Business Case for Nutrition Investment in the Philippines by Bianca Bueno

Business Case for Nutrition Investment in the Philippines

Foreword The Undernutrition Costing Study is an important milestone in addressing the multi-dimensional issue of undernutrition in the Philippines; as well as in improving the overall health and development of Filipino children. UNICEF wishes to acknowledge the strong support, cooperation and commitment of the Department of Health (DOH) and the National Nutrition Council (NNC) in tirelessly working toward these objectives. Child undernutrition in the Philippines is alarming: the most recent statistics reveal that one in three Filipino children under five years of age is stunted; and one in 10 is wasted. This means 700,000 children under 5 are at-risk of dying and more than 3.3 million children will be deprived of achieving their full potential later in life because of their undernutrition in the early years. Thousands of children’s lives are in danger and millions of them start life disadvantaged. Undernutrition also means economic loss in terms of serious human capital development deficits that result in increased cost of health care, lower work productivity and earnings, and loss of lives. Addressing the problem of undernutrition in the country requires a multi-level and cross-sectoral approach; as well as solid evidence to make a case for investment and policy-making. Evidence shows the link between nutrition and the quality of human capital; suggesting that lower rates of undernutrition achieves sustained national economic development. UNICEF, in partnership with the DOH and NNC, thus commissioned two costing studies that show the impact of undernutrition to the national economy and how much investment we need to address this issue. The first study, “The Economic Consequences of Undernutrition in the Philippines: A Damage Assessment Report (DAR),” shows that the Philippines is losing and will continue to lose around $4.5 billion per year if current rates of undernutrition are not mitigated. In 2015, this loss was equivalent to around 1.5% of the country’s GDP, which has made a significant dent in the national economy.

The second study, “Business Case for Nutrition Investment in the Philippines,” shows how effective implementation of affordable and equity-focused nutrition interventions can significantly decrease the annual economic burden of undernutrition. It identifies necessary nutrition interventions, and the investment that is required. It also presents that for every $1 invested to address undernutrition, there will be a $12 return to the overall economy. We hope these studies will be useful to gather the support of the leaders of our government – the decision-makers and development partners – to increase the resources and effectively implement the interventions needed to address undernutrition. Not only to improve the national economy, but more importantly because we have a duty to ensure that every Filipino child enjoys the right to good nutrition for shaping a healthier, brighter and better future generation of the Philippines. Mabuhay kayong lahat!

LOTTA SYLWANDER Representative UNICEF Philippines

Message

from the Cabinet Secretary

Nutrition is a smart investment that any country would pursue to help generations of children reach their full potential. Recognizing that undernutrition among children leads to diminished physical, mental, psychological and emotional development, it is our mutual commitment to ensure an enabling environment to mainstream nutrition and wellness. Advocacy and policy development play a key role in this transformational journey. When backed by solid and clearly presented evidence, advocacy can bring about tangible and lasting change. Meanwhile, policy development is crucial in reducing susceptibilities and risks to diseases, which results in poor learning and development, ultimately, less productivity in adult life. This study will provide a profound understanding of the economic impact of undernutrition, particularly stunting. The importance of the first 1000 days in a childâ&#x20AC;&#x2122;s life is underscored in the lens of critically looking into the window of opportunity to reach Ambisyon Natin 2040. Communities, individuals, governments, the media, academia, and private sector alike need to be mobilized and empowered to raise voices of concern and action for nutrition. Each of us needs to be part of a collective process to ensure mutual accountability in combating hunger and malnutrition. Although much has been done in this front, there will still be a great deal of advocacy, planning and policy intervention in the years to come. The effort of UNICEF, Department of Health, and National Nutrition Council in publishing this piece of evidence is beyond commendation. Indeed, it is time for all development sectors to have a common understanding of this condition for us to approach it in a holistic and integrated manner. As steward of participatory governance, we call on all agencies to align development plans to incorporate doable strategies to curtail economic loss brought about by undernutrition. Conscientiousness and purposiveness in addressing this condition are seen as beacon of light and hope of our future generation. For certain, this should be identified as one of the major goals for which all the different sectors will be held accountable.

LEONCIO B. EVASCO, JR. Cabinet Secretary Office of the President of the Philippines

Message

from the Department of Health

Undernutrition remains to be one of the biggest threats to Filipino children. Using available national data, it is estimated that there are more than 3.3 million children who are stunted, more than 600,000 pregnant women who are anemic, around 2.8 million children who are not optimally breastfed, and around 800,000 children who suffer from acute malnutrition and are at increased risk of dying. Together with other national government agencies, the Department of Health has always been at the forefront in the country’s fight against undernutrition. However, we also recognize that there are capacity and quality gaps in service delivery, standards not being met or implemented efficiently, and “go-to” interventions done at the LGU level that are neither sustainable nor effective. We thus welcome this collaborative study done by UNICEF, NNC, and DOH that provides the much needed evidence on undernutrition and the cost of doing nothing. It not only quantifies the enormous cost of stunting and undernutrition on the health care system and the Philippine economy but also outlines the needed interventions and their corresponding budgetary estimates. This will allow the DOH to revisit its policies and strategies and see if DOH is adequately investing on evidence-based and cost-effective nutrition-specific interventions. On behalf of the Department of Health, I thank all the partners and stakeholders who spent their time and effort in order to contribute to such an important study. It is time that we start investing in the health and nutrition of the Filipino people especially during the first 1000 days towards “Boosting Universal Health Care via FOURmula One Plus for Health.”

FRANCISCO T. DUQUE III, MD, MSC. Secretary Department of Health

vii

Message

from the National Nutrition Council

The year 2017 marks the first year of implementation of the Philippine Plan of Action for Nutrition (PPAN) for 2017-2022, which outlines the countryâ&#x20AC;&#x2122;s goals, targets, strategies and programs for the next six years for the nutritional well-being of the Filipino people. One of the most pressing problems that the PPAN aims to address is the high rates of undernutrition among Filipino children. Most recent studies show that more than 3 million children under-five years old are stunted, indicating compromised physical and cognitive development, consequences of which are felt even in adulthood through reduced economic productivity. In addition, around 700,000 children under-five years old suffer from wasting or being thin for height. These children, at their early age are already exposed to serious health risks that threaten their survival. These show that we need urgent actions to address the nutritional needs of children, and assist parents and caregivers in nurturing them. These costing studies developed through the efforts of UNICEF, NNC and DOH quantify the economic burden of undernutrition and present how much resources are needed to uplift the nutritional status of our children. These studies serve as a useful advocacy tool in rallying the support of our national and local government leaders, civil society and development partners to invest in the strategies, programs, and projects outlined in the PPAN. It is our hope that the study results can bring all of us to reflect on our roles and responsibiities as duty bearers in fulfilling our childrenâ&#x20AC;&#x2122;s right to the best start in life, and align our resources to scale up nutrition for a brighter future for Filipino children and for the Philippines. Let us work together in our pursuit to end all forms of malnutrition, invest in the Philippine Plan of Action for Nutrition 2017-2022!

MARIA-BERNARDITA T. FLORES Assistant Secretary of Health and Executive Director National Nutrition Council

viii

Acknowledgements Acknowledgement is due to the following organizations and individuals who provided support, shared their expertise, time and effort for the development of these studies, as well as to those who provided invaluable inputs through participation in the two consultation workshops held in August 2016: NATIONAL NUTRITION COUNCIL (NNC) Assistant Secretary of Health Maria-Bernardita T. Flores, Maria Lourdes Vega, Jovita Raval, Dianne Cornejo, Jasmine Tandingan, Strawberry Francia, Jana Culla and Benjamin Pretsch DEPARTMENT OF HEALTH (DOH) Dr. Joyce Ducusin, Dr. Anthony Calibo, Luz Tagunicar, Arlene Rivera, June Corpuz, Marissa Ortega, Lindsay Orsolino and Danica Galvan NATIONAL ECONOMIC AND DEVELOPMENT AUTHORITY (NEDA) Arlene Ruiz and Kevin Godoy DEPARTMENT OF BUDGET AND MANAGEMENT (DBM) Director Cristina Clasara and Nenita Cabral PHILIPPINES STATISTICS AUTHORITY (PSA) Mildred Addawe and Driesch Cortel FOOD AND NUTRITION RESEARCH INSTITUTE (FNRI) of the DEPARTMENT OF SCIENCE AND TECHNOLOGY (DOST) Dr. Imelda Angeles Agdeppa, Charmaine Duante, Apple Joy Ducay, Lilibeth Dasco and Dr. Eldridge Ferrer PHILIPPINE HEALTH INSURANCE CORPORATION (PHILHEALTH) Merla Rose Reyes, Dr. Robert Balaoing, Rodelyn Ang, Emylou Raymundo and Gemma Vecina COUNCIL OF THE WELFARE OF CHILDREN (CWC) Emmanuel Mapili NUTRITION CENTER OF THE PHILIPPINES (NCP) Dr. Mary Christine Castro WORLD VISION Gem Kathleen Macanan UNICEF Lotta Sylwander, Julia Rees, Dr. Willibald Zeck, Joris van Hees, Maria Evelyn Carpio, Dr. Rene Gerard Galera, Janice Datu-Sanguyo, Melvin Marzan, Ruth Francisco, Angelita Evidente, Dr. Raoul Bermejo, Manual Alexander Haasis, Dr. Pura Angela Wee-Co, Dr. Mariella Castillo, Dr. Andrew Bucu, Alvin Manalansan, Bianca Stella Bueno, Flora Sibanda-Mulder, and Christiane Rudert Recognition is also given to Mr. Jack Bagriansky, the international consultant whose technical expertise has made the completion of these studies possible.

Table of Contents Foreword

Message from the Cabinet Secretary

Message from the DOH

vii

Message from the NNC

viii

Acknowledgements

List of Tables

List of Figures

List of Annexes

xii

Acronyms and Abbreviations

xiii

Introduction and Rationale

National Nutrition Damage Assessment Report

A. Considering strategic approaches to the nutrition intervention scenario

B. NIS focus on nutrition-specific interventions

Components of the Proposed National Nutrition Intervention Scenario (NIS) Program A. Antenatal maternal package

B. Components of the NIS Child Package

C. Developing the capacity of barangay health stations nationwide

D. Multiple micronutrient powders and nutrition education delivered by the Pantawid Pamilyang Pilipino Program

E. Food fortification and mass media

F. Budget summary

Benefits and Benefit-Cost Ratio of the Proposed NIS Program

A. Benefits of the proposed NIS Program

B. Benefit-cost ratio of the NIS program

Annexes

List of Tables Table 2.1

Estimated attributable child deaths by age group

Table 2.2

Status quo: Annual economic losses per risk group categorized by indicator, prevalence and cases

Table 2.3

Distribution of economic burden by type of required intervention and indicator

Table 3.1

NIS Intervention Components

Table 3.2

Annual costs of the inputs to the NIS Antenatal Package

Table 3.3

Imputed value of RHU time and effort (in-kind) to deliver NIS antenatal package

Table 3.4

Costs of the inputs to the NIS Child Package

Table 3.5

Estimated value of RHU time and effort (in-kind) to deliver NIS Child Package

Table 3.6

Added workload to BHW/BNS in urban and rural barangays

Table 3.7

Estimated cost of total incentive to activate BHW/BNS network

Table 3.8

Estimated cost of support materials for BHW/BNS

Table 3.9

Estimate of additional cost to the Pantawid Pamilyang Pilipino Program

Table 3.10

Ten-Year NIS budget

Table 4.1

Annual benefits of the NIS at program scale by pathway

Table 4.2

Costs, benefits, and BCR of the proposed 10-year NIS program

List of Figures Figure 2.1

Distribution of economic losses by indicator

Figure 2.2

10 Nutrition-specific interventions

Figure 3.1

Association of timely introduction of complementary foods with key nutrition indicators

Figure 3.2

Coverage of Key Nutrition Interventions

Figure 3.3

Cost centers: A sectoral representation of budget perspective

List of Annexes

xii

ANNEX 1 Unit Prices for NIS Ingredients

ANNEX 2 Unit Value of RHU Time

ANNEX 3 Estimated Training Costs for ToT, RHU and BHS

ANNEX 4 Review of Potential Nutrition-Sensitive Interventions and Sectoral Programs

