Those effective nutrition interventions in Kenya and compares interventions are consistently identified as some of the different scale-up scenarios to determine which one most cost-effective development actions, with huge produces the best results for the lowest cost. The goal of potential to reduce poverty and boost prosperity (Hoddinott the analysis is to inform program planning by identifying the et al. 2013; World Bank 2010). Investing in nutrition can most cost-effective packages of interventions and by increase a country’s GDP by between 3 and 11 percent leveraging additional resources from domestic budgets and annually (Horton and Steckel 2013). Investments in early development partners. nutrition boost wages by 5 to 50 percent and make children Page 1 HNPGP Knowledge Brief  33 percent more likely to escape poverty in the future, and An Effective Package of Interventions to have a potential to reduce gender inequities (Hoddinott et Reduce Malnutrition al. 2008; Hoddinott et al. 2011). This analysis considers 11 evidence-based nutrition- specific interventions identified by the Kenyan Ministry of Health as priority actions (Box 1)1 We modelled the impact Malnutrition in Kenya of the interventions on DALYs averted, lives saved and The prevalence of chronic undernutrition in children under cases of stunting averted. Cost-effectiveness was five, as measured by stunting, was 26 percent in 2014. established by estimating the cost per DALY averted, the Although this is a marked decline from 35 percent in 2008– cost per life saved, and the cost per case of stunting 09, it nevertheless represents a heavy burden of averted. The estimation includes the total costs for scaling undernutrition in Kenya. In 2014 Kenya met the Millennium up all 11 interventions nationwide, and also more modest Development Goal for underweight, bringing underweight scale-up options: (1) scale-up in counties with high burden rates down to 11 percent. However, micronutrient of malnutrition, (2) scale-up of the most cost effective deficiencies (hidden hunger) are prevalent, with vitamin A interventions and (3) scale-up of the most cost effective deficiency and anemia rates particularly high. Finally, there interventions in high burden counties. is great geographical disparity in stunting rates, varying from 15 percent in Nyeri to 46 percent in West Pokot, highlighting the need for well-targeted interventions (Figure Box 1: Eleven Effective Interventions Considered 1). in the Analysis 1. Promotion of good infant and young child Figure 1: Prevalence of stunting in Kenya by nutrition and hygiene practices including county, 2014 promotion of breastfeeding and appropriate complementary feeding 2. Vitamin A supplementation 3. Therapeutic zinc supplement with oral rehydration salts for diarrhea treatment 4. Micronutrient powder supplementation for children 5. Deworming 6. Iron-folic acid supplementation for pregnant women 7. Iron fortification of staple foods 8. Salt iodization 9. Public provision of complementary food 10. Treatment of severe acute malnutrition in children 11. Management of moderate acute malnutrition in children Scaling up the 11 nutrition-specific interventions to full 100% coverage in all counties in Kenya would cost $76 million in public and donor investments annually in addition Note: Dark blue shading represents stunting rates of 30% or to current expenditures and would produce tremendous higher; medium blue 20-29% and light blue stunting rates below health benefits (Table 1). The cost per DALY averted is 20%. $207 which is highly cost-effective by WHO standards. Source: KDHS 2014. These investments have the potential to increase economic productivity by $457 million over the productive lives of the beneficiaries and are estimated to yield an impressive internal rate of return of almost 22.2 percent. Page 2 HNPGP Knowledge Brief  Table 1: Cost, Benefits and Cost-effectiveness of Key Scenarios to Scale Up Nutrition interventions in Kenya Scale up scenario Additional Lives saved Cases of DALYs Cost/DALY annual public stunting averted averted (thousands) and donor averted (thousands) investment (thousands) (US$, millions) Scale Up all 11 interventions nationwide $76 5.1 700.0 455.0 $207 Scale up 10 cost-effective $62 4.3 — 385.0 $198 interventions* nationwide Scale up 10 cost-effective interventions* $48 3.4 — 295.0 $179 in 37 high- burden counties *excludes the public provision of complementary food. — = not available The benefit cost ratio is 22, which means that every dollar important next step will be to identify the most cost- invested in nutrition interventions would results in 22 effective nutrition-sensitive interventions to complement dollars in economic returns. the interventions identified here. Resource constraints are likely to prevent immediate and full national scale-up. Therefore, we also identified two Sources more modest and cost–effective scale-up options, as Hoddinott, J., H. Alderman, J. R. Behrman, L. Haddad, and S. shown in the table. The first is to scale up 10 most cost- Horton. 