The Case for Investment in Nutrition in Senegal Julie Ruel-Bergeron ANALYSIS & PERSPECTIVE: 15 YEARS OF EXPERIENCE IN THE DEVELOPMENT OF NUTRITION POLICY IN SENEGAL The Case for Investment in Nutrition in Senegal January 2018 Julie Ruel-Bergeron Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal © 2018 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202–473–1000 Internet: www.worldbank.org Attribution—Please cite the work as follows: Ruel-Bergeron, Julie. 2018. “The Case for Invest- ment in Nutrition in Senegal.” Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal. World Bank, Washington, DC; CLM, Dakar, Sénégal. License: Creative Commons Attribution CC BY 3.0 IGO This work is a product of the staff of The World Bank with external contributions. 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Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202–522–2625; e-mail: pubrights@worldbank.org. Cover photo: Adama Cissé/CLM Cover design: The Word Express, Inc. Acknowledgments T his report was written by Julie Ruel-Bergeron, Nutrition Specialist with the World Bank. The author would like to acknowledge Menno Mulder-Sibanda who commissioned this important work, and whose passion and perseverance for improving nutrition in Africa and globally is a true inspiration. Thanks are also due to the authors of this series, Babacar Ba, Gabriel Deussom, Ashley Fox, Marc Nene, Marie Jeanne Offosse, Andrea Spray, Denise Vaillancourt, and Christian Yao, whose technical and analytical work greatly contributed to the content and quality of this investment case. A strong appreciation is extended to Andrea Spray, who coordinated and oversaw the development of the many moving pieces in this series, and who ensured consistency and rigor across the various documents. The author would also like to specifically acknowledge Abdoulaye Ka, Malick Faye, and Adama Cissé for their continued sup- port, responsiveness, and engagement, without which this investment case could not have been finalized and pushed forward. About the Series T he government of Senegal, through the Cellule de Lutte contre la Malnutrition (Nutrition Coordination Unit) (CLM) in the Prime Minister’s Office is embarking on the development of a new Plan Stratégique Multisectoriel de Nutrition (Multisectoral Strategic Nutrition Plan) (PSMN), which will have two broad focus areas: (1) expanding and improving nutrition ser- vices; and (2) a reform agenda for the sector. The reform agenda will include policy reorientation, governance, and financing of the PSMN. The PSMN will discuss the framework and timeline for the development of a nutrition financing strategy, which will require specific analysis of the sector spending and financial basis, linking it to the coverage and quality of nutrition services. Senegal is known for having one of the most effective and far-reaching nutrition service delivery systems in Africa. Chronic malnutrition has dropped to less than 20 percent, one of the lowest in continental Sub-Saharan Africa. Government ownership of the nutrition program has grown from US$0.3 million a year in 2002 to US$5.7 million a year in 2015, increasing from approximate- ly 0.02% to 0.12% of the national budget. Yet, these developments have not led to enhanced visibility of nutrition-sensitive interventions in relevant sectors such as agriculture, education, water and sanitation, social protection, and health. The absence of nutrition-sensitive interven- tions in the relevant sectors, combined with the recent series of external shocks, has favored continued fragmentation of approaches, discourse, and interventions that address nutrition. In addition, there is no overall framework for investment decision making around nutrition, which puts achievements made to date in jeopardy. Meanwhile, nutrition indicators are stagnating and other issues with major implications (such as low birth weight, iron deficiency anemia, maternal undernutrition, and acute malnutrition) have received little or no attention. A review of policy effectiveness can help raise the importance of these issues, including house- hold and community resilience to food and nutrition insecurity shocks, as a new priority in nutrition policy development. This series of analytical and advisory activities, collectively entitled Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal (“the se- ries”), aims to support the government of Senegal in providing policy and strategic leadership for nutrition. Further, the series will inform an investment case for nutrition (The Case for Investment in Nutrition in Senegal) that will: (1) rationalize the use of resources for cost-effective interven- tions; (2) mobilize actors and resources; (3) strengthen the visibility of nutrition interventions in different sectors; and (4) favor synergy of interventions and investments. The series was produced with guidance from a task force of development partner organizations under the leadership of the World Bank, and in close collaboration with the CLM. The task force comprised representatives from the following organizations: Government of Canada, REACH, UNICEF and the World Bank. Documents in the series: Report Description Nutrition Situation in Senegal An analysis of the nutritional status of key demographic groups in Marc Nene Senegal, including the geographic and sociodemographic inequalities in nutrition outcomes and their determinants. Evolution of Nutrition Policy in An historical analysis of the nutrition policy landscape in Senegal, Senegal including the evolution of nutrition policies and institutions, and Andrea L. Spray their respective implications for programming and prioritization of interventions. Political Economy of Nutrition An analysis of the policy and political levers that can be used in Senegal Policy in Senegal to foster government leadership and galvanize intersectoral coordination Ashley M. Fox needed to mainstream nutrition into government policies and programs and effectively, efficiently, and sustainably deliver nutrition interventions. Nutrition Financing in Senegal An analysis of the allocated funding to nutrition interventions in Senegal Marie-Jeanne Offosse N. from 2016 to 2019, estimates of budgetary availability for financing nutrition by government, and estimated costs for selected high-impact interventions. Capacities of the Nutrition Sector An analysis of the organizational and institutional capacities for in Senegal addressing nutrition in Senegal, covering the CLM, key ministries, and Gabriel Deussom, Victoria Wise, other stakeholders contributing to achieving improvements in nutrition at Marie Solange Ndione, Aida central, regional, and local levels. Gadiaga Cost and Benefits of Scaling Up Analysis of the relative costs and effectiveness of alternative scenarios Nutrition Interventions in Senegal for scaling up nutrition interventions in Senegal over the five years Christian Yao covering the PSMN. Risks for Scaling Up Nutrition in Analysis of the potential risks to the scale-up of nutrition in Senegal, Senegal likelihood of occurrence, potential impact, and potential mitigation Babacar Ba measures. A Decade of World Bank Support The World Bank Independent Evaluation Group (IEG) Project to Senegal’s Nutrition Program Performance Assessment Report (PPAR) on the recent 10 years of Denise Vaillancourt support for nutrition in Senegal, which evaluates the extent to which World Bank operations achieved their intended outcomes and draws lessons to inform future investment. Acronyms Acronym English Acronyme Français AEC Community Executing Agency AEC Agence d’Exécution Communautaire BEN National Executive Bureau BEN Bureau Exécutif National BMI body-mass index IMC indice de masse corporelle CL Local Government Collectives CL Collectivités Locales CLM Nutrition Coordination Unit CLM Cellule de Lutte contre la Malnutrition DALY disability-adjusted life year AVAI année de vie ajustée en fonc- tion de l’incapacité DHS Demographic and Health EDS Enquête sur la Démographie Survey et la Santé DPNDN National Policy for the Develop- DPNDN Document de Politique Natio- ment of Nutrition nale de Développement de la Nutrition GDP Gross Domestic Product PIB Produit Intérieur Brut IQ intelligence quotient QI quotient intellectuel IYCF Infant and Young Child Feeding ANJE Alimentation du Nourrisson et du Jeune Enfant MAD Minimum Acceptable Diet MAD Régime alimentaire minimum acceptable MICS Multiple Indicator Cluster MICS Enquête à indicateurs Survey multiples NGO Nongovernmental Organization ONG Organisation Non Gouvernementale PQDES Quadrennial Economic and So- PQDES Plan Quadriennal de Dével- cial Development Plan oppement Économique et Social PRN Nutrition Enhancement PRN Programme de Renforcement Program de la Nutrition PSMN Multisectoral Strategic Nutrition PSMN Plan Stratégique Multisectori- Plan el de la Nutrition SDG Sustainable Development ODD Objectif de Développement Goals Durable SUN Scaling Up Nutrition Movement SUN Mouvement pour le Renforce- ment de la Nutrition Acronym English Acronyme Français UNICEF United Nations Children’s Fund UNICEF Fonds des Nations Unies pour l’Enfance WASH water, sanitation, and hygiene EAH eau, assainissement, et hygiène WHA World Health Assembly AMS Assemblée Mondiale de la Santé WHO World Health Organization OMS Organisation Mondiale de la Santé Unless otherwise indicated, child nutrition indicators referenced in this report are taken from the UNICEF- WHO-World Bank Joint Child Malnutrition Estimates1. Contents Acknowledgments iii Executive Summary 1 Introduction 7 The Case for Investment in Nutrition in Senegal 11 Barriers to Good Nutrition in Senegal 17 What is Needed? 