ANNEX 5 Weighted Average Cost for SAM Protocol

ANNEX 6 Losses and Benefits by Pathway

Acronyms and Abbreviations 4Ps

Pantawid Pamilyang Pilipino Program

MDD

minimum dietary diversity

ARI

acute respiratory infection

MNP

multiple micronutrient powder

BCR

benefit-cost ratio

NCP

Nutrition Center of the Philippines

BHS

barangay health station

NDHS

National Demographic Health Survey

BHW

barangay health worker

NEDA

National Economic and Development Authority

BNS

barangay nutrition scholar

NIS

nutrition investment scenario

DBM

Department of Budget and Management

NNC

National Nutrition Council

DOH

Department of Health

NNS

National Nutrition Survey

DOST

Department of Science and Technology

NPV

net present value

DRPI

Drug Price Reference Index

NTD

neural tube defect

DSWD

Department of Social Welfare and Development

ORS

oral rehydration salt

EAR

estimated average requirements

PhilHealth

Philippine Health Insurance Corporation

FAD

folic acid deficiency

per protocol

FDA

Food and Drug Administration

PPAN

Philippine Plan of Action for Nutrition

FDS

family development session

PSA

Philippine Statistics Authority

FNRI

Food and Nutrition Research Institute

RHU

rural health unit

GDP

gross domestic product

RUSF

ready-to-use supplementary food

HAZ

height-for-age Z score

RUTF

ready-to-use therapeutic food

IDA

iron deficiency anemia

SAM

severe acute malnutrition

IDD

iodine deficiency disorders

SGA

small for gestational age

IFA

iron folic acid

UNICEF

United Nations Childrenâ&#x20AC;&#x2122;s Fund

IYCF

infant and young child feeding

USI

universal salt iodization

LBW

low birth weight

VAC

vitamin A capsule

LGU

local government unit

VAD

vitamin A deficiency

LNS

lipid-based nutrition supplement

WAZ

weight-for-age Z score

MAM

moderate acute malnutrition

WHO

World Health Organization

medical doctor

WHZ

weight-for-height Z score

xiii

Business Case for Nutrition Investment in the Philippines

@UNICEF Philippines/2017/ATorralba

Introduction and Rationale Undernutrition is both a cause and consequence of poverty. Poverty and undernutrition are locked in a vicious cycle that includes child mortality and morbidity, poor health, retarded cognitive development and physical growth, diminished learning capacity and school performance, and ultimately, lower adult productivity and earnings. The negative impacts of undernutrition ripple across economies. This is by eroding the foundation of economic growth: peoples’ strength and energy, creative and analytical capacity, and initiative and entrepreneurial drive. Global scientific evidence strongly indicates that lowering the rates of undernutrition is highly indispensable to raising the quality of human resources and the value of human capital. In recent years, the gross domestic product (GDP) of the Philippines has been expanding by an average of over 6% annually, among the highest economic growth rates in Southeast Asia. However, the nation’s nutrition indicators continue to lag behind most countries in the region, creating a drain of about $4.5 billion per year from the national economy.1 Sustaining the country’s economic growth will require investments to lower the high prevalence of undernutrition in the country and promote human capital development. Beyond moral and humanitarian rationales, the high cost of doing nothing to lift the economic burden of undernutrition in the Philippines is a compelling economic argument for taking urgent action.2 Using available effective and affordable interventions, public investments to address the burden of undernutrition can be highly cost-effective. Based on a recent review of the economic returns of various development investments, an expert panel at the Copenhagen Consensus Center identified lowering chronic malnutrition by 40% as the top best value-formoney global development target over the period 2016 to 2030.3 Because effective interventions for addressing undernutrition are affordable and the economic cost of undernutrition is high, nutrition investments can have very high returns.4

Department of Health/National Nutrition Council/UNICEF, 2017, ‘Economic Cost of Undernutrition in the Philippines: A Damage Assessment Report (DAR)’. UNICEF Philippines.

Obesity is a type of malnutrition that represents a growing area of concern in the Philippines. However, this is beyond the scope of this paper, which focuses on undernutrition only.

The Copenhagen Consensus Center is composed of a group of economists including four Noble Prize laureates. To assess the economic returns of various development investments, the expert panel of the Center recently reviewed over 100 papers by 82 of the world’s top economists and 44 sector experts. For more details, visit http://www. copenhagenconsensus.com/post-2015-consensus/nobel-laureates-guide-smarter-global-targets-2030.

For instance, according to the expert panel of the Copenhagen Consensus Center, for every dollar invested on nutrition in the first 1,000 days of a child’s life to reduce stunting can save around $153 in future earnings. https://www.theguardian.com/global-development-professionals-network/2014/nov/28/every-dollar-spent-on-childhood-nutrition-cansave-up-to-166.

I N T R O D U C T I O N A N D R AT I O N A L E

This report presents a financial case for nutrition investment in the Philippines. It outlines the rationale for investing in a national nutrition program and potential ways forward for the Philippine government to improve nutrition status, especially among the most vulnerable groups. This report also provides the following: •

•

A discussion of the national economic implications of the current national nutrition status in the Philippines (Section II). The current prevalence of undernutrition in the country has an economic cost of around $4.5 billion per year in lost earnings. An accompanying document to this report entitled ‘Economic Cost of Undernutrition in the Philippines: A Damage Assessment Report (DAR)’5 discusses this estimate in more detail. An outline of an evidence-based intervention package to address the structure of the national damage. Section III of this report describes a program for a generic and hypothetical scenario for the Philippines, the ‘Nutrition Intervention Scenario’ (NIS), including 15 distinct interventions involving public and private primary health care centers, community nutrition workers and volunteers, the Pantawid Pamilyang Pilipino Program (4Ps) involving low income families, and private industries and the media.

•

Conceptual budgets for individual interventions of the NIS program based on parameters appropriate to the Philippines and a coverage scenario of 90%. It provides a general outline of the resource requirements of the NIS program, amounting to around $113 million per year. This includes a government share of about $73 million per year. The remainder will be covered by the marketplace and includes the value of time and effort by health workers.

•

A discussion of the estimated benefits of the NIS based on global scientific evidence of effectiveness. The benefits include: returning US$1.5 billion per year to the national economy, and preventing the deaths of nearly 14,000 children under five years of age. The estimated net benefits of NIS over a 10-year period is around US$12.8 billion. Benefit-cost ratios (BCRs) indicate that for each dollar investment to address undernutrition, there is a return of US$12.

Throughout a series of meetings, consultations and a technical workshop, this report, along with the DAR, benefitted from the inputs provided by national experts and stakeholders and the World Bank.6 The methodology, data and assumptions of the DAR were reviewed during a technical workshop. The NIS entails countering the economic impact of undernutrition with an affordable and effective yet generic national program. The presentation of the NIS includes some specific assessments on interventions and makes some detailed budget estimates. However, this should be considered a generic or “conceptual” analysis - sufficient to drive the computer modeling necessary to make general projections. It does not provide detailed operational plans and budgets. Nevertheless, this financial case endeavors to understand and adapt the NIS to the national and local contexts, and present a concrete framework for the Philippine government and its development partners to consider, discuss, develop and improve upon. It is the hope of the National Nutrition Council (NNC), the Department of Health (DOH) and the United Nations Children’s Fund (UNICEF) that this financial case for nutrition investment will serve as a useful tool as the country continues to consider investment in public nutrition services as a significant component of national social and economic development. It will assist public and private stakeholders in the roll-out of the Philippine Plan of Action for Nutrition (PPAN) 2017-2022.

Department of Health/National Nutrition Council/UNICEF, 2017, ‘Economic Cost of Undernutrition in the Philippines: A Damage Assessment Report (DAR)’. UNICEF Philippines.

The national stakeholders include the Department of Health (DOH), National Nutrition Council (NNC), National Economic Development Authority (NEDA), the Food and Nutrition Research Institute (FNRI), Philippine Health Insurance Corporation (Philhealth), Philippine Statistics Authority (PSA), Department of Budget and Management (DBM), and the Nutrition Center of the Philippines (NCP).

I N T R O D U C T I O N A N D R AT I O N A L E

National Nutrition Damage Assessment Report In the Philippines, data from recent national surveys indicate that undernutrition represents a significant barrier to the country’s human capital development—a key input to economic growth.7 Fourteen indicators of undernutrition estimate over 28 million cases of stunting, wasting, micronutrient deficiencies and other undernutrition issues in the country. For each indicator, scientific evidence suggests serious survival and health risks. Evidence also points to deficits in cognitive development, physical growth, learning capacity and student performance, and ultimately, lower work productivity and earnings.

The cost of doing nothing for 2015 is measured across the following four discrete pathways:

Affecting a significant portion of the country’s population, particularly women and children, the economic burden emerging from undernutrition ripples across the Philippine economy. Undernutrition erodes the human capital that lays the foundation of economic growth: peoples’ strength and energy, creative and analytical capacity, and initiative and entrepreneurial drive.

The NPV of depressed adult productivity due to deficits in child growth and cognition is measured across several indicators of undernutrition, including childhood stunting, anemia and iodine deficiency disorders. The NPV of this future productive potential lost to undernutrition in 2015 is projected at around $3.1 billion per year.

Based on the current prevalence rates for these 14 indicators of undernutrition, along with the globally established coefficients of risk and deficit, the damage assessment report estimates the cost of doing nothing or the Future Economic Losses (FEL) from current rates of undernutrition using national demographic, health, economic and labor statistics.

PATHWAY #1 The net present value (NPV) of the forgone future workforce lost due to child mortality attributable to undernutrition is measured across five indicators of undernutrition: i) poor maternal nutrition status, ii) maternal underweight, iii) suboptimal breastfeeding, iv) zinc deficiency, and v) vitamin A deficiency. About 38% of child mortality in the country can be attributed to these indicators (Table 2.1). The NPV of the economic losses due to the 29,000 lives lost in 2015 is estimated at around $667 million per year. PATHWAY #2

PATHWAY #3 The current value of depressed productivity among anemic adults working in agriculture, industry and other employment manual labor is projected at $233 million per year. PATHWAY #4 The current value of excess and preventable healthcare utilization due to zinc deficiencies, suboptimal breastfeeding and low birthweight is around $379 million per year.

Food and Nutrition Research Institute of the Department of Science and Technology (FNRI-DOST), 2013, ‘8th National Nutrition Survey,’ Taguig City: FNRI-DOST.

N AT I O N A L N U T R I T I O N D A M AG E A S S E S S M EN T R E P O R T

TABLE 2.1 Estimated attributable child deaths by age group

AGE GROUP AND INDICATOR

NUMBER OF DEATHS

ADJUSTED NUMBER OF DEATHS*

RISK GROUP (%)

1. Maternal nutrition status

6,187

5,462

2. Maternal folic acid deficiency (FAD) neural tube defect (NTD)

3,774

3,331

3. Suboptimal breastfeeding, less than 1 month

1,353

1,195

4. Suboptimal breastfeeding, 1–5 months

5,376

4,746

16,690

14,734

1,900

1,506

404

320

7. Underweight (weight-for-age Z score)

7,279

5,771

8. Wasting (weight-for-height Z score)

5,057

4,009

9. Vitamin A deficiency (VAD)

1,815

1,438

10. Zinc deficiency

2,249

1,783

Subtotal (5 + 6 + 7 + 8 + 9 + 10)

18,704

14,827

C. CHILDREN UNDER AGE 5 (A + B)

35,395

29,561

A. CHILDREN, 0–5 MONTHS

* Statistically adjusted to account for overlapping cases of undernutrition.

Subtotal (1 + 2 + 3 + 4) B. CHILDREN, 6–59 MONTHS 5. Suboptimal breastfeeding, 6-24 months 6. Handwashing

The undernutrition status quo is estimated at around $4.5 billion per year (equivalent to around 1.5% of 2015 GDP, see Table 2.2). The full analysis is available in the accompanying document to this report entitled ‘Economic Cost of Undernutrition in the Philippines: A Damage Assessment Report (DAR)’.8 The burden of undernutrition represents a substantial drag on national economic growth, a loss of human capital that significantly diminishes the potential of other national investments in education, manufacturing, technology and other key sectors to achieve optimal returns. Over the next decade, a growing economy and associated improvement in diet and living conditions will doubtless

work to lower this annual burden of undernutrition in the Philippines. However, indicators of nutrition status respond slowly to economic growth. A World Bank analysis including reviews of nutrition and economic growth in 79 countries concluded “that income growth can play an important role in malnutrition reduction, but it is not enough. Increases in the number and effectiveness of direct nutrition interventions have a crucial role to play if nutrition goals are to be met.”9 Counting on the benefits of economic growth to lift the burden of undernutrition is not sufficient to meet the Philippines’ national economic, social, health, nutrition and other development objectives.

Department of Health/National Nutrition Council/UNICEF, 2017, ‘Economic Cost of Undernutrition in the Philippines: A Damage Assessment Report (DAR)’. UNICEF Philippines.

Alderman, H., et al., 2003, “Reducing child undernutrition: How far does income growth take us?,” World Bank Economic Review, (17)1:107-31.

