OPPORTUNITIES TO ACCELERATE THE REDUCTION OF CHILDHOOD UNDERNUTRITION IN THE SAHEL Nakawala Lufumpa, Anne Hilger, Odyssia Ng, and Bénédicte de la Brière SASPP Policy Note Series FEBRUARY 2023 SASPP Policy Note Series 1 February 2023 SUMMARY Chronic high rates of childhood undernutrition in the Sahel have resulted in significant costs to human capital. What opportunities exist to accelerate the reduction of childhood undernutrition in this region? This brief details the findings of research examining context- consequently, build and sustain human capital in the region. We specific determinants of growth faltering and childhood detail the determinants that have the largest associations with undernutrition in five Sahel countries—Burkina Faso, Chad, childhood undernutrition in the Sahel; examine our findings in Mali, Niger, and Senegal. Notably, this research underscores the context of existing research; and provide recommendations opportunities to strengthen nutrition action in the Sahel and, to improve the effectiveness of nutrition action in this region. Childhood Undernutrition and Growing Human Capital Costs 1 in Sub-Saharan Africa Despite concerted efforts, the prevalence of childhood decreased future wages, and poor health outcomes in adulthood.3 undernutrition remains high in Sub-Saharan Africa, costing countries up to US$4.7 billion and 16.5 percent In Sub-Saharan Africa, the Sahel region bears one of the of GDP annually. 1 The inadequate intake, absorption, or highest burdens of childhood undernutrition and its associated utilization of nutrients in childhood is associated with an impact on human capital.4 The prevalence of stunting in children increased risk of mortality and morbidity and impairments under five ranges from 17.9 percent in Senegal to 37.8 percent to cognitive and physical development.2 This has resulted in Chad. The prevalence of wasting ranges from 8.1 percent in in significant health, education, and productivity costs at the Senegal and Burkina Faso to 13.9 percent in Chad. Although individual, community, and country level (Figure 1). Individuals progress has been made, the six Sahel countries are currently who were stunted (low height-for-age) in the first five years not on track to meet the childhood stunting and wasting Global of life are more likely to have decreased educational attainment, Nutrition Targets by 2030. SASPP Policy Note Series 2 February 2023 FIGURE 1. Cost of Hunger in Africa Framework of Consequences of Undernutrition Increased Increased public public and and private private costs costs productivity Lowerproductivity Lower Higher labour Increased demand to Social inclusion Lower performance in Increased demand performance Lower labour Higherabsenteeism labour absenteeism social services problems Social inclusion problems manual to social services in manual labour Lower educational performance Lower educational performance Higher morbidity risk: Cognitive and Higher mortality Lower physical acute and chronic psychomotor risk Higher morbidity risk : Cognitive and psychomotor capacity Higher mortality risk illnesses underdevelopment Lower physical capacity acute and chronic illnesses underdevelopment Undernutrition Undernutrition Direct costs Indirect costs Opportunity costs Direct costs Indirect costs Opportunity costs Source: Adapted from African Union Commission, UN Economic Commission for Africa, and UN World Food Programme. 2014. “The Cost of Hunger in Africa: Social and Economic Impact of Child Undernutrition in Egypt, Ethiopia, Swaziland and Uganda.” Addis Ababa: UN Economic Commission for Africa. Source: Adapted from African Union Commission, UN Economic Commission for Africa, and UN World Food Programme. 2014. “The Cost of Hunger in Africa: Social and Economic Impact of Child Undernutrition in Egypt, Ethiopia, Swaziland and Uganda.” Addis Ababa: UN Economic Commission for Africa. Reducing Childhood Undernutrition: Building and Sustaining 2 Human Capital The e ective reduction of childhood undernutrition and This brief analyzes the findings and policy implications growing costs to human capital in the Sahel requires the of research examining the determinants of childhood identification of context-specific determinants which can undernutrition and growth faltering specific to the Sahel, be integrated into nutrition action. The UNICEF conceptual with an additional focus on factors that have not been framework on the determinants of maternal and child nutrition examined in detail. The most recent Demographic and Health broadly categorizes the determinants of undernutrition according Survey data, collected between 2010 and 2018, were assessed to the level of impact (Figure 2). Within each category and level of for five Sahel countries—Burkina Faso, Chad, Mali, Niger, and determinants, many potential factors may impact the likelihood of Senegal. The sample population included almost 37,000 children one or more forms of childhood undernutrition. Additionally, and under five. Multilevel regression models were used to examine importantly, the statistical significance and ranking of individual risk the association between childhood undernutrition and child, factors are context-specific—varying within and across populations. parental, and household-level factors. SASPP Policy Note Series 3 February 2023 FIGURE 2. UNICEF Conceptual Framework of Maternal and Child Nutrition MATERNAL AND CHILD NUTRITION Outcomes for children Improved survival, health, physical growth, cognitive development, school readiness and school and women performance in children and adolescents; improved survival, health, productivity and wages in women and adults; and improved prosperity and cohesion in societies. DIETS CARE Immediate determinants Good diets, driven by adequate food and Good care, driven by adequate services and dietary practices for children and women. practices for children and women. FOOD PRACTICES SERVICES Age-appropriate, nutrient- Age-appropriate feeding Adequate nutrition, Underlying rich foods – including and dietary practices health, education, determinants breastmilk in early from early childhood, sanitation and social childhood – with safe and with adequate food protection services palatable drinking water preparation, food with healthy food and household consumption and environments that food security. hygiene practices. support good diets. RESOURCES NORMS Sufficient resources – including Positive social and cultural norms and environmental, financial, social and human actions to enable children´s and women´s resources – to enable children´s and right to nutrition. women´s right to nutrition. Enabling determinants GOVERNANCE Good governance – including political, financial, social and public and private sector actions – to enable children´s and women´s right to nutrition. Source: Adapted from UNICEF. 