27 Economic Analysis 35 Summary and Conclusions: A Call to Action 39 Appendix A: Nutrition Activities Included in Budgetary Projections, by Sector 41 Endnotes 45 References 47 Glossary 51 List of Boxes Box 1: Reports in the series Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal 9 List of Figures Figure Stunting in Children under Five in Senegal 1: 13 Figure Stunting in Children under Five by Per Capita GDP 2: 13 Figure Conceptual Model of the Determinants of Undernutrition 3: 21 Figure Prevalence and Absolute Number of Stunted and Wasted Children 4: in Senegal by Region 24 Figure 5: Conceptual Framework of the Multisectoral Approach for Nutrition 28 Figure 6: Institutional Arrangements for the Delivery of Nutrition Services in Senegal 30 List of Maps Map 1: Effects of Shortfalls in Rain on Food Insecurity and Undernutrition 18 Map 2: Regional Divides of Prevalence of Stunting and Wasting in Senegal, 2015 23 List of Tables Table 1: Estimated Costs by Sector and Year for Nutrition in Senegal, 2017–21 36 Table 2: Budget Breakdown by Type of Nutrition Intervention by Sector and as a Proportion of the Total Budget, 2017–21 37 Table 3: Financial Analysis of Sector-Specific Budgetary Needs and Sources, 2017–21 37 Executive Summary S enegal has made impressive gains in improv- for Nutrition Interventions; The Risks of Scaling Up ing the nutritional status of its population in Nutrition; and An Independent Review of a Decade recent decades. The prevalence of all forms of World Bank Support of Nutrition. Based on this se- of child undernutrition, whether stunting, wasting, or ries of reports, this investment case will outline future underweight, is lower than that in most other countries directions for Senegal in alignment with the country’s in the region, even among the poorest segments of new Plan Stratégique Multisectoriel de la Nutrition the population. These gains are largely the result of (Multisectoral Strategic Nutrition Plan) (PSMN) and decades-long political, financial, and capacity building Document de Politique National de Développement efforts. Nevertheless, the remaining burden of under- de la Nutrition (National Policy for the Development nutrition across all population groups continues to of Nutrition) (DPNDN), while stimulating the mobiliza- threaten child survival, contributing to 45 percent of tion of resources for the scaled-up implementation of deaths among children under five globally every year cost-effective interventions across sectors in Senegal. and accounting for at least 13,000 under-five deaths per year in Senegal. Given the progress that has been achieved in recent decades, reversals in global funding Why Invest In Nutrition in Senegal? for nutrition in Senegal constitute a significant threat to the economic and social development of the country, People who are well nourished throughout their lives especially if the remaining high and growing burdens are better able to achieve their full physical and de- of under- and overnutrition are not addressed. velopmental potential. Poor nutrition often starts in utero and continues to deteriorate during childhood, This investment case is based on a synthesis of eight adolescence, and pregnancy, contributing to an inter- analytical documents that delve into various aspects generational cycle of undernutrition. Thus, ensuring of nutrition in Senegal: The Nutrition Situation in good nutrition during each of these critical life phases Senegal; The Evolution of, and Political Economy of contributes directly to healthy and productive pop- Nutrition Policy; Nutrition Financing; Capacity Assess- ulations and to economic development and poverty ment of The Nutrition Sector; The Cost of Scale-Up reduction at a national and global level. The Case for Investment in Nutrition in Senegal 1 In addition to the importance of investing in nutrition shocks from rising food and fuel prices, the global fi- for improved individual and national development out- nancial crisis, floods and droughts, and health-related comes, Senegal is well-placed to implement nutrition crises (such as the Ebola outbreak) in recent years. interventions. The country has prioritized nutrition Economic and climatic shocks have led to sharp de- since the birth of the republic and has institutionalized clines in agricultural production, stagnation in poverty nutrition policy, programming, and coordination at the reduction, and high levels of food insecurity (16 per- highest level, under the office of the Prime Minister’s cent in 2014) (FEWS NET 2014; WFP 2014). The Nutrition Coordination Unit (CLM). The political place- health consequences brought on by a rising burden ment of the CLM is of crucial importance to Senegal’s of overweight and obesity among adults and children ability to absorb, coordinate, and implement funding, also constitute an unanticipated threat. In the midst of policies, and programs throughout the country, and its nutrition transition, Senegal bears a double and tri- across line ministries. ple burden of malnutrition, under which undernutrition, overnutrition, and micronutrient deficiencies coincide Finally, Senegal has demonstrated that it can achieve in households and individuals. progress in nutrition. Between 1992 and 2012, and in contrast to many of its African neighbors who saw The determinants of malnutrition in Senegal are com- either a stagnation or deterioration in child nutrition plex, interrelated, and deeply rooted in the social, indicators, Senegal reduced the prevalence of child economic, and political contexts in which populations stunting from 34.4 percent to 19.2 percent. Though still grow and develop. Immediate causes of undernutri- high, child anemia also saw some improvement, with tion among children are poor diet and high morbidity. a reduction from 82.6 percent in 2005 to 66.3 percent Children’s diets are inadequate both in terms of qual- in 2015 (Ndiaye and Ayad 2006; ANSD 2016; Nene ity and frequency, with an all-too-low proportion of 2018).2 And despite persistent overweight and obesity 33.3 percent of children who are exclusively breastfed among women, the proportion of children under five (ANSD 2016). Adding insult to poor nutrition among who are overweight remains quite low, affecting only young children is the high burden of common child- 1.2 percent of children in 2014 (ANSD 2015b; Nene hood illnesses, such as diarrhea, fever, and acute 2018). respiratory infection (ANSD 2016). Poor dietary di- versity that contributes to inadequate complementary diets among young children is a consequence of other, What are the Barriers to Good Nutrition in more distal factors, such as household food insecurity Senegal? and insufficient maternal knowledge. Even if a mother has knowledge of appropriate feeding and care-giv- The nutrition profile of children in Senegal is charac- ing practices, gender norms may inhibit her power to terized by a moderate prevalence of stunting, high make health, food, and nutrition-related decisions. prevalence of wasting and anemia, and low prevalence of overweight and obesity (Nene 2018). Among wom- Though the determinants discussed are relevant en of reproductive age, anemia, thinness, and growing across all regions in Senegal, this investment case em- rates of diet-related noncommunicable diseases phasizes the importance of both regional determinants continue to be problematic (Nene 2018). New and and burdens. Geographic and sociodemographic dif- emerging threats to nutrition—including external global ferences in nutrition indicators highlight