N AT I O N A L N U T R I T I O N D A M AG E A S S E S S M EN T R E P O R T

TABLE 2.2 Status quo: Annual economic losses per risk group categorized by indicator, prevalence and cases

* Includes estimated losses in future earnings, current productivity and cost of preventable diseases due to undernutrition.

RISK GROUP AND NUTRITIONAL ISSUE AND INDICATOR

PREVALENCE (%)

CASES

LOSSES* ($ MILLION)

Low BMI

24.8

619,611

346

Low height/stunting

42.7

1,066,831

Anemia

25.2

629,605

Folic acid deficiency

53.6

1,339,160

Iodine deficiency

14.4

1,451,244

PREGNANT WOMEN AND NEWBORNS Maternal nutrition deficit

546

CHILDREN, UNDER 5 YEARS Infant and child care Non-exclusive breastfeeding

241

0-6 months

51.2

1,208,215

6-59 months

46.8

1,623,830

Maternal hygiene

10.2

1,150,420

21.5

2,166,788

222

7.1

715,544

33.4

3,366,080

2,292

Vitamin A deficiency

20.4

2,055,929

Zinc deficiency

21.6

2,176,866

180

Child Anemia

21.0

2,113,038

282

Anthropometry Underweight Weight for height Stunting Vitamin and mineral deficiency

ADULT Adult anemia Women Men

233 14.5

4,628,285

6.0

1,958,005

TOTAL

4,411

A. CONSIDERING STRATEGIC APPROACHES TO THE NUTRITION INTERVENTION SCENARIO Nutrition interventions to lower the current burden are urgently required. And optimizing the physical and intellectual work potential of the nationâ&#x20AC;&#x2122;s work force will be key to fueling additional economic growth. At nearly $4.5 billion per year, the cost of doing nothing is too high to ignore. The structure of the national economic burden of undernutrition projected by the DAR provides some insights into potential interventions.

N AT I O N A L N U T R I T I O N D A M AG E A S S E S S M EN T R E P O R T

Child underweight and wasting, traditional indicators of undernutrition, account around 5% of the overall economic burden (Figure 2.1). An estimated 1 million children suffering from severe acute malnutrition (SAM) or moderate acute malnutrition (MAM) each year require urgent care as they face grave danger. While the risks of mortality and morbidity are not as high and deficits are more modest in the short term, the widespread prevalence of other subclinical or “hidden” cases represent a significant share of the national burden of undernutrition now and in the future. The bulk of economic damage emerges from maternal nutrition and behaviors, micronutrient deficiencies, and more seriously, from the long-term irreversible impact of stunting—low stature attributed to chronic malnutrition in childhood.

Moreover, the importance of maternal nutrition status prior to conception and in the first weeks of pregnancy indicates the need for broad population-wide interventions outside the 1,000-day window of acute risk (from pregnancy until the child reaches 24 months). For example, folic acid, iron or iodine supplementation in pregnancy often begins too late to fully protect against associated birth defects, low birthweight deliveries or cognitive impairment.10 Undernutrition emerges from the quantity, quality, and affordability of food, as well as diet and caregiving behaviors. Table 2.3 shows that 6% of the economic burden of

Wasting and underweight

14%

Micronutrient deficiencies

Stunting

52%

29%

This suggests that while SAM and MAM treatment interventions are urgent and necessary from moral and medical perspectives, these interventions are not enough to address the burden of undernutrition to the national economy. Prevention interventions are also therefore urgent and important. While most interventions targeting infants and children are channeled via primary caregivers, usually mothers, about 32% of the projected burden of undernutrition is attributed specifically to maternal nutrition status, maternal behaviors related to hygiene, sanitation and feeding practices, and over-all adult anemia– not to undernutrition measured in the children themselves. This suggests that addressing about one-third of the burden created by undernutrition in children requires targeting mothers’ health, diet and behavior, in addition to interventions targeting children and infants.

Maternal nutrition and behavior

FIGURE 2.1 Distribution of economic losses by indicator

52%

Stunting

29%

Micronutrient deficiencies

14%

Maternal nutrition and behavior

Wasting and underweight

undernutrition reported in the DAR can be addressed by nutrition education and behavior change strategies, including improving breastfeeding and maternal hygiene practices. Another one-third is associated with micronutrient deficiencies emerging mainly from a low quality diet – and addressed by micronutrient supplementation and fortification strategies for overall population and most vulnerable groups (i.e. children and pregnant and lactating women) as well as infant and young child feeding (IYCF) and nutrition education. Addressing the remaining half of the burden includes education and micronutrient strategies but may also require food supplements with balanced energy-protein, and complementary food supplements with micronutrients and essential fatty acids, particularly for the highest risk pregnant women and children. B. NIS FOCUS ON NUTRITION-SPECIFIC INTERVENTIONS The types of interventions outlined above—food supplements, pharmaceuticals or education or social marketing for behavior change—focus on the proximal causes of undernutrition. These are commonly referred 10 http://www.unsystem.org/SCN/archives/npp19/ch08.htm

N AT I O N A L N U T R I T I O N D A M AG E A S S E S S M EN T R E P O R T

TABLE 2.3 Distribution of economic burden by type of required intervention and indicator * Total exceeds 100% due to rounding.

to as nutrition-specific interventions. However, to reduce the burden of undernutrition, nutrition-sensitive interventions are required.11 Nutritionsensitive interventions are those that are targeted towards addressing the underlying determinants of undernutrition, including food insecurity, low agricultural productivity and gender inequality as well as inadequate access to a health, water, and sanitation services. Widespread undernutrition implies a multisectoral failure. It requires a nutrition-sensitive approach that seeks to integrate and promote nutritionfocused policies and programs across different sectors that can impact nutrition. These include agriculture, social protection, health, education, transport, public works, water and sanitation, and other sectors that can take specific actions to improve nutrition. A recent review by the Lancet Maternal and Child Study Group indicates that the evidence on the impact of nutritionsensitive programs on nutrition remains limited.12 The group suggests a research agenda that will establish evidence on the feasibility and impact of nutrition-sensitive programs. In 2014, a nutrition mortality modeling exercise by an independent expert group (consisting of the Lancet Nutrition Interventions Review Group and the Maternal and Child Nutrition Study Group) concluded that the marginal impact of additional nutrition-sensitive interventions was due to “the relatively small effects of these interventions on stunting, wasting, and small for gestational age (SGA) births in the 11 Ruel, M.T., et al., 2013, “Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition?,” The Lancet, 382(9891):536–551. 12 Ruel, M.T., et al., 2013, “Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition?,” The Lancet, 382(9891):536–551. 13 Bhutta, Z., 2014, ‘Lives Saved Tool (LiST) Analysis for Global Nutrition Report Independent Expert Group,’ http://www. globalnutritionreport.org 14 Annex 4 reviews the potential programs.

TYPE OF INTERVENTION AND INDICATOR

SHARE IN TOTAL BURDEN (%)*

Nutrition education and behavior change

Breastfeeding

Maternal hygiene

Nutrition education plus micronutrient supplementation FAD birth defects IDD

31 2 12

Zinc deficiency

Vitamin A deficiency

Child anemia

Adult anemia

Nutrition education, behavior change, micronutrient supplementation, plus a focus on high risks with treatment and food supplementation Maternal nutrition status Stunting Underweight/wasting

7 52 5

current models.”13 In addition to this lack of a fully elaborated evidence-base, there are few national-scale implementation and financing models for nutrition-sensitive interventions. For these reasons, nutrition sensitive interventions are mainly not included in this financial case.14 In contrast to the more comprehensive or holistic nutritionsensitive approach, nutrition-specific interventions can be brought to scale in the short and medium term. These tend to involve simple, affordable and proven interventions with substantial evidence showing effectiveness in lowering the prevalence of specific indicators. These interventions are often delivered via the health system, community platforms or social mobilization strategies, as well as food fortification (where market systems are well developed). Implementation experience is deep and operational and financial models are relatively clear. With sufficient political and financial commitment these interventions can be organized, implemented and produce results within a relatively short period of time. While planning for a range of nutritionsensitive strategies should continue to explore the underlying multisectoral causes of undernutrition, given the urgent needs indicated by the DAR, the cost of the status quo is too great to ignore. Short and medium term interventions are imperative. Therefore, this financial case focuses on nutrition-specific interventions where evidence of impact will enable setting objectives that are specific, measurable, attainable, realistic, time-bound (SMART) and results-based, while clear implementation pathways will enable developing reasonable cost estimates. Cost-benefit estimates can guide policydecision making.

N AT I O N A L N U T R I T I O N D A M AG E A S S E S S M EN T R E P O R T

FIGURE 2.2

10 NUTRITION-SPECIFIC INTERVENTIONS

Maternal nutrition education during pregnancy

Micronutrient supplementation in pregnancy

Balanced energy and protein in pregnancy (as needed)

Promotion of exclusive and continued breastfeeding

Complementary feeding education (for food secure)

Vitamin A supplementation: child 6-59 months

Complementary food supplementation (for food insecure)

Preventative zinc supplementation: child 12-59 months

Components of the Proposed National Nutrition Intervention Scenario (NIS) Program Recently, the second Lancet Maternal and Child Undernutrition Series (2013) published findings of the international expert group that reviewed evidence for a range of nutrition specific interventions (Bhutta et al, 2013). The group projected impact for a package, which consists of the 10 nutrition-specific interventions on child mortality, stunting and other indicators (Figure 2.2). A simulation model based on data from 34 countries (including the Philippines) indicates that if these 10 interventions were to be scaled up to cover 90% of each population, stunting, prevalence could be reduced by an average of 20.3%. The simulation exercise also suggests that it could reduce child mortality from severe wasting by 79%, child mortality from diarrhea by 35% and child mortality from respiratory diseases by 29%.15 In this financial case, the national NIS program builds on this 10-intervention model to develop a package of 15 nutrition-specific interventions. The selection of the following NIS components is guided by widely accepted global evidence of feasibility and impact, as well as national program environment, experience and capacity for intervention in the Philippines. These components are outlined in Table 3.1. Five-component antenatal package: Builds on the current package of antenatal services to reach pregnant women with pharmaceuticals, nutrition education, and balanced protein energy food supplements for the highest risk groups. Seven-component child package: Targets children under five years old with zincenhanced diarrhea treatment, breastfeeding

15 Bhutta, Z., et al., 2013, â&#x20AC;&#x153;Evidence-based interventions for improvement of

Management of severe acute malnutrition (SAM)

Management of moderate acute malnutrition (MAM)

maternal and child nutrition: What can be done and at what cost?,â&#x20AC;? The Lancet, 382(9890): 452â&#x20AC;&#x201C;477.

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TABLE 3.1 NIS Intervention Components

INTERVENTION COMPONENT

TARGETING STRATEGY

DELIVERY MECHANISM

Iron folic acid supplements

Universal

RHU with BHS/4Ps support

Deworming treatment

Universal

RHU

Anti-malarial treatment

High risk (~10%)

RHU

Protein energy supplement

High risk (~13%)

RHU with BHS support

Education and promotion

Universal

ANTENATAL MATERNAL PACKAGE

CHILD PACKAGE Breastfeeding promotion

Universal

RHU and BHS/4Ps

IYCF

Universal

RHU

Zinc treatment diarrhea

All cases

RHU

SAM management

Identified/referred cases (2.5%)

RHU and BHS

MAM management

Identified/referred cases (2.5%)

RHU and BHS

VAC/Deworming

Universal

RHU and BHS

Zinc and Iron (MNPs) supplementation

Lowest income (25%)

4Ps CCT

Flour fortification

Market: (~60%)

Private sector with FDA

Salt iodization

Market: (>90%)

Private sector with FDA

Mass media

National coverage

DOH-NNC and private sector

INTERGENERATIONAL ADULT PACKAGE

RHU BHS 4Ps IYCF

— rural health unit — Barangay Health Station — Pantawid Pamilyang Pilipino Program — infant and young child feeding

promotion, and complementary feeding promotion, vitamin supplements and home food-based fortification of complementary food, as well as identification, referral and treatment of MAM and SAM. Three-component, population-wide, intergenerational food fortification package: In the Philippines, food fortification to deliver populationwide protection as well as mass media to encourage positive nutrition behaviors are feasible and effective among the general population.