2021. “UNICEF Conceptual Framework on Maternal and Child Nutrition”, 2021 (All Rights Reserved.) https://www.unicef.org/media/113291/file/UNICEF%20 Conceptual%20Framework.pdf SASPP Policy Note Series 4 February 2023 Findings: Determinants of Childhood Undernutrition and 3 Growth Faltering in the Sahel In our representative sample of children under five in five 1.6 times higher in children who recently suffered from diarrhea Sahel countries, level of maternal education, exposure to and 1.5 times higher in children who recently had a fever. household air pollution (HAP), and recent child illness had the largest associations with growth faltering and childhood In the Sahel, the association between childhood undernutrition undernutrition (Table 1). Children with mothers with less than a and exposure to HAP from biomass cooking fuels was larger than primary school level of education were three times more likely to that with water and sanitation. Although the likelihood of stunting be stunted (low height-for-age) than children with mothers who in children exposed to high levels of HAP was three times that of had above a secondary school level of education. In comparison children exposed to low levels of HAP, the association between to children living in households cooking primarily with clean fuels, improved sanitation and/or drinking water sources and childhood children living in households cooking primarily with biomass undernutrition was small. The likelihood of undernutrition was 1.1 fuels were 2.65 times more likely to be stunted. The likelihood times higher in children who lived in households with unimproved of concurrent stunting and wasting (low weight-for-height) was sanitation facilities or drinking water sources. TABLE 1. Ranking of Factors Associated with Child Undernutrition and Growth Stunting Wasting WaSt HAZ WHZ Child Age 9 8 8 Child Sex 4 4 3 4 7 Recent Cough 7 Recent Diarrhea 3 5 3 3 2 Recent Fever 3 5 3 Number of Children 8 9 Maternal Education 1 1 1 2 1 Maternal Employment 5 6 6 6 5 Paternal Employment HAP Exposure 2 2 2 1 4 Sanitation 5 4 Drinking Water 7 7 6 6 Orange boxes signify the association was not statistically significant or that no association exists 1 indicates the largest association HAP: Household Air Pollution WaSt: Concurrent wasting and stunting HAZ: Height-for-age z-score WHZ: Weight-for-height z-score There was a small but statistically significant association who was empowered in terms of decision-making abilities and between childhood undernutrition and social issues of perceptions of domestic violence. Additionally, child marriage importance to the Sahel and similar regions. The likelihood and polygamy were associated with a slight increase in the of childhood undernutrition was lower in children with a mother likelihood of childhood undernutrition. SASPP Policy Note Series 5 February 2023 Dietary diversity, a strong indicator of micronutrient status, undernutrition and childhood anemia—commonly the result of was associated with childhood macronutrient undernutrition micronutrient deficiencies.6 in the Sahel. The likelihood of childhood stunting was 1.3 times higher in children between 6 and 23 months old whose diet did The statistical significance and magnitude of association not meet the WHO minimum dietary diversity requirement— between childhood undernutrition and child, parental, and the daily consumption of food from five or more food groups.5 household level factors varied within subpopulations. The The intertwined relationship between macronutrient and determinants of childhood undernutrition varied according micronutrient undernutrition was further supported by to country, household wealth quintiles, urban or rural area of a statistically significant association between childhood residence, child sex, and child age. Conclusions and Implications for Future Social Protection Operations 4 in the Sahel First, our findings suggest a need to direct additional attention illnesses or symptoms associated with undernutrition include toward improving maternal socioeconomic status in the anemia, diarrhea, respiratory infections, and fevers. Children Sahel. The importance of maternal socioeconomic status is who are ill normally experience decreased nutrient intake, extensively detailed in literature specific to low- and middle- difficulty absorbing nutrients, and increased biological demand income countries (LMICs) and, in particular, the Sahel.7 8 9 Maternal for nutrients to ensure appropriate immune system functioning. socioeconomic status can impact child nutrition while the child is in This is compounded by the fact that undernutrition weakens utero and after birth. During pregnancy, maternal socioeconomic immune system functioning, making children more vulnerable status can impact health-seeking behaviors and the quality of to infectious diseases and severe illness. accessible healthcare services, disrupting in utero growth. After birth, maternal socioeconomic status can further impact child care Coordinated action between Social Protection and Health, and feeding practices, ultimately faltering postnatal growth. Nutrition, and