important economic and climate-related shocks that risk destabi- regional disparities (Nene 2018). For example, along lizing international, national, and household-level food the poverty incidence lines, the more urban and production, access, and availability—further consti- wealthy northern and western regions exhibit a much tute barriers to good nutrition in Senegal. Senegal has lower prevalence of stunting than do the central and been particularly affected by the successive economic southern regions. Some regions that have extremely 2 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal high levels of poverty also exhibit uncharacteristical- The DPNDN, on which the PSMN is based, lays out ly high levels of stunting (Nene 2018). Residence, a conceptual framework for multisectoral action in wealth, and sex are important determinants of child nutrition. This framework integrates four pillars, or stunting in Senegal. Although almost all sociodemo- categories, of intervention that support an optimal nu- graphic groups shared in the recent reduction in child tritional status, as well as transversal, cross-cutting stunting, wealthier, female, and urban-based children issues at the base of each of those pillars. The inter- have experienced the greatest reductions in child vention pillars include: production of nutritionally rich stunting over time (Nene 2018). foods in sufficient quantities; adequate processing, distribution, and tarification (appropriate distribution In addition to physical, sociodemographic, and geo- and import-export taxation schemes) of nutritionally graphic barriers to good nutrition, several other risks rich foods; education, sanitation, and hygiene; and have been identified as threats to the implementation essential health and nutrition services. Cross-cutting of the PSMN. These include, inadequate engagement issues include: ownership through local governance by relevant political authorities and the private sec- and territorial development; sustainable financing; tor; significant human capacity gaps; the inability of advocacy and communication for social and behavior critical personnel to effectively mainstream nutrition change; multisectorality through community participa- through relevant sectors; and inadequate intrasec- tion and equity; and research through monitoring and toral coordination (Deussom N. et al. forthcoming; Ba evaluation, capacity building, and coordination. Oper- forthcoming). The human capacity gap, in particular, ationally, the institution of a common results framework presents a challenge to integrating nutrition both hor- that translates national targets at the regional, district, izontally (across sectors) and vertically (at various and community levels, will become essential for track- political and organizational levels), given the dearth of ing nutrition progress across sectors, as well as across skilled people who are adequately trained in both nu- geographic regions and populations. trition and their sectoral specialty (Deussom N. et al. forthcoming; Ba forthcoming). Beyond the four pillars and their bases are three stra- tegic objectives that are meant to guide actors in the Although the barriers presented here are long and development and implementation of key interventions daunting, Senegal has demonstrated that, with ade- that will contribute to the final seven targets that rep- quate technical and financial support, it can move the resent an optimal nutritional status, as laid out in the needle on nutrition indicators and achieve improved PSMN. The three strategic objectives are meant to nutrition outcomes for all its people. be applied to each of the four pillars of intervention discussed above and include: mainstreaming nutrition across sectors; decentralization of program delivery; What is Needed to Address Nutrition in and use of a community-based approach. Finally, Sen- Senegal? egal recognizes four principles of engagement that are aligned with those that are used for all public service The important variations in the nutrition profile of delivery: proximity and subsidiarity; equity and social women and children across regions within the country, justice; good governance; and contracting. These where malnutrition does not affect all equally, require principles constitute the ethical, legal, and moral guid- regionally tailored nutrition interventions. The broad ance for nutrition interventions implemented across all goal is to strengthen community and household resil- sectors. ience against malnutrition using specific actions that are developed on the basis of each region’s epidemi- The institutional arrangements needed to deliv- ological, sociodemographic, and geographical profile er nutrition services to the Senegalese population and how these interact to affect nutritional status. are in place. The CLM supports the Prime Minister The Case for Investment in Nutrition in Senegal 3 in technical matters relating to nutrition and in the for nutrition-specific and nutrition-sensitive activities implementation, monitoring, and evaluation of cor- for all children under the age of five. This estimate responding action plans and activities for nutrition at corresponds to an investment of US$5 per person per the national level. Line (technical) ministries, includ- year, and US$29 per child under the age of five per ing those in charge of agriculture, health, education, year, and includes funding for the implementation of a water, sanitation and hygiene, social protection, com- full package of nutrition-specific (30 percent of budget) merce, industry, and local government collectives and nutrition-sensitive (70 percent of budget) activities (CLs), fall under the CLM, which ensures that nutrition from the following sectors: health; water, sanitation, activities are mainstreamed into each sector. Also un- and hygiene; social protection; agriculture; fisheries; der the CLM, but responsible for the operationalization livestock; education; higher education and research; and management of community-level nutrition activi- CLs (which are responsible for the delivery of most ties, is the Bureau Exécutif pour la Nutrition (National nutrition-specific interventions); industry; environment; Executive Bureau for Nutrition) (BEN). All communi- and commerce. ty-level activities are managed directly by CLs, which reach communities and individuals through Agences Parallel to these nutrition-specific and nutrition-sen- d’Exécution Communautaire (Community Execution sitive interventions, a certain number of investments Agencies) (AEC) that operate across the country’s have been identified in 12 sectors with the goal of im- 14 regions. The AECs are directly responsible for the proving the global nutrition environment in Senegal. recruitment, capacity building, monitoring, and super- These favorable nutrition investments aim to improve vision of direct service providers and service delivery the quality of life of the Senegalese population through to communities, households, and individuals. the development and enforcement of policies in all sectors associated with nutrition, but also through This institutional arrangement for nutrition in Sene- employment, infrastructure, and equipment that are gal is ideally primed for the mainstreaming of nutrition necessary for the delivery of nutrition-specific and nu- across sectors, as it enables the country to “think mul- trition-sensitive services. These global investments tisectorally, and act sectorally” (World Bank 2013). are estimated at 650 billion F CFA (approximately $US Sectors have the freedom and mandate to implement 1 billion) (République du Sénégal, forthcoming). relevant nutrition activities sectorally (vertically), while benefitting from the CLM’s transversal view and coordi- An analysis of returns on investment for implementing nation across all sectors (horizontally). In parallel, the a package of nutrition-specific and nutrition-sensitive Programme de Renforcement de la Nutrition (Nutrition (health, water, and sanitation) activities (smaller in Enhancement Program) (PRN) has developed the foun- scope than that which is proposed by PSMN) at scale dation for a well-functioning service delivery platform or that prioritizes regions with a heavy burden of un- for maternal and child nutrition services at the commu- dernutrition with specific interventions demonstrates nity level using partnerships between CLs and AECs. that all of the scenarios considered would bring high returns to investment (Yao forthcoming). In other words, the choice between the various scenarios pre- What Will it Cost? sented