SAM — severe acute undernutrition MAM — moderate acute malnutrition VAC — vitamin A capsule MNP — multiple micronutrient powder

FDA — Food and Drug Administration DOH-NNC—Department of HealthNational Nutrition Council

A. ANTENATAL MATERNAL PACKAGE The DAR projects estimates that nearly 8,793 deaths (around 30% of child deaths) is attributable to deficits in maternal nutrition status, as defined by four indicators: low BMI, short stature, anemia and folic acid deficiencies. The 2013 National Nutrition Survey (NNS) classifies about 25% of pregnant women as “nutritionally at risk.” This is despite the frequent and widespread antenatal contacts among pregnant women with the health system during their pregnancy. For instance, over 90% of pregnant women had antenatal care in 2013; more than 85% had four or more contacts with health professionals; and in more than two-thirds of cases, antenatal care started during the critical first trimester. Height and

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weight measurements and blood pressure were taken in 95-97% of cases; around 80% received tetanus toxoid; and more than half underwent urinalysis and blood tests. Building on this wide outreach and high coverage of non-nutrition-related antenatal products and services, the proposed NIS includes a package of evidence-based nutrition-related antenatal products and services to be delivered by the rural health unit (RHU) and barangay health station (BHS), and supported with strategic use of mass media. Universal iron folic acid supplementation.16 The World Health Organization (WHO) recommends universal preventative iron folic acid (IFA) supplementation as part of antenatal care. A Cochrane Review concludes that both daily and intermittent supplementation reduces iron deficiency anemia by 67% and the incidence of low birthweight by 19%.17 Substantial evidence also links folic acid supplementation with 72% reduction of neural tube defects, which is associated with around 3,300 child deaths annually in the country according to the DAR.18 While provision of IFA supplements is part of the official antenatal care protocol, distribution is far from universal. Although around 85% of pregnant Filipino women receive iron supplements during antenatal consultations, only less than 20% receive the recommended IFA supplements. Challenges on the compliance with iron supplementation are well known worldwide. According to the 2013 Philippine National Demographic and Health Survey (NDHS), only 47% of women receiving supplements report consuming 90 tablets (or the minimum effective dosage).19 Moreover, while iron supplementation addresses underlying iron deficiency, malaria and helminths are also causes of anemia. Coverage of deworming tablets among pregnant women is reported at less than 5%.

which must be taken on a daily basis over the course of pregnancy, requires motivation and education to explain the threats, the requirements, and discuss possible side effects. The proposed NIS program provides adequate financing to ensure supply of IFA during antenatal contacts, as well as active education to ensure compliance with the supplementation regime. The education component includes: counseling by nurse-midwife during antenatal sessions, supported take-home materials; follow-up at the community and household levels by the barangay health worker (BHW); and intermittent regional and national communication and mass media support. Universal nutrition education (no food supplement) Poor maternal nutrition status (i.e., low weight, short stature and poor micronutrient status) increases the risk of premature delivery, low birthweight and birth defects.20 In addition to lack of access to sufficient and quality diet, there is a range of behavioral and other contextual factors that contribute to poor maternal nutrition status.

Implementation of the proposed NIS program will include improvements to the procurement and distribution systems, as well as overall program enhancements, including rigorous monitoring and surveillance. For optimal effectiveness, provision of supplements, @UNICEF Philippines/2014/KatPalasi

16 While the basic package modeled in the Lancet series includes calcium supplementation, the proposed NIS program excludes it mainly because evidence of its positive impact on child mortality is lacking. Also, the recommended protocol (i.e., consisting of large doses three times daily during pregnancy) is both complicated and costly, with no established program experience at scale. 17 Peña-Rosas J.P., et al., 2012, “Intermittent oral iron supplementation during pregnancy,” Cochrane Database of Systematic Reviews, 2012(7):CD009997. 18 De-Regil L.M., et al., 2010, “Effects and safety of periconceptional folate supplementation for preventing birth defects,” Cochrane Database of Systematic Reviews, 2010(10):CD007950. 19 Philippine Statistics Authority (PSA) and ICF International, 2014, ‘Philippines National Demographic and Health Survey 2013,’ Manila, and Maryland: PSA and ICF International. 20 WHO e-Library of Evidence for Nutrition Actions (eLENA), 2013, ‘Nutrition counselling during pregnancy: Biological, behavioural and contextual rationale,” http://www.who.int/ elena/bbc/nutrition_counselling_pregnancy/en.

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@UNICEF Philippines/2016/ShehzadNoorani

According to the 2013 NNS, over 18% of the mothers interviewed consider nutritionrelated concerns as an important factor in seeking out antenatal care (advice on proper diet, micronutrient supplement and weight monitoring).23 Nevertheless, despite high coverage of many components of antenatal care, only 44% of pregnant women report receiving nutrition counseling during antenatal consultation. Discussions with national stakeholders did not identify a comprehensive national program with specific behavioral objectives, achieved by delivering a set of field-tested messages and support materials. The NIS program includes nutrition education as an integral part of antenatal counseling: counseling by nursemidwife during antenatal sessions; supportive take-home materials; follow-up at community and home level by BHWs; and intermittent regional and national communication and mass media support.

Nutrition education and counseling focusing on enhancing quantity and quality of foods in the normal diet, educating women on which foods and what quantities they need to consume in order to achieve optimal dietary intake is a proven approach to improving birth outcomes. A systematic review of 13 studies providing antenatal dietary advice found that nutrition advice alone was sufficient to improve protein intakes during pregnancy, reduce the risk of preterm birth by 54% and increase head circumference at birth.21 A meta-analysis covering 34 studies finds that nutrition education and counseling improve gestational weight gain by 0.45 kg, reduce the risk of anemia in late pregnancy by 30%, increased birthweight by 0.105 kg, and lower the risk of preterm delivery by 19%.22 Nutrition education targeting pregnant women can also include counseling on the use of micronutrient supplements and demand creation of activities to encourage full utilization of health care services for pregnancy and delivery.

Balanced protein energy for nutritionally at-risk pregnant women. While several studies suggest that nutrition education alone can achieve a significant impact, evidence from multiple studies shows that in food insecure populations, balanced protein energy supplementation resulted in a significant 34% reduction in the risk of small for gestational age among infants, especially in the food insecure areas and in malnourished women.24 The Food and Nutrition Research Institute’s (FNRI) food consumption survey indicates that two-thirds of Filipinos are consuming insufficient calories (even when there are no emergencies), 40% consume below the recommended levels of protein, and intakes of seven required micronutrients are only about 9% of the level recommended by the WHO.25 In addition to the high prevalence rate of nutritionally at-risk pregnant women (24.8%), these dietary deficits suggest that for many women, the risk of food insecurity and malnutrition during the antenatal period is likely high. With more than 90% of pregnant women seeking antenatal care, and 95% of these were weighed and measured at RHUs or BHS,

21 Ota, E., et al., 2012, “Antenatal dietary advice and supplementation to increase energy and protein intake,” Cochrane Database of Systematic Reviews, 2012(9):CD000032. 22 Girard A.W. and O. Olude, 2012, “Nutrition education and counselling provided during pregnancy: effects on maternal, neonatal and child health outcomes,” Paediatric and Perinatal Epidemiology, 26(s1):191-204. 23 FNRI-DOST, 2016, ‘8th National Nutrition Survey,’ Taguig City: FNRI-DOST. 24 Imdad, A. and Z.A. Bhutta, 2011, “Effect of balanced protein energy supplementation during pregnancy on birth outcomes,” BMC Public Health, 11(s3):S17. http://www. biomedcentral.com/1471-2458/11/S3/S17. 25 FNRI, 2016, ‘2015 Food Consumption Among Filipino Households, 2016,’ Powerpoint presentation during the Dissemination Forum.

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most nutritionally at-risk women are identified during pregnancy. This offers an opportunity for targeted and timely intervention. While the most appropriate protocol has not been developed for the Philippines, the proposed NIS intervention includes a 150-dose box of lipid-based nutrition supplement (LNS) formulated for pregnancy to be distributed to each pregnant woman identified as “nutritionally at risk” at the RHU (a multisectoral consensus definition for “nutritionally at risk” has yet to be developed). LNS is recommended as opposed to distributing fortified staple cereals or specially formulated super cereals because of evidence showing higher effectiveness in community settings as well as significant associated logistics, distribution and other and supply challenges of bulky and weighty grain products.26 27

TABLE 3.2

Conceptual budget for antenatal package The generic budget developed for NIS indicates an annual cost of around $11.8 million to reach 90% of pregnant women with the model antenatal package of products and services (Table 3.2). This $11.8 million includes the budget for procuring pharmaceuticals, as well as for producing communication materials. In addition to this, the value of time and effort by medical doctors, nurses and midwives at RHUs is estimated at around $6.4 million (Table 3.3; media and BHS contributions budgeted in other sections of this report).

Annual costs of the inputs to the NIS Antenatal Package

INTERVENTION

TARGETING STRATEGY

90% COVERAGE

UNIT28

QTY

$ PER UNIT

$ PER PP

TOTAL ($)

IFA capsule

Universal

2,248,589

IFA Pills

180

0.0123

2.22

4,985,162

Deworming

Universal

2,248,589

Mebendazole

0.0304

0.03

68,357

LNS supplementation

At-risk: 13%29

278,825

Carton LNS

1.65

19.80

5,520,737

Antimalarial

High risk: 10%

224,859

Per protocol

0.06

0.12

26,598

Nutrition education

Universal

Communication materials

0.53

1,180,509

2,248,589

ALL INTERVENTIONS

TABLE 3.3

11,781,363

Imputed value of RHU time and effort (in-kind) to deliver NIS antenatal package30

INTERVENTION

TARGETING STRATEGY

90% COVERAGE

CONTACTS PP PER YEAR

$ PER UNIT

$ PER YEAR

TOTAL ($)

IFA capsule

Universal

2,248,589

0.07

0.22

485,898

Deworming

Universal

2,248,589

0.07

161,966

LNS Supplementation

At-risk: 13%31

278,825

1.07

3.21

895,945

Antimalarial

High risk: 10%

224,859

0.07

16,197

Nutrition education

Universal

2,248,589

1.07

2.14

4,816,908

ALL INTERVENTIONS

IFA — iron folic acid LNS — lipid-based nutrition supplement PP — per protocol

6,376,913

26 Webb, P., et al., 2011, ‘Delivering Improved Nutrition: Recommendations for Changes to U.S. Food Aid Products and Programs,’ Tufts University. 27 Thakwalakwa, C.M., et al., 2015, “Impact of lipid-based nutrient supplements and corn–soy blend on energy and nutrient intake among moderately underweight 8–18–month-old children participating in a clinical trial,” Maternal & Child Nutrition, 11(s4):144–150. 28 Unit prices were obtained from either DOH’s Drug Price Reference Index (DPRI) or the UNICEF Procurement Copenhagen. See Annex 1 for more details. Includes additional 10% to account for wastage, and 20% to cover distribution costs. 29 The clinical standard for nutritionally at-risk children is not defined. Discussions with stakeholders suggest using a more flexible standard using the findings of the FNRI survey that 24.5% of children under five are nutritionally at-risk. 30 Unit value of time is based on the ‘Philhealth Maternity Care Package Costing Study’ shown in Annex 2. 31 The clinical standard for nutritionally at-risk is not defined, but discussions with stakeholders suggest using a more flexible standard that used by FNRI survey finding 24.5% nutritionally at-risk.