2013. “The Economic Rationale for Investing in Stunting Reduction.” Maternal and Child Nutrition 9 (Suppl. 2): 69–82 effective interventions (all interventions with the exception of the public provision of complementary foods 2) in all counties in Kenya. The second is to scale up 10 cost- Hoddinott, J, Maluccio, JA, Behrman, JR, Flores, R, and Martorell, effective interventions only in 37 counties where stunting R. 2008. “Effect of a nutrition intervention during early childhood prevalence exceeded 20 percent.3 on economic productivity in Guatemalan adults. ” Lancet. 371: 411–416 The second of those scenarios - scale up 10 cost-effective Hoddinott, J., J. Maluccio, J. R. Behrman, R. Martorell, P. Melgar, interventions (excluded is the public provision of A. R. Quisumbing, M. Ramirez-Zea, A. D. Stein, and K. M. Yount. complementary food) from current coverage levels to full 2011. “The Consequences of Early Childhood Growth Failure coverage in 37 high-burden counties, is most cost effective over the Life Course.” Discussion Paper 1073. International Food one, with a cost per DALY averted of $179. It is also the Policy Research Institute, Washington, DC. least costly, requiring $48 million in public and donor resources annually in addition to current expenditures on Horton S. and R. Steckel. 2013. “Global Economic Losses Attributable to Malnutrition 1900–2000 and Projections to 2050.” nutrition. This expansion of services would avert almost In The Economics of Human Challenges, ed. B. Lomborg. 295,000 DALYs and save more than 3,000 lives. Cambridge, UK: Cambridge University Press. KDHS (Kenya Demographic and Health Survey). 2014. Kenya Conclusion Demographic and Health Survey 2014. Rockville, MD: ICF Our findings suggest that scaling up nutrition-specific International and Kenya National Bureau of Statistics (KNBOS). interventions in Kenya is an excellent investment with a (Published in 2015). potential to generate 22 dollars in economic returns for every dollar invested. The analysis also suggests that WHO (World Health Organization). 2014. Cost-Effectiveness and scaling up 10 most cost-effective interventions in a targeted Strategic Planning: Threshold Values for Intervention Cost- Effectiveness by Region. Geneva: WHO-CHOICE (Choosing fashion focusing on the 37 countries with a high burden of Interventions that are Cost-Effective) Program. chronic malnutrition would be the most cost-effective http://www.who.int/choice/costs/CER_levels/en/ investment strategy. Even though this brief focuses exclusively on nutrition- World Bank. 2010. Scaling Up Nutrition. What Will It Cost? Washington, DC: World Bank. specific interventions, the causes of malnutrition are multifactorial. Therefore, the longer-term approach to improving nutrition outcomes must also include nutrition- sensitive interventions through multiple sectors. An Page 3 HNPGP Knowledge Brief  Notes This brief is based on the report: Dayton Eberwein, J., J. Kakietek, D. de Beni, G. Moloney, A. Pereira, J.K. Akuoku, M. Volege, S. Matu, and M. Shekar. 2016. An Investment Framework for Nutrition in Kenya: Reducing stunting and other forms of child malnutrition. HNP Discussion Paper. Washington, D.C.: World Bank Group. A DALY (also known as a disability-adjusted life year) is equivalent to a year of healthy life lost due to a health condition and premature death. All dollar amounts in US dollars. 1. An examination of the cost-effectiveness of nutrition-sensitive interventions—those that address nutrition in sectors other than health—is not included in this analysis. 2 All 11 interventions are very cost-effective, although one intervention, the public provision of complementary foods, is much less cost-effective than the others according to WHO- CHOICE criteria (WHO 2014). 3 The counties include: Nyandura, Mombasa, Kwale, Kilifi, Tana River, Lamu, Taita-Taveta, Marsabit, Meru, Tharaka-Nithi, Embu, Kitui, Machakos, Makueni, Wajir, Mandera, Siaya, Migori, Kisii, Nyamira, Turkana, West Pokot, Samburu, Tran Nzoia, Uasin Gishu, Elgeyo-Marakwe, Nandi, Baringo, Laikipia, Nakuru, Narok, Kericho, Bomet, Kakamega, Vihiga, Bungoma, Busia. Acknowledgements: We are grateful for the strong collaboration provided by the Government of Kenya in supporting this work. In particular, we would like to acknowledge the leadership and commitment of Gladys Mugambi, Head of Nutrition Division at the Ministry of Health and John Mwai, Ministry of Health. This work was carried out in partnership with UNICEF and we would like to thank DFID who funded the UNICEF component of the exercise. The report also benefitted from the advice and consultation provided by other partners, including the World Food Program, Hellen Keller International, and GAIN. Finally, the Bill & Melinda Gates Foundation (BMGF) was a strong partner with the World Bank in advancing this work and provided financial support. Ellen Piwoz from the BMGF provided valuable technical inputs. The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, go to: www.worldbank.org/health. Page 4