depend on the amount of public resources that can be mobilized for nutrition in Senegal. Over the period from 2017 through 2021, the budget needed to operationalize the DPNDN and the PSMN and implement nutrition-specific and nutrition-sensitive Call to Action interventions across all sectors will grow to an estimat- ed average of US$71 million per year. This number is The rationale for investing in nutrition in Senegal is derived from a total budget of US$355 million required well established in this investment case. Good nu- 4 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal trition is essential for ensuring good health, saving ®® Support the integration of nutrition activities into lives, and building human capital for a prosperous other sectors, as dictated by the DPNDN and and economically productive Senegal. The timing for PSMN; intervening in nutrition in Senegal is equally critical: ®® Adequately prepare for additional nutrition chal- The country has entered its nutrition transition, with an lenges that lie ahead, such as the growing burden unfinished agenda in undernutrition parallel to a rising of overweight and obesity. threat of overweight, obesity, and their associated con- sequences on health, well-being, and longevity. Most This investment case urges the global community to importantly, and to tackle the double and triple bur- support and contribute to Senegal’s momentum in dens of malnutrition, Senegal is embarking on a new, redefining the country’s nutrition policies and opera- multisectoral approach that deviates from “business tions and to sustain longstanding efforts in nutrition, as usual”3 to achieve its ambitious nutrition goals. The not only to prevent a stagnation—or worse, a deteri- next decade marks a new era for nutrition in Senegal, oration—in progress that has been made in nutrition where continued and renewed efforts are needed to: in recent decades, but also to increase the ability of even the most vulnerable members of society to be ®® Expand the delivery of nutrition services from the nutrition secure. Today, Senegal is at a critical stage of current coverage of 400 to a goal of 571 communes ramping up key nutrition interventions to scale and in (municipalities); an unconventional way that engages multiple, relevant ®® Intensify and reach full coverage of nutrition sectors, with a focus on capacity building that will yield services for all children under five in the 400 com- sustained changes in behavior and improved nutrition munes in which the national nutrition program is for all of Senegal’s people. The time to invest in the already operational; country’s new, exciting era for nutrition is now. The Case for Investment in Nutrition in Senegal 5 Photo: Adama Cissé/CLM 1 Introduction S enegal is among the few countries in Sub-Sa- 13,000 under-five deaths per year in Senegal (Black haran Africa that have succeeded in improving et al. 2013). Progress against malnutrition achieved their population’s nutritional status in recent over time notwithstanding, reversals in global funding decades. The prevalence of key nutrition indicators, for nutrition in Senegal neglect the still-too-high prev- such as the proportion of children stunted, wasted, alence of child stunting, wasting, and micronutrient and underweight, is lower than that in most other deficiencies, as well as the persistent prevalence of countries in the region, and even among the poorest under- and overweight and anemia among women. segments of the population. Such gains likely could This unfinished agenda for nutrition in Senegal will be not have been achieved without significant political, presented in this investment case. financial, and capacity building investments includ- ing the establishment of the CLM and the scale-up of Good nutrition is a fundamental and necessary driver community-based nutrition interventions throughout of human capital because of its major role in cognitive the country. Government ownership of nutrition pro- and physical development (Black et al. 2008). Nutri- gramming and intervention, in the form of increased tion in early childhood has been deemed by the global financial investment over time, further demonstrates community to be a key determinant of both labor pro- the importance placed on nutrition policy, planning, co- ductivity and economic growth (World Bank 2006). ordination, and programming at the country’s highest In economic terms, it is estimated that global annual political levels. productivity losses associated with all forms of under- nutrition (most of which occur during childhood and Despite a significant reduction in child stunting of 15 result in short stature and poorer cognition and school percentage points between 1992 and 2012, the burden attainment for both adolescents and adults) can reach of malnutrition in all its forms continues to contribute to 6 percent of gross domestic product (GDP) (Horton excess morbidity and mortality, especially in the most and Steckel 2013). For this reason, many of the inter- vulnerable segments of the population. Child under- ventions that seek to improve the nutritional status of nutrition contributes to 45 percent of deaths among children during the critical window of opportunity, that children under five globally and accounts for at least is, the first 1,000 days of a child’s life, are understood The Case for Investment in Nutrition in Senegal 7 to be the most cost-effective investment a country can efforts are needed to carry out an ambitious nutrition make. Recent analysis suggests that, in Africa, ev- agenda that deviates from the business-as-usual ap- ery dollar invested to reduce child stunting generates proach to reach the WHA goals and the SDGs and US$16 in economic returns (Hoddinott 2016). to continue to yield progress in nutrition indicators. Specifically, such activities include an expansion of In Senegal, a cost-effectiveness analysis of nutri- the scale and operation of nutrition programming, the tion-specific and handwashing interventions found that integration of nutrition activities into other sectors, as a US$11.2 million investment to scale up coverage to dictated by the DPNDN and the PSMN, and the use 100 percent would prevent 5,280 deaths, 159,398 dis- of innovative funding mechanisms that will enable im- ability-adjusted life years (DALYs), and 101,587 cases proved results. of stunting (Yao forthcoming). The comparison of vari- ous scenarios to implement a package of activities—at This investment case outlines future directions in scale or that prioritize regions with the highest burden, nutrition for Senegal on the basis of the PSMN and or with interventions specific to the type of burden in synthesizes a series of eight reports (box 1) pre- each region—demonstrates that all of the considered pared for the purpose of understanding the country’s scenarios promise a high return on investment (Yao progress to date, while highlighting remaining gaps forthcoming). Therefore, the choice of which scenario in funding and implementation for nutrition. The first to implement will depend more on the amount of public section presents the developmental and economic ra- resources made available to address nutrition, rather tionales for investing in nutrition, including a review of than on the cost-effectiveness of each scenario (Yao Senegal’s unique political climate, which lends itself to forthcoming). the development of new, unconventional policies. The second section draws from a situation analysis, a po- The importance of nutrition for human development is litical economy study, and an institutional performance widely known and increasingly being represented in assessment to describe ongoing barriers to good nu- global initiatives, such as the World Health Assembly trition in Senegal, while the third section proposes (WHA) and the United Nations’ new Sustainable De- solutions on how to overcome them, in alignment with velopment Goal (SDG) nutrition targets. Both of these the PSMN. The fourth section presents the financial include ambitious targets for the reduction of stunting requirements for these activities, which are based on and wasting, with the WHA also broadening its focus a calculation of sector-specific financial needs costed to include targets for improved breastfeeding practices during the development of the PSMN, secured funding and reductions in micronutrient deficiencies, low birth- identified in the financing analysis study (Offosse N. weight, and childhood overweight. 