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@UNICEF Philippines/2016/ShehzadNoorani

B. COMPONENTS OF THE NIS CHILD PACKAGE The NIS program includes a package of evidence-based products and services mainly targeting children 6-24 months to be delivered by a coordinated effort of RHU and BHS and supported by strategic use of mass media. The 2013 Philippine NDHS suggests that current health care utilization patterns offer the opportunity to deliver some key interventions. Multiple vaccinations reach over 90% of children during the first six months of life, suggesting multiple contacts with health workers. Although coverage of measles and other vaccines drops to 70-80% after six months, contacts with the health care system for diarrhea, respiratory and other childhood illness likely rise. In addition to integrating NIS with mother-child contacts at the RHU, the NIS package of child nutrition interventions will likely require building capacity to reach out at the community level through the BHWs or barangay nutrition scholars (BNS). Twice annual vitamin A supplementation NNS 2013 reports prevalence of vitamin A deficiency in children 6-59 months over 20% and DAR projects around 1,400 associated deaths. A Cochrane review of 43 randomized trials finds that vitamin A supplementation reduces overall child mortality by 24% and diarrhea-related mortality by 28% among children aged 6–59 months. There is some evidence, albeit insufficient, that vitamin A supplementation reduces both the incidences of diarrhea and measles. High dose vitamin A capsules are currently distributed by a mix of campaign-style events, along with routine health system contacts. Although DOH policy is clear and the program initiated more than two decades ago, the DOH Annual Report for 2014 shows coverage of only 44%. NIS modeling assumed coverage can reach 90% of children with two annual high dose vitamin A capsules. Combined zinc ORS treatment for diarrhea Evidence suggests that zinc supplementation, as part of diarrhea treatment, reduces child mortality by 46% and lower diarrhea-related hospital admissions by 23%.32 Currently, the DOH reports 77% of childhood diarrhea contacts receiving oral rehydration salt (ORS), but only 44% of contacts receiving the recommended zinc. The NIS program includes zinc therapy as a part of current ORS distribution at all primary health contacts. This protocol would target the approximately 42%, or 8-9 million annual diarrhea cases expected to seek care at RHU or other health facilities.33 For cases not accessing health professionals, NIS includes media based nutrition education with the aim of expanding market supply and demand of ORS/zinc pack via pharmacies and other appropriate outlets.

breastfeeding, and continued breastfeeding is practiced by only 57% of mothers.35 Moreover, analysis of the 2013 NNS results suggests that over 20% of children 1-5 months of age are not breastfed at all – and consequently face high risks of mortality, morbidity and growth deficits.36 The DAR estimates that nearly 7,500 annual deaths (25% of the nutrition-attributed child mortality) are due to suboptimal breastfeeding. Even though the national surveys find that over 90% of mothers understand that “the breast is best,” these same surveys indicate that “intention to breastfeed” is low at a range of about 21-29%, depending on the age of the mother.37 In parallel, use of breast milk substitutes is

32 Salam R.A., et al., (2013) “Effectiveness of micronutrient powders (MNP) in women and children,” BMC Public Health, 13(3):1. 33 See the DAR for more details. 34 Horta, B.L., et al., 2007, “Evidence on the long-term

Breastfeeding promotion Among a long list of benefits, evidence from both developing and developed countries shows the critical lifesaving significance of exclusive breastfeeding during the first six months of life as well as of continued breastfeeding to 2 years of age.34 Less than half of Filipino children enjoy the protection of exclusive

effects of breastfeeding: Systematic review and meta-analysis,” WHO. 35 FNRI-DOST, 2015, ‘8th National Nutrition Survey,’ Taguig City: FNRI-DOST. 36 See the DAR. 37 FNRI-DOST, 2015, ‘8th National Nutrition Survey,’ Taguig City: FNRI-DOST.

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widespread with the 2015 NNS update reports 37% of 6-11 month olds and 43% of 11-23 month olds are fed with breast milk substitutes.38

weight and height in both food secure and food insecure populations.41 The IYCF promotion, as part of the full Lancet modeled package, is considered a significant component in stunting reduction and is included in the NIS package via multiple channels: counseling at RHU, follow-up via BHS and 4Ps FDS, as well as supporting mass media.

The NIS program includes a more intensive breastfeeding education and promotion using multiple channels – antenatal and postnatal primary health care contacts; follow-up via BHS in the community or in the home; enhancing breastfeeding components of the 4Ps Family Development Sessions (FDS); and supportive mass media campaign channels. A 2011 review of multiple studies from multiple countries concluded that counseling and other breastfeeding promotion activities increased exclusive breastfeeding by 30% to 1 month, and by 90% from 1–5 months.39

Despite the fact that over 80% of women receive “enough counseling on IYCF”, results for many IYCF indicators in the Philippines remains low. This suggests the need for a revitalized approach: based on a careful review of IYCF global evidence, program experience as well as possibly some additional research to define the most appropriate strategies, effective messages and cost-efficient application of resources for the Philippines.

Infant and young child feeding promotion and education

Evidence associating improved MDD or other complementary feeding indicators with reduced stunting are ambiguous. Some studies find significant linkages: “high dietary diversity was associated with a 15, 26 and 31% reduced odds of being stunted among children aged 6-11, 12-23 and 24-59 months.”42

Only 16% of Filipino 6-23 month olds meet the minimum dietary diversity (MDD) standards.40 A meta-analysis of ten studies finds that IYCF promotion and education, with no distribution of supplementary food, is effective in increasing

100

88.9 81.7

FIGURE 3.1 Association of timely introduction of complementary foods with key nutrition indicators

89.6

82.0 75.2

72.9 Source: 2013 NNS.

Untimely introduction

Timely 24.9

20 18.4

27.1

18.1 11.1

10.5

0 not underweight

underweight

WEIGHT-FOR-AGE

not stunted

stunted

HEIGHT-FOR-AGE

38 FNRI-DOST, 2015, ‘8th National Nutrition Survey,’ Taguig City: FNRIDOST. 39 Imdad, A., 2011, “Effect on breastfeeding promotion interventions on breastfeeding rates, with special focus on developing countries,” BMC Public Health, 11(s3):S24. 40 FNRI-DOST, 2015, ‘8th National Nutrition Survey,’ Taguig City: FNRIDOST. 41 Bhutta, Z., et al., 2013, “Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost?,” The Lancet, 382(9890):452–477. 42 Rah, J.H., et al., 2010, “Low dietary diversity is a predictor of child stunting in rural Bangladesh,” European Journal of Clinical Nutrition, 64(12):1393-1398. 43 Jones, A.D., et al., 2014, “World Health Organization infant and young child feeding indicators and their associations with child anthropometry: a synthesis of recent findings,” Maternal & Child Nutrition, 10(1):1–17.

not thin

thin

THINNESS

However, a WHO systematic review including data from nine countries found only “mixed associations with child anthropometric indicators” concluding that “complementary feeding indicators did not show consistent relationships with child stunting.”43 In fact, for the Philippines, the 2013 NNS finds no difference in underweight, stunting or “thinness” among children who enjoyed “timely” as opposed to “untimely” introduction of complementary foods. This is not to question the importance of IYCF, and this intervention is included in NIS because of its key importance in improving feeding behavior to improve diet quality. However, without consensus on evidence of potential impact, the benefits of IYCF promotion is not modeled, although they do represent a cost in the benefit cost analysis.

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Targeted supplementary feeding to address moderate acute malnutrition The NNS 2015 update findings of 4.6% of children 6-59 months with weight for height of minus 2-3 standard deviations, suggest moderate acute malnutrition or MAM prevalence of over 400,000 and incidence of possibly 760,000 – with projected mortality of over 2,000 annually. The segmented evidence regarding impacts of supplementary food on food secure versus food insecure populations described by the Lancet Maternal and Child Nutrition Study Group, suggests targeting high-risk children with food supplements. While nutrition education alone has some impact among food insecure populations, the Lancet draws on a systematic review including seven studies providing complementary food supplements for food insecure children 6-24 months of age found significant gains in height-for-age Z score (HAZ) and weight-for-age Z score (WAZ).44 When defined as MAM, identifying and treating these high-risk children is feasible in the Philippines. Weighing and measuring children is an integral component of the national primary health care protocol, suggesting that theoretically over 90% of children should be weighed and measured at least once annually. In addition, growth monitoring is a key responsibility of BHS, although community workers may not be sufficiently equipped, trained or incentivized. However, there is currently no comprehensive follow-up protocol for children identified as MAM.45 NIS includes optimizing this existing capacity by: ensuring full implementation of primary healthcare protocol; strengthening capacity and motivation of BHW/BNS to monitor and refer to RHU; and implementing a protocol for nutrition education and supplementary feeding for children identified as MAM. While this protocol has yet to be defined, NIS ventures a regimen of Ready-to-use Supplementary Food (RUSF), a compact and easy to deliver LNS, together with necessary nutrition education in best use of the RUSF and general IYCF practices.

Management of severe acute malnutrition The NNS 2015 update found about 2.5% of 6-59 month olds, around 250,000 children, with severe wasting (<3SD WHZ), suggesting severe acute malnutrition or SAM incidence of about 400,000 cases annually.46 This relatively small but high risk group accounts for an estimated 3,000 deaths—and the survivors are likely to suffer a range of lifelong physical and intellectual deficits. As discussed above, identification, referral and treatment of these children is feasible in the Philippines. A protocol for community treatment of SAM has been tested, adopted by DOH as a standard component of the Philippines child primary health care package. While facility based care following WHO protocols for treatment of complex SAM remains important, a range of evidence shows that provision of Ready-to-use Therapeutic Food (RUTF), therapeutic spreads or other LNS, offer superior results. A review of pooled studies comparing RUTF with standard care concludes that children who received RUTF had faster rates of weight gain and had 51% greater likelihood of recovery than those receiving standard care.47 With a fully implemented system of identification, referral and community-based treatment, 79% of SAM associated mortality is preventable.48 Scaling up the nationally tested SAM protocol policy, included as part of the NIS, is projected to save around 2,500 of the projected 3,000 lives lost annually. Conceptual budget for Childhood Package Tables 3.4 and 3.5 suggest it will cost around $60.8 million per year to reach 90% of children less than 5 years of age with the proposed NIS program,. This includes $42 million for procurement of pharmaceuticals and production of communication materials along with $18.8 million as the value of estimated time and effort by medical doctors, nurses and midwives. Nearly 60% of these costs emerge from purchase of therapeutic and supplementary feeding inputs to address a projected 1 million children suffering MAM or SAM.

44 Bhutta, Z., et al., 2013, “Evidence-based interventions for improvement of maternal and child nutrition: What can be done and at what cost?,” The Lancet, 382(9890):452–477. 45 As of the writing of this report, a national protocol for the community treatment of MAM is already being drafted. 46 Based on the UNICEF incidence factor of 2.6 47 Jones, A.D., et al., 2014, “World Health Organization infant and young child feeding indicators and their associations with child anthropometry: a synthesis of recent findings,” Maternal & Child Nutrition, 10(1):1–17. 48 Bhutta, Z., et al., 2013, “Evidence-based interventions for improvement of maternal and child nutrition: What can be done and at what cost?,” The Lancet, 382(9890): 452–477. @UNICEF Philippines/2017/ATorralba

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TABLE 3.4 Costs of the inputs to the NIS Child Package INTERVENTION

TARGETING STRATEGY

90% COVERAGE

QTY

$ PER UNIT

$ PER PP

ANNUAL TOTAL ($)

Breastfeeding Education

Universal, 0-6 months

1,124,295

Education

0.53

590,255

IYCF Promotion

Universal, 6-24 months

3,372,884

Material

0.53

1.05

3,541,528

VAC

Universal, 6-59 months

9,070,275

VAC

0.03

0.06

501,419

Zinc treatment for diarrhea

Cases at RHU

0.019

0.19

1,495,695

SAM management

As identified

362,811

Protocol

62.6051

62.6

22,711,849

MAM management

As identified

667,572

RUSF carton

1.65

19.8

13,217,931

7,923,79350

UNIT49

Zinc tablet

ALL INTERVENTIONS

TABLE 3.5

42,058,677

Estimated value of RHU time and effort (in-kind) to deliver NIS Child Package52

INTERVENTION

TARGETING STRATEGY

90% COVERAGE

CONTACTS PP PER YEAR

$ PER CONTACT

$ PER YEAR

ANNUAL TOTAL ($)

Breastfeeding education

Universal 0-6 months

1,124,295

0.22

0.43

485,898

IYCF promotion

Universal 6-24 months

3,372,884

0.22

0.43

1,457,693

VAC

Universal 6-59 months

9,070,275

0.07

0.14

1,306,664

Zinc treatment diarrhea

Cases at RHU

7,923,793

0.07

570,751

SAM management

As identified

362,811

2.14

15.00

5,440,473

MAM management

As identified

741,747

2.14

12.85

9,533,782

ALL INTERVENTIONS

IYCF — infant and young child feeding VAC — vitamin A capsule SAM — severe acute undernutrition MAM — modetate acute undernutrition RHU — rural health unit RUSF — Ready-to-use Supplementary Food

49 Unit prices were obtained from either the DOH’s DPRI or the UNICEF Procurement Copenhagen. See Annex 1 for more details. Includes additional 10% to account for wastage, and 20% to cover distribution costs. 50 A 42% of total incidence is estimated from the 2013 Philippine NDHS. 51 See Annex 5 for more details. 52 Unit Value of Time Based on on Philhealth Maternity Care Package Costing Study shown in Annex 2. 53 Department of Health (DOH), 2014, ‘DOH Annual

18,795,260

C. DEVELOPING THE CAPACITY OF BARANGAY HEALTH STATIONS NATIONWIDE The Philippines’ health system offers significant capacity to implement the antenatal and childcare described in the NIS. The nation is served by 2,588 rural health units or RHUs, primary health care centers in rural and urban areas, along with outpatient services found in most of the 1,975 secondary and tertiary health care facilities nationwide. These centers, which are complemented by medical doctors (MDs), nurses and midwives, have technical capacity to deliver the proposed NIS components. With appropriate training, the capacity of RHUs to implement the NIS components is considered sufficient. NIS includes a budget of $1.25 million to train 13,000 RHU personnel every three years, including an MD, a nurse and two midwives for each RHU. Over 20,000 barangay health stations or BHS support these RHUs, including over 15,000 in rural areas.53

Report, 2014’.