Population teams could improve child health outcomes in the Sahel. First, and similarly to the above, Social protection programs, particularly cash transfer behavioral change interventions can be introduced as interventions, are uniquely placed to improve maternal accompanying measures of cash transfer programs to encourage socioeconomic status in the Sahel. Cash transfer programs can clinically recommended health and nutrition practices. Second, address financial, social, and cultural barriers to education. The basic healthcare services can be provided alongside social provision of cash would address financial barriers to education. protection services. Third, the provision of cash transfers could In settings where female children typically experience social and be conditional on child health requirements. Evidence-based cultural barriers to education, accompanying behavioral change policy options to address poor child health include improving intervention measures can further encourage school attendance. immunization rates, child care practices, health literacy, and Furthermore, and to encourage earlier improvements in child health-seeking behavior among caregivers of young children. nutritional outcomes, accompanying behavioral change More long-term evidence-based policy solutions include intervention measures should integrate messages about the improving household/community-level environmental conditions, impact pathways detailed above—clinically-recommended which increase the likelihood of poor health, and improving the health-seeking behaviors and child care and feeding practices. quality of healthcare services. Second, the findings of this research suggest that existing Furthermore, given the high prevalence of childhood anemia approaches seeking to improve child health in the Sahel may in the Sahel and its well-documented association with child need to be strengthened. Biomedical research has detailed the health, there may be a need to strengthen or broaden the reach correlation between child health and nutritional status.10 Common of policies addressing micronutrient deficiencies. In addition SASPP Policy Note Series 6 February 2023 to the association between micronutrient deficiencies and child Multisectoral collaboration, particularly between Social health, it is important to note that a growing body of research Protection and Energy teams, could further minimize child demonstrates that present undernutrition is a risk factor for future exposure to HAP and increase the accessibility of improved undernutrition—pertaining to both micronutrient and macronutrient cookstoves and cleaner cookfuels. Cash or in-kind transfers undernutrition.11 Social protection programs can improve child could address financial barriers to accessing cleaner cookfuels micronutrient status through the provision of in-kind transfers to and improved cookstoves, which emit fewer pollutants. vulnerable households. This includes micronutrient supplements, Accompanying behavioral change intervention measures can food supplements such as lipid-based nutrient supplements, be used to encourage the use of improved cookstoves and and/or fortified food. cleaner cookfuels and to encourage behavior that limits child exposure to pollutants. Behavioral interventions seeking to Third, our findings indicate an opportunity to strengthen minimize child exposure to HAP should encourage caregivers nutrition action in the Sahel by including interventions that to cook in a separate room/location from children and improve address the high prevalence of solid fuel use and child ventilation in households. Long-term solutions include improving exposure to pollutants. This reflects a growing body of evidence the affordability of clean cooking fuels and energy infrastructure. demonstrating an association between exposure to HAP and childhood undernutrition in LMICs.12 13 14 Evidence suggests the Fourth and lastly, this research suggests differences in the potential pathways through which exposure to household air determinants of child undernutrition across subpopulations. pollution from solid cooking fuels could result in childhood This is in line with earlier evidence demonstrating that the statistical undernutrition (Figure 3). Despite the high prevalence of solid significance and magnitude of association vary within different fuel use in LMICs and extensive research highlighting the contexts. In order to effectively address high rates of undernutrition in associated negative effects on maternal and child health, HAP the Sahel, interventions must be specific to the populations of interest. has largely been excluded from nutrition research and policy. Effective nutrition action may vary across and within countries. FIGURE 3. Potential Biological Mechanisms for the Association between HAP and Child Undernutrition Socioeconomic Infrastructure Energy status Decreased Wasting appetite and absorption of nutrients Increased risk of respiratory infections Disruption of Energy the endocrine Poverty system Stunting Exposure to household air pollution Surplus of free Cooking Fuel radicals in the Chronic Preferences body inflammation Source: Adapted from Lufumpa, N. 2021. “Child Undernutrition in Sub-Saharan African Countries: An Investigation of Limitations of Current Approaches and Recommendations for Change.”, 2021. 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Advance online publication. https://doi.org/10.1093/inthealth/ihab090 ACKNOWLEGEMENTS SASPP is a multi-donor trust fund managed by the World Bank that supports the strengthening of adaptive social protection systems in the Sahel (Burkina Faso, Chad, Mali, Mauritania, Niger and Senegal) to enhance the resilience of poor and vulnerable households and communities to the impacts of climate change. The program is supported by Denmark, France, Germany and the United Kingdom. NOTE DESIGN: ANDRES DE LA ROCHE / ADELAROCHEDESIGNS.COM For more information: saspp@worldbank.org www.worldbank.org/saspp