2017), and the costs of scaling up to 90 percent cover- age as calculated in the economic analysis report (Yao For Senegal, which has arguably entered its nutrition forthcoming). This investment case concludes with a transition and which is embarking on a new, multisec- call to action, with the objective of stimulating the mobi- toral approach to tackle the double and triple burdens lization of resources for the scaled-up implementation of malnutrition, there is no better time to ramp up nutri- of cost-effective interventions, while strengthening the tion investment. At this turning of the tide for nutrition visibility and synergy of nutrition interventions and in- programming nationwide, new, innovative, and resolute vestments across sectors in Senegal. 8 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal BOX 1:  Reports in the series Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal • Nutrition Situation in Senegal. An analysis • Capacities of the Nutrition Sector in Senegal. of the nutritional status of key demographic An analysis of the organizational and institutional groups in Senegal, including the geographic capacities for addressing nutrition in Senegal, and sociodemographic inequalities in nutrition covering the CLM, key ministries, and other outcomes and their determinants. stakeholders contributing to improvements in • Evolution of Nutrition Policy in Senegal. An nutrition at the central, regional, and local levels. historical analysis of the nutrition policy landscape in • Cost and Benefits of Scaling Up Nutrition Senegal, including the evolution of nutrition policies Interventions in Senegal. Analysis of the relative and institutions and their respective implications for costs and effectiveness of alternative scenarios for programming and prioritization of interventions. scaling up nutrition interventions in Senegal over • Political Economy of Nutrition Policy in the five years covering the PSMN. Senegal. An analysis of the policy and political • Risks for Scaling Up Nutrition in Senegal. levers that can be used in Senegal to foster Analysis of the potential risks to the scale-up of government leadership and galvanize the nutrition in Senegal, their likelihood of occurrence, intersectoral coordination needed to mainstream potential impact, and potential mitigation nutrition into government policies and programs, measures. and effectively, efficiently, and sustainably deliver • A Decade of World Bank Support to Senegal’s nutrition interventions. Nutrition Program. The World Bank Independent • Nutrition Financing in Senegal. An analysis of Evaluation Group Project Performance the allocated funding to nutrition interventions Assessment Report, which evaluates the extent to in Senegal from 2016 to 2019, estimates of which World Bank operations supporting nutrition budgetary capacity for financing nutrition by in Senegal from 2002–14 achieved their intended government, and estimated costs for selected outcomes and draws lessons to inform future high-impact interventions. investments. The Case for Investment in Nutrition in Senegal 9 Photo: Adama Cissé/CLM 2 The Case for Investment in Nutrition in Senegal Nutrition is Central to Development from reductions in disease, mortality, and increases in health care expenditures (World Bank 2006). People who are well nourished throughout their early lives—that is, from conception through the intrauterine The intergenerational transmission of undernutrition period and during the periods of rapid growth in child- is important in Senegal, where, in 2010–11, wom- hood and adolescence—are better able to achieve en underweight (thinness) hovered at 22.0 percent, their full physical and developmental potential (Black and more than half (54.3 percent) 4 of all women et al. 2008). Nutrition intervention during the first 1,000 of reproductive age were anemic (ANSD 2012). In days of a child’s life (from conception to age 2), also addition, 16.3 percent of mothers interviewed in referred to as “the critical window of opportunity,” is the 2015 Demographic and Health Survey (DHS) important because of the irreversibility of the negative reported that their children suffered from low birth- effects of undernutrition on cognitive and physical de- weight, setting them on poor growth trajectories for velopment after this period. the remainder of their early childhood and beyond (ANSD 2016). Breaking this cycle requires a com- Poor nutrition often starts in utero and continues to prehensive and holistic approach that addresses deteriorate during childhood, adolescence, and preg- the multiple determinants of malnutrition to most nancy, contributing to an intergenerational cycle of effectively change the human development trajec- undernutrition (United Nations and IFPRI 2000). En- tory of children and of the nation. As estimated in suring good nutrition during each of these critical the cost-effectiveness analysis undertaken by Yao life phases contributes directly to healthy and pro- (2017), scaling up the coverage of nutrition-specif- ductive populations, and more broadly, to economic ic and nutrition-sensitive interventions as early as development and poverty reduction at a national and adolescence (for young mothers) and throughout global level (World Bank 2006). Improvements in the reproductive and early childhood periods holds cognitive development, school performance, physi- enormous potential for preventing undernutrition cal development and work capacity, and health result and saving children’s lives. The Case for Investment in Nutrition in Senegal 11 Finally, investing in nutrition is necessary to fulfill US$0.3 million in 2002 to US$5.7 million annually in Senegal’s ambition to become an emerging economy 20155—further demonstrates the administration’s com- by 2035. Nutrition investments are perfectly aligned mitment to nutrition through institutionalizing “funding with the second strategic axis of the Emerging Sen- for nutrition beyond the life of any single project or ad- egal Plan to improve the population’s human capital ministration” (Spray 2018). through significant improvements in “access to health care, safe drinking water and sanitation, as well as The political placement of the CLM was—and contin- strengthening nutrition” (République du Sénégal 2014, ues to be—of crucial importance to Senegal’s ability to 62). Moreover, investments in nutrition will indirectly absorb, coordinate, and implement funding, policies, contribute to the Emerging Senegal Plan’s first strate- and programs throughout the country. At the time of gic axis of a structural transformation of the economy, its inception, the CLM represented a much-needed through the links between nutrition and cognitive and restructuring of the previous entity, the Commission physical development and, subsequently, economic Nationale de Lutte contre la Malnutrition (National productivity. Committee for the Fight against Malnutrition), which had been widely criticized for its failure to coordinate across ministries (Spray 2018). Today, and under Senegal’s Political Climate Promotes and continued efforts to scale up nutrition activities in ac- Facilitates Nutrition Investments cordance with the DPNDN and the PSMN, the CLM is aptly placed to mainstream nutrition across major Nutrition has been prioritized in Senegal since the birth line ministries and to support the implementation of of the Republic, as evidenced in key social and de- both nutrition-specific and nutrition-sensitive interven- velopment policies that date back to the 1950s. Since tions at scale (Fox 2018). Furthermore, it represents then, nutrition policy has evolved over a series of dis- a platform that coordinates external funding and part- tinct generations described in detail in Spray (2018); nerships and sets clear lines of accountability (Spray the various “generations” of nutrition policy and pro- 2018). gramming highlight “a constant interplay between social, environmental, and economic events; politics; Senegal solidified its already extensive and long- the state of nutrition knowledge; and the engagement standing political support for nutrition by its public and influence of external stakeholders” (Spray 2018). and international pledge to join the Scaling Up Nutri- tion (SUN) Movement, which it did in 2011. Senegal Most notable across time was the importance of and the CLM have adopted—and are working toward nutrition in the Quadrennial Economic and Social reaching—the SUN Movement vision of becoming a Development Plans (PQDESs), which led to the devel- country free from malnutrition in all its forms by build- opment of institutions dedicated to food and nutrition ing an enabling environment for