Existing public health infrastructure, including RHU and BHS, is already delivering many of the interventions included in NIS. However, based on the DOH Annual Report 2014, coverage

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Source: DOH Annual Report 2014.

FIGURE 3.2 Coverage of Key Nutrition Interventions Pregnancy IFA

52.0%

Diarrhea ORS +ZN 0-59m

45.8%

Vitamin A 6-59m

44.2%

Deworming 12-59m

28.6%

Iron 6-11m

18.6%

Iron 12-59m

3.6%

MNP 12-23m

2.6%

MNP 6-11m

2.0% 0%

10%

remains low and quality of nutrition services is unknown (Figure 3.2). Given the expanding national budget for health (including nutrition), financing for nutrition products and services is not considered by most stakeholders as a major obstacle to achieving optimal application of this infrastructure.54 Relatively low coverage may be largely attributable to policy, program design and inefficiencies in implementation. This report is not the place to delve into these challenges, but only to conclude that while deficiencies in delivery exist, the current technical and financial capacity are substantially sufficient to implement the NIS package described above with population coverage of 90% or more. An exception may be the capacity at the community level. Community level capacity is significant to NIS because quality implementation of all NIS components involves some form of sustained nutrition education. In some cases, this is to ensure compliance with recommended clinical, pharmaceutical and other protocol initially communicated at RHU by a nurse or midwife. However, a number involve more complex behavior changes requiring sustained contacts and continued reinforcement including: compliance with IFA regime; exclusive breastfeeding; IYCF behaviors

20%

30%

40%

50%

60%

including feeding and hygiene; proper utilization of multiple micronutrient powders (MNP); and follow-up to community based SAM and MAM treatment. BHS are community centers complemented with over 200,000 barangay health workers or BHW and barangay nutrition scholars or BNS. Initially conceived as a volunteer program, in todayâ&#x20AC;&#x2122;s decentralized system, BHW or BNS are compensated via a range of incentive schemes that vary from one local government unit (LGU) to another. BHW and BNS are well placed to offer the sustained and consistent community outreach and face-to-face contact required for quality implementation of NIS including: growth monitoring services, group and peer counseling, and face-to-face follow-up via home visits. While the job descriptions of BHW and BNS are ultimately defined by LGU officials and LGU financing, for the purposes of realistically building a scenario and budget for the various interventions, NIS assumes eight distinct face-to-face contacts between BHW/BNS and mother/ child over the 1000 Days period: Two contacts during the antenatal period to followup RHU services. Provide â&#x20AC;&#x153;triggersâ&#x20AC;? and reinforce compliance with IFA regime, monitor weight gain, provide tips for increasing food intake and build demand for RHU services including encouraging women to make more than four antenatal visits, deliver in a health facility and other services. Two contacts during the first 6-month post-natal period focusing on education and motivation to exclusively breastfeed, monitor mother and child

54 Personal communication, August 2016, Consensus of stakeholder consultation where NIS budget was presented.

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status and continue building awareness and demand of products and services available at the RHU.

Currently, the performance of this decentralized community health system of BHS is not considered optimum – and nutrition related activities are not prioritized. Therefore, NIS calls for investment in capacity and motivation of BHS/BNS.

Two contacts during the high risk 6-11 month period when anemia rates spike to 40%, underweight nearly doubles and stunting rises by one-third.55 Contacts focus on IYCF promotion, including introduction of complementary foods, maternal hygiene and growth monitoring and referral as well as other appropriate issues including promoting full vaccination and ORS/Zinc for home treatment of diarrhea, etc.

Table 3.6 outlines a conceptual calculation for urban and rural BHS. It indicates that covering pregnant women and children up to 2 years of age with eight contacts would require on average 136 eight-hour work days within the average catchment of urban BHS, and on average 56 work days to reach the 1,000-day population within the average catchment area of a rural BHS. Time per contact is more than twice as long in rural areas due to longer travel times - but the much larger population served by the average urban BHS requires many more contacts. Roughly, this suggests a half time job in urban BHS and quarter time job in rural BHS. How this is to be integrated into current BHS capacity and work programs, whether additional personnel are required or whether this can be integrated into the current BHS capacity, is not addressed and left as part of NIS.

A less intensive work program of two contacts over the one-year, 12-23-month period, with IYCF promotion, growth monitoring, and other age appropriate activities including promoting full vaccination and ORS/zinc for home treatment of diarrhea.

TABLE 3.6 Added workload to BHW/BNS in urban and rural barangays BHS

90% OF 20,028 BHS

TOTAL CONTACTS

CONTACTS/BHS

during 1,000 days

DAYS PER YEAR

15 min. contact

Per bhs

Urban

2,704 (15%)

8,814,470 (49%)

3,260

20 minutes

136

Rural

15,321 (85%)

9,174,244 (51%)

599

45 minutes

18,025 (100%)

17,988,715 (100%)

3,859

TOTAL

TABLE 3.7 Estimated cost of total incentive to activate BHW/BNS network

BHS

DAYS / BHS

BUDGET PER BHS

TABLE 3.8 Estimated cost of support materials for BHW/BNS

BHW — barangay health worker BNS — barangay nutrition scholar BHS — barangay health station

TOTAL (PHP)

TOTAL ($)

at Php 150 per day + 15% Urban

136

23,432

63,354,004

1,345,373

Rural

9,683

148,364,734

3,150,644

211,718,738

4,496,017

TOTAL

TOTAL TIME:

ITEM

NUMBER

UNIT COST

TOTAL COST ($)

at 90% coverage 1,000-day kit

16,223

$50

811,134 per year

Growth monitoring

16,223

$35

567,794 per 5 years

55 FNRI-DOST, 2016, ‘2015 Updating Survey Result,’ http://www.fnri.dost.gov.ph/index.php/national-nutrition-survey.

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powders seemed as effective as daily use of iron supplements in reducing anemia.”61 In the NIS model, MNPs specifically represents iron and zinc supplementation interventions defined in the Lancet modeled package to reduce mortality and stunting.

@UNICEF Philippines/2015/JeoffreyMaitem

No matter how the additional workload is addressed, a systematic and accountable implementation of NIS will in all likelihood require incentives and payments to BHW/BNS. Therefore, as seen in Table 3.7, the NIS budgets Php 150 per day for additional BHW/ BNS workload, annually totaling Php23,000-24,000/urban BHS and around Php10,000/rural BHS (with added 15% for anticipated management expenses). NIS also includes budget for annual provision of nutrition education tools to each BHS and growth monitoring equipment on a 5-year basis (to identify children at high risk of MAM and SAM for referral to RHU). Training is projected for roughly four BHW/BNS per BHS - 80 thousand workers on a rotating basis at a projected cost of $3.7 million every three years.56 D. MULTIPLE MICRONUTRIENT POWDERS AND NUTRITION EDUCATION DELIVERED BY THE PANTAWID PAMILYANG PILIPINO PROGRAM Data from the National Household Food Consumption Survey indicates intake for 7 of 8 micronutrients to be 9-32% of the WHO Estimated Average Requirements (EAR).57 With 15 vitamins and minerals that are “sprinkled” and mixed into traditional complementary foods, multiple micronutrient powders or MNPs have been demonstrated to lower a range of micronutrient deficiencies among children 6-59 months. Lancet review of 16 randomized controlled trials found iron deficiency anemia (IDA) reduced by 57% and retinol deficiency by 21%.58 Several studies find improvements in iron status associated with enhanced cognitive development, reduced zinc deficiency leads 13% lower incidence of diarrhea and 19% for pneumonia.59 Some, though not all, studies suggest possible improvement in linear growth or reduced stunting.60 WHO guidelines state “use of multiple micronutrient 56 See Annex 3 for more details on the training costs. 57 FNRI-DOST 2016, ‘Updating Nutritional Status of Filipino Children,’ Regional Dissemination Forum. 58 Salam R.A., et al., (2013) “Effectiveness of micronutrient powders (MNP) in women and children,” BMC Public Health, 13(3):1. 59 Yakoob M.Y., et al., 2011. “Preventive zinc supplementation in developing countries: impact on mortality and morbidity due to diarrhea, pneumonia and malaria,” BMC Public Health, 11(suppl 3):S23. 60 Allen L.H., et al., 2009. “Provision of multiple rather than two or fewer micronutrients more effectively improves growth and other outcomes in micronutrient-deficient children and adults,” Journal of Nutrition,

Currently, distribution of MNPs or iron supplement for children 6-11 month and 12-23 month old is low at around less than 2% and 3%, respectively. Iron syrups reach only 3% of children aged 12-59 months and 18% of 6-11 month olds, a period when anemia rates in infants spike up to 40%.62 In an environment where anemia rates are high and average family intakes of iron reach only 9% of EAR, universal prophylactic intervention may be most effective.63 However, given the expense of MNPs, around $5 per child over the 18-month period, the NIS broadly targets high-risk children among 25% of the low-income families qualifying for the Pantawid Pamilyang Pilipino Program or 4Ps of the Department of Social Development and Welfare (DSWD). Moreover, creating a market covering the nearly 900,000 6-24 month olds in the 4Ps population, an estimated $3.8 million annual procurement, may likely encourage the development of a private market for MNPs and open opportunities for public private social marketing partnerships to reach populations who do not qualify for 4Ps benefits. In addition, the 4Ps reaches around 25 million low-income Filipinos via a number of channels including required monthly Family Development Sessions or FDS. On paper, 61 World Health Organization (WHO), 2011, ‘Guideline: Use of multiple micronutrient powders for home fortification of foods consumed by infants and children 6–23 months of age,” Geneva, WHO. 62 FNRI-DOST, 2015, ‘8th National Nutrition Survey,’ Taguig City: FNRI-DOST. 63 FNRI-DOST, 2015, ‘8th National Nutrition Survey,’ Taguig City: FNRI-DOST.

139:1022–30.

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FDS modules include well-developed education packages for antenatal care, breastfeeding and IYCF. However, capacity, interest and actual implementation of these modules is unknown – and widespread high quality implementation is considered unlikely. NIS includes enabling full implementation of nutrition education components of the 4Ps required monthly FDS. This includes one

session annually targeting nutrition education in the antenatal period and four sessions annually for mothers and families of children <24 months of age. A conceptual figure of $5 per meeting is projected to cover meeting materials and/or act as an incentive. Local BHS and RHU personnel should closely coordinate their nutrition education efforts with managers and facilitators of the FDS.

TABLE 3.9 Estimate of additional cost to the Pantawid Pamilyang Pilipino Program

INTERVENTION

TARGET STRATEGY

MNPs

MNP — multiple micronutrient powders 4Ps — Pantawid Pamilyang Pilipino Program

COVERAGE AT SCALE

ITEM

NUMBER PER ITEM

$ PER ITEM

COST ($)

SUPPLY COSTS ($)

Child 6-24 months

884,063

MNPs

120

0.04

4.34

3,836,161

Counseling

Pregnant women

25,22264

Incentive/Cost for 4Ps family

5.00

126,108

Counseling

< 24 month mothers

Developmental session

5.00

20.00

504,432

25,222

ALL INTERVENTIONS

E. FOOD FORTIFICATION AND MASS MEDIA While the 1,000-day window is critical to reduce the prevalence of stunting, pre-conceptual and intergenerational determinants of stunting may be significant. Although possibly around 60% of the measured burden of undernutrition projected by the DAR emerges from the 1,000 day period itself, about one-quarter of the indicated losses emerge from adult nutritional deficiencies, particularly woman’s nutrition status. The Philippine economy includes well-developed industrial food industries and markets. Ubiquitous mass media marketing, particularly from the food industry, plays a large role in shaping consumer nutrition behaviors. Both these private channels reach over 90% of the population – and offer opportunities for population wide intervention. Food fortification with iron, iodine, zinc, folic acid and other vitamins and minerals is a proven approach to reducing micronutrient deficiencies – representing about one-third of the economic burden projected in the DAR. When industrial and market conditions are favorable, food fortification offers the potential for significant impact.

4,466,701

While a full assessment was not available, some preliminary research suggests two promising approaches, which are included in this initial NIS package. These opportunities are described in the following section. The wide penetration and impact of mass media marketing in the Philippines offers a key channel to improve nutrition related behaviors. At least once each week, 81% of Filipinos watch television, 53% listen to radio, 30% surf the internet and 27% read newspapers.65 Global evidence suggests national media communication can be successfully used to support optimal breastfeeding, complementary feeding and other IYCF behaviors as well as special nutritional needs during pregnancy. However, in the Philippines these “marketing spaces” are currently dominated by less than optimal, and sometimes negative, commercial information. NIS includes a $5 million annual national allocation for educational media campaigns (annual or biennial as budget allows and strategic planning suggests) focusing on appropriate themes on a rotating basis and closely coordinated to reinforce messages and materials produced for other components of the program.