nutrition, mobilizing and making maternal and infant protection a national the necessary resources to do so, and aligning im- priority as early as the 1960s. The institutionalization plementation of activities across sectors to maximize of nutrition in the 1990s, the shift toward the preven- results. tion of malnutrition using a community-based and preventive approach, and the subsequent creation of Senegal has emerged as a pioneer in the fight against the CLM in 2001 to coordinate the large-scale imple- malnutrition and is uniquely placed to drive the ambi- mentation of these activities across pertinent sectors, tious and complex multisectoral agenda for nutrition. all contributed to the significant and rapid improve- The country has a long and strong track record for ments in nutrition the country has seen to date (Spray improving nutrition and an even stronger foundation 2018). The parallel addition of an investment line to from which to draw valuable lessons to support future the national budget—and its growth over time, from efforts to face continuing and emerging nutrition chal- 12 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal FIGURE 1: Stunting in Children under Five in Senegal 40 34.4 33.7 28.8 29.5 28.7 30 20.1 20.5 Percent 19.2 19.4 20 10 0 1991–92 1992–93 1996 2000 2005 2010–11 2012–13 2014 2015 Year Source: UNICEF-WHO-World Bank Joint Child Malnutrition Estimates, UNICEF (United Nations Children’s Fund), WHO (World Health Organization) and World Bank (accessed 2017), http://datatopics.worldbank.org/child-malnutrition/, and Spray 2018. lenges. The various political factors discussed here Maintaining Nutrition Gains to Ensure a have been—and will continue to be—indispensable Prosperous and Stable Senegal for mobilizing both internal and external resources, without which the achievement of the WHA and SDG Senegal has demonstrated rapid and significant gains targets will not be possible. across various nutrition indicators in recent decades, FIGURE 2: Stunting in Children under Five by Per Capita GDP 60 Yemen Pakistan 40 Percent Nigeria Cote d’lvoire Kenya Haiti Egypt 20 Senegal Ghana Gabon Peru 0 0 5,000 10,000 15,000 20,000 GDP per capita, PPP (2011 international $) Source: Nene 2018. Based on data from World Development Indicators (database), World Bank, Washington, DC (accessed 2016), http://data.worldbank.org/data- catalog/world-development-indicators; UN DESA 2015; STATcompiler (database), USAID, Washington, DC (accessed 2016), http://www.statcompiler.com/en/. Note: The sizes of the circles are proportional to the number of children under the age of five. The red line indicates the model’s prediction. PPP = purchasing power parity. The Case for Investment in Nutrition in Senegal 13 and its success is even more pronounced when com- quotient (IQ) of those who survive (WHO 2000). More- pared to many of its Sub-Saharan African neighbors, over, given the acute nature of wasting, children tend which saw deterioration in nutritional status during the to go in and out of the state of wasting, which leads same period. Most notable is its performance in child to an IQ estimated to be 8–18 points lower than the stunting: Between 1992 and 2012, the prevalence of level they could have achieved in the absence of wast- stunting fell from 34.4 percent to 19.2 percent, with ing (Alif Ailaan 2015). In fact, the relationship between the most rapid reduction occurring between 2000 undernutrition and IQ is graded and linear; even less and 2005 (figure 1). The reductions in child stunting severe forms of undernutrition negatively affect cogni- coincided closely with the establishment of the CLM tive performance (Venables and Raine 2016). in 2001, despite the slow annual average per capita GDP growth rate of 1.8 percent during that same pe- Nutrition indicators among women of reproductive riod (Nene 2018). The extent to which income growth age also demonstrate slow progress, particularly in leads to nutritional improvements is still a topic of de- anemia, which affects more than half of all women of bate, but irrespective of its economic growth, Senegal reproductive age and remained largely unchanged be- performed exceptionally well in child stunting (Ruel tween 2005 and 2010–11, when it was last measured and Alderman 2013; Nene 2018). As shown in figure 2, (Nene 2018). Among women who are pregnant—a the prevalence of stunting is much lower than that ob- time during which anemia typically worsens as a served in countries with comparable per capita income result of increased blood volume needs and hemodi- and on a par with countries that have much higher in- lution—anemia presents among the most responsive come levels (Nene 2018). Child anemia has also seen outcomes: scale-up to 90 percent coverage of intermit- some improvement, falling from 82.6 percent in 2005 tent iron folate supplementation could yield a reduction to 66.3 percent in 2015, though it remains high (Ndiaye in anemia of more than half, from 64 percent to 29 per- and Ayad 2006; ANSD 2016; Nene 2018). Despite cent, or more than 200,000 cases averted in the five persistent overweight and obesity among women, the years from 2016 to 2021.6 proportion of children under five who are overweight remains quite low, at only 1.2 percent of children in Finally, the rapidly changing epidemiology of nutrition 2014 (ANSD 2015b; Nene 2018). cannot be ignored, further challenging the country as it attempts to address the persistent burden of over- Despite the nutrition gains among children under five, weight and obesity in this period of transition. The recent data show that certain nutrition indicators contin- country continues to struggle with maternal under- ue to lag and threaten progress toward the achievement weight (22.0 percent in 2010–11) and anemia (54.3 of WHA and SDG targets. The most recent DHS sur- percent in 2010–11),7 while almost the same propor- vey, conducted in 2016, indicates an increase in child tion of women (21.3 percent) was estimated to be stunting, with the prevalence creeping back up to 20.5 overweight or obese (ANSD 2012; Nene 2018). And percent from 19.2 percent and 19.4 percent in 2012– despite a dearth of data on how much overweight and 13 and 2014, respectively (figure 1) (ANSD 2016). In obesity currently contribute to the development of non- addition, prevalence of wasting demonstrated a near communicable diseases, small surveys in the urban complete stagnation, hovering at about, or just under, areas of Dakar and Saint-Louis point to an alarming- 10 percent, beginning in 1991–92, with the exception ly high prevalence of associated risk factors, such as of 2014, when it reached a record low of 5.8 percent. high blood pressure, high cholesterol, and metabolic The 2015 DHS, however, indicated an increase to 7.8 syndrome (Duboz 2012; Seck 2015; Pessinaba et al. percent (ANSD 2016). The World Health Organization 2013; Nene 2018). (WHO) classifies a prevalence of wasting of 10–14 per- cent as a serious public health emergency because of In sum, Senegal has registered impressive gains in the risks of wasting on mortality and on the intelligence certain areas of child and maternal nutrition thanks 14 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal to the establishment of a national implementation of a more comprehensive package of interventions and service delivery framework. However, significant to an unprecedented 80–90 percent, is a complex, challenges and threats remain to ensuring optimal nu- resource-intensive endeavor, particularly with new trition for the Senegalese population, especially in the political leadership and frequent economic and envi- context of the country’s ambitious goals to become an ronmental shocks. Supporting the country—technically emerging economy by 2035. There is no better time and financially—through this key transitional phase, to invest in nutrition in Senegal than now. Despite the and readying it to tackle an entirely new dimension of favorable political climate for nutrition, mainstreaming nutritional challenges, present a unique opportunity to nutrition-sensitive and nutrition-specific interventions pave the way toward ensuring a prosperous and sta- across multiple sectors, while expanding the coverage ble Senegal for generations to come. The Case for Investment in Nutrition in Senegal 15 Photo: Adama Cissé/CLM 3 Barriers to Good Nutrition in Senegal Nutrition challenges in Senegal creased morbidity from exposure to pathogens, and greater female participation in the labor market, which The nutrition profile of children in Senegal is character- often separates mothers from their children (Martorell ized by moderate stunting, high wasting and anemia, and Young 2012; Schwinger et al. 2014; Nene 2018). and low overweight and obesity (Nene 2018). In the most recent decade, the prevalence of stunting has Child anemia has seen an average decline of 3.4 per- hovered around 20 percent. The prevalence of wast- centage points per year since 2005 when it affected ing among children under five also represents a case 82.6 percent of children under five, yet remains very of stagnation over time, yet at a more alarming 8–10 high, with 66.3 percent of children affected (Ndiaye percent, which borders on the WHO threshold for a and Ayad 2006; ANSD 2016). Reductions in child “serious” situation (WHO 2000). It dropped to an all- anemia registered their most impressive gains in re- time low of 5.8 percent in 2014, but rose again slightly cent years, falling from 76.4 percent in 2010–11 to in 2015 to 7.8 percent, remaining at unacceptably high the current rate of 66.3 percent (ANSD 2012; ANSD levels, given the strong association of wasting with 2016). The burden of anemia sees significant variation child mortality and impaired cognitive development across different regions in the country, with Ziguinchor (Black et al. 2008). Wasting, unlike stunting, is also registering the lowest prevalence at 54.4 percent and more sensitive to shocks, thus the high prevalence Diourbel the highest, at 77.3 percent (ANSD 2015a). that has been documented over time is likely a result Deficiency of iodine, an important micronutrient, con- of the frequent and successive economic shocks that tinues to be problematic in Senegal, with just over half have been brought on by environmental and climate (53.3 percent) of children under five living in house- changes, rising food and fuel prices, and the global holds without adequately iodized salt (15ppm) in 2015 financial crisis (WHO, UNICEF, and WFP 2014; Nene (ANSD 2016). Though this represents an improvement 2018). The prevalence of wasting may also reflect the since 2005 when the proportion of children living in season during which the survey is conducted; for ex- households with adequately iodized salt was only 35.8 ample, rates generally surge during rainy seasons and percent, the low availability of iodine and the potential before the harvest as a result of food shortages, in- for iodine deficiency presents a significant threat to the The Case for Investment in Nutrition in Senegal 17 cognitive and brain development of children (Ndiaye and Ayad 2006; ANSD 2015b). Also holding important and Ayad 2006). Iodine deficiency disorders, which implications for the health and nutrition of a moth- can begin in utero, lead to an irreversible mental im- er and her child, are pregnancies that occur among pairment that lowers an individual’s ability to perform young mothers (17.6 percent of women aged 15–19 well at home, in school, and at work (WHO 2017). have begun childbearing), for whom nutritional vulner- ability is essentially doubled because of the increased Among women of reproductive age, anemia, thinness, requirements needed to sustain the growth of both the and overweight continue to be problematic. Anemia mother and her fetus (ANSD 2015b). remains the third highest in the region (behind Ga- bon and The Gambia), with a 54.3 percent prevalence Although not accounted for in the national statistics rate in 2010–11.8 Progress in this indicator over time presented here—but critical for planning purposes and has been very slow, with only a minimal decrease thus deserving mention—are new and emerging threats from 2005, when the prevalence rate was 59.1 per- to nutrition. These include external global economic cent (Ndiaye and Ayad 2006). Maternal thinness (22.0 and climate-related shocks that risk destabilizing inter- percent) and overweight (21.3 percent) both hovered national, national, and household-level food production, at about 20 percent in 2010–11, holding different yet access, and availability. Senegal has been particularly important consequences for the health of the child and affected by successive economic shocks from rising the mother (ANSD 2015b). Maternal thinness has in- food and fuel prices, the global financial crisis, and creased from 18.2 percent in 2005 to 22.0 percent in floods and droughts in recent years. These external 2010–11, while overweight was 21.9 percent and 21.3 shocks contributed to poor economic growth, sharp percent in 2005 and 2010–11, respectively (Ndiaye declines in cereal, groundnut (the country’s main cash MAP 1: Effects of Shortfalls in Rain on Food Insecurity and Undernutrition SHOULD GSD CARTOGRAPHY PROVIDE A BETTER QUALITY MAP? THEY CAN IMPROVE a. Rain shortfall BOTH MAP AND TEXT QUALITY. IF YOU WISH, WE CAN MAKE THE REQUEST. compared to annual average, 2014 Source: FEWS NET 2014. (continued on next page) 18 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal MAP 1: Effects of Shortfalls in Rain on Food Insecurity and Undernutrition (continued) SHOULD GSD CARTOGRAPHY PROVIDE A BETTER QUALITY MAP? THEY CAN IMPROVE b. Food insecurity BOTH MAP AND TEXT QUALITY. IF YOU WISH, WE CAN MAKE THE REQUEST. by Department, 2014 percent The Gambia Weak <=15% Moderate >15% – <=30% High >30% – <=50% Very high >50% Source: WFP 2014. Note: Food insecurity estimates were generated by the WFP using the CARI2 methodology and data from the National Food Security and Nutrition Survey conducted in Senegal in June 2013. To estimate food insecurity prevalence, the CARI2 methodology takes into account two dimensions of food insecurity: (1) short-term food security status based on food consumption scores; and (2) long-term access to food, as measured by household-level economic vulnerability (household food expenditures) and coping strategies employed by the household. See WFP (2014) for additional details regarding methodology. SHOULD GSD CARTOGRAPHY PROVIDE A BETTER QUALITY MAP? THEY CAN IMPROVE c. Acute BOTH MAP AND TEXT QUALITY. IF YOU WISH, WE CAN MAKE THE REQUEST. malnutrition by Department, 2014 percent MAURITANIA THE GAMBIA GUINEA-BISSAU GUINEA Source: WFP 2014. The Case for Investment in Nutrition in Senegal 19 crop), and pulses production, and an observed stagna- long list of often deeply rooted societal influences on tion in poverty reduction in the last decade, especially nutrition, Senegal represents a strong example of how among the more vulnerable, rural populations. In late progress in nutrition can be achieved. Cost-effective, 2014, for example, the cereal harvest was estimated efficacious interventions to address nutrition exist, to be more than 20 percent below average due to poor are known, and can be—or already are being—im- rainfall in the northern and central regions of the country plemented in Senegal. Rather than allowing the sheer (FEWS NET 2014). Lower production levels, in com- complexity of malnutrition to discourage action, this bination with border closures resulting from the Ebola section presents various means through which nutri- outbreak in West Africa in 2014, drove up coarse grain tion can be improved, while highlighting the necessity prices (FEWS NET 2014); consequently, 16 percent of of a multisectoral approach. the population was found to be food insecure in 2014 (WFP 2014). As shown in map 1 below, food insecurity The determinants of child growth and nutritional status is closely tied to dietary intake and nutritional status; are numerous, linked, and deeply rooted in the social, areas that experience climatic shocks are the same as economic, and political context in which children and pop- those that suffer the brunt of food insecurity and under- ulations grow and develop (figure 3) (Black et al. 2008; nutrition (FEWS NET 2014; WFP 2014; ANSD 2015b). Black et al. 2013). Dietary intake and disease—both of which act synergistically—are the two proximal deter- Finally, it is important to acknowledge the health minants of nutrition, followed by the underlying causes consequences of increasing overweight and obesi- that influence them, such as household food insecurity, ty among adults and children, their associated risk inadequate care, and household environment and ac- factors, and the resulting strain on the health care cess to health services. These underlying causes can system. Although the quantification of these costs in be quite broad, are often interrelated, and are largely low- and middle-income countries is limited, a study driven by various dimensions of poverty; essentially, in the Asia-Pacific region finds that the economic bur- they represent an inability to fulfill the