64 Estimated in two-thirds of the barangays. 65 Philippine Statistics Authority (PSA) and ICF International, 2014, ‘Philippines National Demographic and Health Survey 2013,’ Manila, and Maryland: PSA and ICF International.

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Salt iodization Iodine deficiency disorder (IDD) represents nearly 14% of the economic burden of undernutrition—an NPV of more than $500 million annually in lost productivity due to cognitive deficits in children borne with IDD. WHO recognizes salt iodization as an intervention which can virtually eliminate IDD at >90% coverage – and has documented an over-all 8 point increase in IQ score among children reached with iodized salt. While the Philippines has promulgated mandatory regulation of salt iodization, national surveys indicate coverage and quality are low. However, the industry structure is favorable. A few large enterprises effectively control the national supply; most technical challenges to iodization at the point of production have been addressed; and consumer acceptance has been demonstrated. Challenges to Universal Salt Iodization (USI) include policy issues such as tax disincentives and lax enforcement of mandatory iodization standards and USI program management. The NIS assumes an environment where these issues are addressed and coverage of quality iodized salt reaches 90% of the population at a cost of $0.10 per person per year— about $5 million annually.66 Wheat flour fortification Entering pregnancy with good iron and folic acid status is critical to reducing maternal mortality and small for gestational age or SGA deliveries as well as reducing the Philippines’ annual burden of around 6,000 neural tube birth defects. A meta-analysis of 60 trials showed that iron fortification of foods resulted in 41% reduction in the risks of anemia and a 52% reduction in iron deficiency.67 Following the addition of folic acid to the national flour supply, reductions in national incidence of neural tube defect have ranged from 30% to more than 70%.68 While rice is the primary staple food in the Philippines, production by tens of thousands of small farmers does not present a feasible environment for fortification. On the other hand, nearly the entire national wheat flour supply, around 4 million metric tons annually, is milled by a handful of large millers and managed by sophisticated national corporations. While no definitive surveys have been undertaken, food consumption data for bread, noodles, crackers and other flour products suggests possibly 60% of the population regularly consume flour products.69 While the industrial environment is promising, the required open and collaborative partnership between public and private sectors has not been achieved. Moreover, the fortification standards do not reflect “best practices” for iron compound or inclusion of folic acid. NIS presumes flour fortification can be optimized at the indicated cost of $2.50 per metric ton or around $10 million annually for fortification of the national supply.

66 GAIN internal figure for cost of USI including procurement of KIO3, management, monitoring and communications. 67 Gera, T., et al., 2012, “Effect of iron-fortified foods on hematologic and biological outcomes: systematic review of randomized controlled trials,” The American Journal of Clinical Nutrition, 96(2):309–324. 68 Food Fortification Initiative, http://www.ffinetwork.org/. 69 FNRI-DOST, 2015, ‘8th National Nutrition Survey,’ Taguig City: FNRI-DOST.

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F. BUDGET SUMMARY Table 3.10 suggests that the proposed NIS has an annual total cost requirement ranging from $60-$114 million over a ten-year period or a total of around $1 billion. When this total cost figure excludes the imputed value of the time and effort among current health workers ($231.6 million) and the costs of fortification absorbed by the private sector, a public annual financing of around $73 million over the 10-year period or a total of $679 million is required. Along with the 3-year rolling training scheme, the budget assumes 3-year start-up with program scale reached in the third year.

TABLE 3.10

Ten-Year NIS budget (in $ million)

ITEM

YEAR

TOTAL

100

Rolling 3-year training

2.0

1.0

2.0

1.0

2.0

1.0

2.0

Growth monitoring kits

0.2

0.5

0.6

0.2

0.5

0.6

Training sub-total

2.2

2.5

1.6

2.0

1.2

2.5

2.6

1.0

2.0

19.5

Effort in-kind

10.1

20.1

25.2

231.6

Ingredients/input

21.5

43.1

53.8

495.3

Primary Health Care (PHC) subtotal

31.6

63.2

79.0

726.9

BNS incentives+

1.8

3.6

4.5

41.4

BNS ingredients

0.3

0.6

0.8

7.5

BHS subtotal

2.1

4.2

5.3

48.8

Total health system

36.0

69.9

85.9

86.3

85.5

86.8

86.9

85.3

86.3

795.2

4Ps

1.79

3.57

4.47

41.09

5.1

50.8

Flour fortification, $2.5 per metric ton

10.0

100.0

Fortification subtotal

15.1

150.8

Management and monitoring

2.5

25.0

Media

5.0

50.0

TOTAL COST

113

114

112

113

1,062

Operating scale (%)

($)

STARTUP TRAINING 17.0 2.5

RHU ACTIVITIES

BARANGAY HEALTH STATION (BHS)

FORTIFICATION USI, $0.1 per piece

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2% 1%

Figure 3.3 shows that RHU activities represent about two-thirds of the NIS budget. These activities will be delivered through the support of community channels such as the 4Ps and BHS (9%), and through the private market (14%).

Primary Health Care At-Risk

22%

Primary Health Care package

14%

Salt and flour fortification

Barangay Health Station

Annual media campaign

DSWD CCT FDS

Management and monitoring

Startup and training

5% 5%

FIGURE 3.3 Cost centers: A sectoral representation of budget perspective

47%

14%

47%

22%

Benefits and Benefit-Cost Ratio of the Proposed NIS Program As mentioned earlier, each component intervention of the proposed NIS program is selected based on availability of evidence on their impact, from systematic reviews of multiple studies and trials by the Cochrane Database, the Lancet Maternal and Child Study Group, and the WHO. In addition to the synthetic impacts on complex outcomes like stunting and mortality, individual indicators have independent effects (regardless of stunting or mortality rates). The independent risks and functional deficits are described in the accompanying DAR. The current report estimates the additional benefits of the intervention not considered in Lancet modeling, which focuses on mortality and stunting. These include the NPV of reduced loss of future productive potential from childhood anemia and IDD; or current value of health care cost savings from lower incidence of diarrhea and acute respiratory infection (ARI) resulting from improved zinc status or breastfeeding practices.

A. BENEFITS OF THE PROPOSED NIS PROGRAM Based on the evidence for decreased prevalence and on the losses defined in the DAR, benefits projections can be made for each indicator. Furthermore, a benefit-cost ratio or BCR is computed using the following simple logic model and the estimated budget: BENEFIT = economic losses (status quo; $4.5 billion per year) x coverage (90%) x effectiveness The NIS sets the evidence of impact against each individual parameter of loss measured in the DAR to project the value of improvement in each indicator of undernutrition, i.e. benefit of the intervention. In some cases, the evidence focuses on the reduction in prevalence or improved behavior. In other cases, the indicator directly measures decreased mortality or morbidity. Evidence is sometimes based on single interventions or a package of interventions. Annex 6 describes the “guts” of the computer modeling exercise, shows the logic model and results, and provides links to the relevant literature.70 In summary, the modeling analysis suggests that with a 90% coverage, the NIS is likely to prevent 13,000 to 14,000 cases of child death each

70 FNRI-DOST, 2015, ‘8th National Nutrition Survey,’ Taguig City: FNRI-DOST.

B EN EF I T S A N D B EN EF I T- C O S T R AT I O O F T H E P R O P O S E D N I S P R O G R A M

year, and reduce the burden of undernutrition by less than $1.5 billion per year (Table 4.1). This represents reductions in the national burden of undernutrition. The following table summarizes these benefits across the four pathways of losses discussed in the DAR.

TABLE 4.1 Annual benefits of the NIS at program scale by pathway PATHWAY

TABLE 4.2 Costs, benefits, and BCR of the proposed 10-year NIS program

REDUCTION

($ million)

(%)

667

312

3,132

1,059

3 Adult anemia

233

4 Higher morbidity

379

117

4,410

1,561

1 Child mortality 2 Child productivity

B. BENEFIT-COST RATIO OF THE NIS PROGRAM Nutrition specific interventions enable a concrete and detailed, albeit conceptual, year-by-year estimate for costs and projection as detailed in the previous sections. This in turn enables calculation of a BCR as shown in Table 4.2. Benefits are taken from Table 4.1, projecting $1.56 billion reduction in the economic burden at program scale. The $1.56 billion benefit is scaled up over 10 years

BASELINE LOSS

ALL

along with implementation scale-up of the NIS, starting at 30% and reaching 100% in year 5. Presuming a year of intervention is needed for achieving correction or prevention of nutrition deficiency, costs will likely exceed benefits by a year. Therefore, the table below shows no benefits in the first year and final year’s benefits not included in the 10-year calculation.

ITEM

YEAR 1

0.62

1.25

1.56

12.80

113

114

112

113

1,062

10.4

13.0

13.8

13.9

13.7

13.9

12.1

680

Benefits ($ million) Costs ($ million)

TOTAL BCR Public finance ($ million) Public finance BCR

TOTAL

BCR — benefit-cost ratio

Assuming that the operation will go on full scale in the final five years of the program, benefits of $1.5 billion per year, and costs ranging from $60 million to $114 million annually are expected. Operating the 10-year NIS program at scale is expected to yield a BCR of 12. This is obtained by dividing the total benefits of the investment ($12.8 billion) by its total cost ($1.062 billion). It implies that for each $1 invested in the nutrition program, the Philippine economy will save $12 in forgone earnings and health expenditures due to undernutrition. More importantly, the value of lives saved and improved is immeasurable. Excluding the cost of fortification and the imputed value of RHU support, the public financial requirement of the proposed NIS program amounts to $35-$74 million per year

over 10 years or a total of $680 million. This investment represents an attractive return on local health system’s investment. A consultation of national and international nutrition partners in Manila confirmed that the costs of NIS are affordable within the context of DOH revenues.71 The partners also affirmed that it is very timely to consider a coordinated national planning and resource mobilization approach, along with a more comprehensive nutrition strategy, such as the proposed NIS. Stakeholders believe that given the right environment—with coordinated planning, selected reform, strategic capacity building of all public health systems and sufficient resources— the proposed NIS can achieve 90% quality coverage within four to five years. 71 Partner Consultation, UNICEF, August 2016.

B EN EF I T S A N D B EN EF I T- C O S T R AT I O O F T H E P R O P O S E D N I S P R O G R A M

ANNEX 1 Unit Prices for NIS Ingredients

ITEM

PROTOCOL AND TARGET GROUP

UNIT PRICE

Iron Folic Acid Supplements

Protocol for Pregnancy Women: minimum of 180 pills (1 tablet/day for at least 6 months)

Iron 60mg and Folic acid 400mcg film coated tablets in packs of 100; $0.79

Mebandazole (Deworming)

Protocol for pregnant women and children: 1 tablet for pregnant women during 2nd or third trimester; 1 tablet annually for children >12 months

Mebendazole 500 mg tablets, pack of 100 tablets; $ 3.04

Vitamin A

Lactating women: 1 capsule 200,000 IU within a month post delivery

Vitamin A (Retinol), soft gelatin capsule 200,000 IU, pack of 500; $10.47

Children: 1 capsule 100,000 IU single dose for 6-11 month old children; 1 capsule 200,000 IU every 6 months for 12-59 month old children

Vitamin A (Retinol), soft gelatine capsules 100,000 IU, pack of 500; $8.42

Anti-malarial

Protocol for pregnant women and children: DOH program requirement; from DOH procurement service

Artemether 20mg + Lumefantrine 120mg fixed dose combination tablets, strip of 24 tablets/ pack of 30; $32.27

Multiple micronutrient powder

Protocol 6-24 month old: 120 sachets per year

Iron 60mg and Folic acid 400mcg film coated tablets in packs of 100; $0.79

Little to no experience with pregnant women to date Zinc supplements Diarrhea

Following DOH/WHO protocol

Oral Rehydration Salt, flavoured, 2 sachets for 1 L + Zinc 20mg dispersible tablets, blister of 10, packed together in a kit; $0.54

Lipid-based (Plumpy Doz, Plumpy Pot)

Protocol under development

Ready-to-use Therapeutic Food (RUTF), spread, 150 sachets of 92 g per carton; $50 Ready-to-use Supplementary Food (RUSF), Lipid-based Nutrient Supplement (LNS Medium Quantity) for the prevention of malnutrition, 36 pots of 325g per carton; $40.30 Ready-to-use Supplementary Food (RUSF), spread, for the treatment of moderate acute malnutrition, 150 sachets of 92g per carton; $40.57

Typical "take-home" material

MNP flyer, Accordion guide

Php 20

ANNEXES

ANNEX 2 Unit Value of RHU Time

HEALTH PROFESSIONAL

MONTHLY SALARY (PHP)

UNIT COST PER MINUTE (PHP)

Nurse

24,315

2.30

Physician

52,578

4.98

Midwife

19,533

1.85

Diarhhea Consult Cost

INPUTS Nurse time Physicianâ&#x20AC;&#x2122;s supervisory time

UNITS

UNIT COST

COST PER CONTACT (PHP)

20 minutes

2.30

2 minutes

4.98

Facility overhead, indirect

Lump Sum

Total cost per contact

20 minutes

102

1 minute

$0.11

2 minutes

$0.21

5 minutes

$0.54

10 minutes

$1.07

15 minutes

$1.61

20 minutes

$2.14

ANNEXES

ANNEX 3 Estimated Training Costs for ToT, RHU and BHS

UNIT

# UNITS

COST/UNIT (Php)

TOTAL COST (Php â&#x20AC;&#x2DC;000)

TOTAL ($)

days

1,600

720

15,289.78

R/Trip

150

10,000

1,500

31,853.70

Book

150

1,000

150

3185.37

2-4/REGION PROVINCE Training of 150 trainers Travel Take home Guidelines

50,328.85 PHC 1MD/2N/2MIDWIFE RHU (2,588 x 5 = 12,940) Travel (12,940) Take home guidelines (12,940)

days

800

31,056

659,499

Travel

1,000

12,940

274,791

Book

1.000

12,940

274,791 1,209,082

BHS TRAINING, 4 PER STATION BHS (20,028 x 4 = 80,112)

Days

Travel Take home guidelines

Book

800

128,179.2

2,721,988

100

8,011.2

170,124

500

40,056

850,621 3,742,733 5,002,144

ANNEXES

ANNEX 4 Review of Potential Nutrition-Sensitive Interventions and Sectoral Programs

A Lancet article by Ruel et al. (2013) finds that:72

Agriculture:

The potential for leveraging value chains remains untapped and “experience and evidence of effectiveness are scarce” and studies “showed no overall effect of targeted agricultural programmes on underweight, wasting, or stunting.”

Homestead food production:

Evidence on the effectiveness of homestead food production programmes on maternal or child nutritional status (anthropometry or micronutrient status) is limited.

Biofortification:

While the many advantages of the approach are well documented, evidence regarding the effectiveness of biofortification, is still confined to vitamin A in orange sweet potato, and the scalability of delivery is yet to be shown.

Gender empowerment:

Despite explicit targeting of women in many agricultural programmes, few studies have measured specific aspects of women’s empowerment as a pathway to improved nutrition, and results are mixed.

Social safety nets:

Only a few conditional cash transfer studies show effects on anthropometry, and these effects are shown in the youngest or poorest children;

School feeding programs:

Results from a meta-analysis show that school feeding programmes have small effects on school-age children’s anthropometry, particularly in low-income settings. Major effects on height are not expected in schoolage children.

72 Ruel, M.T., et al., 2013, “Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition?,” The Lancet, 382(9891):536-551.

ANNEXES

ANNEX 5 Weighted Average Cost for SAM Protocol SUPPLY

CALCULATIONS

UNIT COST ($)

COST

TREATMENT OF SAM WITH COMPLICATIONS Therapeutic spread, sachet 92g/CAR-150

1 carton/child

59.01

Therapeutic diet, sachet, 102.5g/CAR-120

15 sachets/child; 120 sachets in one carton

72.72

4.85

F-100 therap. diet,sachet,114g/CAR-90

6 sachets/child; 90 sachets in one carton

69.67

11.61

Amoxici.pdr/oral sus125mg/5ml/BOT-100ml

2-4 bottles per SAM child

0.48

1.92

Mebendazole 500mg chewable tabs/PAC-100

1 tablet per SAM child

2.37

0.02 $77.41 PhP 3,632.24

Cost per child

$100,637.38 PhP 4,721,905

Cost, 1,730 children TREATMENT OF SAM WITH NO COMPLICATION Therapeutic spread,sachet 92g/CAR-150

1 carton/child

$59.01

Amoxici.pdr/oral sus 125mg/5ml/BOT-100ml

2-4 bottles per SAM child

$0.48

$1.92

Mebendazole 500mg chewable tabs/PAC-100

1 tablet per SAM child

$2.37

$0.02

Cost per child

$60.95 PhP 2,859.95

Total cost, 173 children

$7,923.98 PhP 371,793

LGU SUPPORT $108,561.36 Training

25-30pax

7,992.33

15,984.65

Refresher/Supportive supervision

25-30pax

2,301.79

Policy/plan development

25 pax; 2/month x 3 mos and 1/month x 3 mos

186.49

1769.66

MUAC,Child 11.5 Red/PAC-50

10 packs per RHU

3.26

32.60

CGS tables (3types/pack)

10 packs per LGU

3.50

35.00

Portable baby/child L-hgt

5 sets/RHU or 1 board/barangay

184.26

921.30

Scale,infant,springtype,25kg x 100g

10 pieces/RHU or 1 scale/barangay

10.89

108.90

Planning and M&E meetings

25 pax; 2/month x 3 mos and 1/month x 9 mos

186.49

2,949.44

Total package for 1 LGU Total for OTC and ITC

24,103.35 1,130,929.00

COST PER CHILD OF WEIGHTED SAM $7.74 $54.86 $62.60

ANNEXES

ANNEX 6 Losses and Benefits by Pathway PATHWAY AND INDICATOR

LOSS

INTERVENTION

INDICATOR

($ million)

EFFECTIVENESS

BENEFITS AT 90% COVERAGE

(%)

($ million)

SGA/LBW

21 73

34.16 74

SGA/LBW

34 75

Anti-malarial

SGA/LBW

43 76

IFA/Flour fortification

NTDs

72 77

43 78

31.20

48 79

3.14

30 80

7.48

PATHWAY 1 Maternal nutrition/Low birthweight (LBW)

Maternal nutrition/NTD Maternal hygiene

116.1

72.2 7.3

Iron Energy/Protein supplementation

IYCF

Suboptimal breastfeeding, less than 1 month

27.70

Breastfeeding promotion

Suboptimal breastfeeding, 1-5 months

110.04

90 81

89.13

Suboptimal breastfeeding, 6-23 months

38.89

90 82

31.50

WAZ diarrhea+

52.52

39 83

18.38

WAZ ARI

78.40

32 84

22.74

WHZ moderate diarrhea+

20.17

39 85

7.06

WHZ moderate ARI +

21.04

32 86

6.10

WHZ severe

49.74

SAM management

35.37

Zinc Deficiency ARI

27.32

Zinc supplementation/ MNP

51 88

12.54

Zinc deficiency diarrhea

13.13

Zinc supplementation/ MNP

51 89

6.03

Vitamin A Deficiency

32.64

VAC

24 90

7.05

Full package

Improved behavior

Deaths

73 Peña-Rosas J.P., et al., 2012, “Intermittent oral iron supplementation during pregnancy,” Cochrane Database of Systematic Reviews, 2012(7):CD009997. 74 Weighted average of 3 estimates. 75 Kramer, M. S., and R. Kakuma, 2003, “Energy and protein intake in pregnancy: Review,” Cochrane Database of Systematic Reviews, 2010(4): CD000032. 76 Bhutta, Z., et al., 2013, “Evidence-based interventions for improvement of maternal and child nutrition: What can be done and at what cost?,” The Lancet, 382(9890): 452–477. 77 De-Regil L.M., et al., 2010, “Effects and safety of periconceptional folate supplementation for preventing birth defects,” Cochrane Database of Systematic Reviews, 2010(10):CD007950. 78 Estimated at 60% coverage. 79 Bhutta, Z., 2014, ‘Lives Saved Tool Analysis for Global Nutrition Report Independent Expert Group,’ http://www.globalnutritionreport.org 80 Lassi, Z.S., et al., 2010, “Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes,” Cochrane Database of Systematic Reviews, 2010(10). 81 Lassi, Z.S., et al., 2010, “Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes,” Cochrane Database of Systematic Reviews, 2010(10). 82 Assume effectiveness in 1-5m olds. 83 Bhutta, Z., et al., 2013, “Evidence-based interventions for improvement of maternal and child nutrition: What can be done and at what cost?,” The Lancet, 382(9890):452–477. 84 Bhutta, Z., et al., 2013, “Evidence-based interventions for improvement of maternal and child nutrition: What can be done and at what cost?,” The Lancet, 382(9890):452–477. 85 Bhutta, Z., et al., 2013, “Evidence-based interventions for improvement of maternal and child nutrition: What can be done and at what cost?,” The Lancet, 382(9890):452–477. 86 Bhutta, Z., et al., 2013, “Evidence-based interventions for improvement of maternal and child nutrition: What can be done and at what cost?,” The Lancet, 382(9890):452–477. 87 Bhutta, Z., et al., 2013, “Evidence-based interventions for improvement of maternal and child nutrition: What can be done and at what cost?,” The Lancet, 382(9890):452–477.

ANNEXES

PATHWAY AND INDICATOR

LOSS

INTERVENTION

INDICATOR

EFFECTIVENESS

($ million)

BENEFITS AT 90% COVERAGE

(%)

($ million)

58 91

7.36

22.6 92

20.3

465.26

PATHWAY 2 NTD Stunting

12.8 2,291.9

IFA/Flour fortification

NTDs

Full package

Stunting

Child Anemia

282.2

MNP

Prevalence

57 93

144.76

IDD

545.7

USI

NTDs

90 94

442.04

Suboptimal breastfeeding, less than 1 month

10.03

Breastfeeding counselling

Improved behavior

30 95

2.71

Suboptimal breastfeeding, 1-5 months

39.8

90 96

32.28

Suboptimal breastfeeding, 6-23 months

14.1

90 97

11.41

Hygiene diarrhea

29.5

Hygiene Education

48 98

12.75

Zinc diarrhea

85.3

MNP

Incidence

13 99

9.98

Zinc ARI Morbidity

54.3

MNP

Incidence

19 100

9.28

29 101

38.46

52 102

72.64

PATHWAY 3

Maternal Nutrition or Low birth weight

145.2

PATHWAY 4 Flour fortification

Adult anemia

PATHWAYS 1 TO 4 1.561

88 Yakoob, M.Y., et al., 2011, “Preventive zinc supplementation in developing countries: impact on mortality and morbidity due to diarrhea, pneumonia and malaria,” BMC Public Health, 11(3):1. 89 Yakoob, M.Y., et al., 2011, “Preventive zinc supplementation in developing countries: impact on mortality and morbidity due to diarrhea, pneumonia and malaria,” BMC Public Health, 11(3):1. 90 Imdad, A., et al. 2010, “Vitamin A supplementation for preventing morbidity and mortality in children from 6 months to 5 years of age.” Cochrane Database of Systematic Reviews, 2010(12): CD008524. 91 Flour fortification plus IFA distribution estimated at 80% coverage. 92 Bhutta, Z., et al., 2013, “Evidence-based interventions for improvement of maternal and child nutrition: What can be done and at what cost?,” The Lancet, 382(9890):452–477. 93 Salam R.A., et al., (2013) “Effectiveness of micronutrient powders (MNP) in women and children,” BMC Public Health, 13(3):1. 94 Aburto N, et al., 2014, ‘Effect and safety of salt iodization to prevent iodine deficiency disorders: a systematic review with meta-analyses,’ WHO eLibrary of Evidence for Nutrition Actions (eLENA), Geneva, WHO. 95 Imdad, A., et al. 2011, “Effect on breastfeeding promotion interventions on breastfeeding rates, with special focus on developing countries,” BMC Public Health, 11(s3):S24. 96 Imdad, A., et al. 2011, “Effect on breastfeeding promotion interventions on breastfeeding rates, with special focus on developing countries,” BMC Public Health, 11(s3):S24. 97 Assume effectiveness among children 1-5 months old. 98 Bhutta, Z., 2014, ‘Lives Saved Tool (LiST) Analysis for Global Nutrition Report Independent Expert Group,’ http://www.globalnutritionreport.org. 99 Salam R.A., et al., (2013) “Effectiveness of micronutrient powders (MNP) in women and children,” BMC Public Health, 13(3):1. 100 Salam R.A., et al., (2013) “Effectiveness of micronutrient powders (MNP) in women and children,” BMC Public Health, 13(3):1. 101 As in maternal nutrition mortality, this takes the averages of 89, 90 and 92. 102 Gera, T., et al., 2012, “Effect of iron-fortified foods on hematologic and biological outcomes: systematic review of randomized controlled trials,” The American Journal of Clinical Nutrition, 96(2):309–324.

ANNEXES