specific, yet ba- den of overweight and obesity accounts for between 2 sic, needs of women and children. Within the realm of percent and 10 percent of a country’s total health ex- food insecurity, issues of household distribution of food penditures (Hoque et al. 2016). In addition, overweight also arise and influence nutrition both at the individual and obese individuals incur health care costs 7–10 and household levels, more so in some contexts than percent and 17–22 percent higher, respectively, than others. Inadequate care, on the other hand, encom- their normal-weight counterparts (Hoque et al. 2016). passes both maternal and child care practices as they relate to behavioral aspects of nutritional care during With its moderate levels of child stunting and high pregnancy and lactation, as well as IYCF, including levels of child anemia, and persistent prevalence of early initiation and exclusive breastfeeding in the first under- and overweight and anemia among women, six months and continued breastfeeding until age two, Senegal bears a double and triple burden of malnutri- parenting and caregiving, and stimulation. Household tion, exhibiting clear characteristics of a country in the environment includes access to safe water and both midst of its transition (Popkin 2002). environmental and personal hygiene and sanitation practices, which are being increasingly understood to play a role in nutrient absorption and nutritional status Determinants of Poor Maternal and Child through environmental enteric dysfunction, even in the Nutrition in Senegal absence of clinical symptoms or illness (Prendergast and Humphrey 2014). In this section, we summarize the various, complex, and interrelated determinants of maternal and child Even more distal are the basic causes of undernutri- nutrition. Although this may appear to be a dauntingly tion, which encompass the broader socioeconomic 20 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal FIGURE 3: Conceptual Model of the Determinants of Undernutrition Long-term consequences Short-term consequences Adult size, intellectual ability, economic productivity, Mortality, morbidity, disability reproductive performance, metabolic and cardiovascular disease Maternal and child undernutrition Inadequate dietary intake Disease Immediate causes Household food Inadequate Unhealthy household environment insecurity care and lack of health services Income poverty: Underlying causes employment, self-employment, dwelling, assest, remittances, pensions, transfers etc Lack of capital: financial, human, Basic causes physical, social, and natural Social, economic, and political context Source: Black et al. 2008, adapted from UNICEF 1990. environment, policies, and availability and access of undernutrition, which is necessary for program plan- to social programs that support economic, human, ning and intervention design purposes. Nevertheless, and physical growth and development (Black et al. the presentation of determinants at the national level 2008). These include the ways in which political provides a global picture of the challenges of achiev- structures, ideologies, and legal systems—both ing good nutrition in Senegal, some of which are more formal and informal institutions—converge and pronounced in some regions than in others. permeate through a society to influence the more proximal and underlying determinants of undernutri- The diets of children are inadequate in both quality and tion referred to above. frequency: Less than half of children are exclusively breastfed from birth to six months (33.3 percent), and The determinants of undernutrition in Senegal are only 10.2 percent of children consume a minimum ac- presented below. An important theme of this invest- ceptable diet (MAD) through age two (ANSD 2016). ment case and of nutrition in Senegal more generally, Of the two indicators used to construct the MAD, how- however, is the variation among determinants and ever, dietary diversity is particularly problematic: just consequently, of burdens, that are specific to each 40.5 percent of all children achieve the meal frequen- region within the country. A critical component of the cy requirement for their age, while not even one-fourth PSMN’s development, for example, is the analysis of (19.3 percent) meet the minimum dietary diversity of regional-level data and indicators on the determinants four food groups (ANSD 2016). The Case for Investment in Nutrition in Senegal 21 Despite acceptable levels of completed childhood many women begin childbearing—and limit their ac- vaccinations (67.8 percent of children 12–23 months cess to resources and decision-making power. These having received all required vaccines), the preva- deeply rooted social constructs hold consequences for lence of common childhood illnesses remains high the health and nutrition of the mother, but also affect (ANSD 2016). For instance, in 2015, 18.1 percent, time allocation and its relationship to child care prac- 15.0 percent, and 3.5 percent of children suffered from tices. Women with less influence or power within their diarrhea, fever, and symptoms of acute respiratory in- household and community are limited in their ability to fection, respectively (ANSD 2016). This is equivalent guarantee a fair distribution of food and resources with- to approximately five episodes of diarrhea per child in the household, are less likely or able to use health per year, for which less than half (39.4 percent) of all services in cases of child illness, and spend less time mothers seek treatment (ANSD 2016). interacting with their children (Oniang 2002). Improving gender equality to provide more equal access to and con- The lack of dietary diversity is a consequence of many trol over household resources and assets has significant more distal factors, namely household food insecurity pay-offs, including higher agricultural output through im- and insufficient maternal knowledge. Even if a mother proved access to land, credit, and information; increased has the knowledge of appropriate feeding and care-giv- investment in child education; improved frequency of ing practices, gender norms, which are discussed in visits to health facilities for infants; food security; and ac- more detail below, may further inhibit a mother’s power celerated child growth and development (Oniang 2002). to make health, food, and nutrition-related decisions. Taking a closer look at the variations in nutrition- Although the average available calories per capita al status across Senegal, we also see geographic (2,480 kilocalories per person per day, as of 2015) are and sociodemographic differences in the basic and sufficient to meet the population’s daily needs, 60 per- underlying causes that highlight important region- cent of calories come from staple foods and less than al disparities. Stunting prevalence is correlated with 10 percent come from protein (FAO 2015). Seasonal- socioeconomic poverty and urbanization; along the ity also plays a role in food insecurity and influences poverty incidence lines, the more urban and wealthy dietary intake of nutrient-rich foods, as well as nutri- northern and western regions exhibit a much lower tional status, among children. prevalence of stunting (less than 20 percent) than do the central and southern regions (ranging from 21 per- Regarding maternal knowledge and care seeking, less cent to 29 percent) (Nene 2018). than half of all mothers seek care when their child is ill with symptoms of diarrhea, fever, or acute respiratory This trend remains evident in the latest DHS (ANSD illness (39.4 percent, 41.4 percent, and 48.2 percent, 2016) (map 2). Kolda, for example, a southern region respectively), which represents a missed opportunity with an extremely high level of poverty, exhibits an for health staff not only to provide needed services but exceptionally high stunting prevalence of 36 percent also to deliver essential nutrition messages (ANSD (Nene 2018). Moreover, the national gains in stunting 2016). Moreover, frequent exposure to such common that were seen from 1990–2005 were uneven across childhood illnesses, because of their high prevalence, regions, with some experiencing large decreases in compromises children’s immune systems and can stunting prevalence while others saw stagnation and have devastating consequences for their nutritional even increases in prevalence. status—and vice versa—given the deteriorative nature of the infection-nutrition cycle (Tomkins 1989). Residence, wealth, and sex are important determi- nants of child stunting in Senegal. Wealthier, female, As briefly mentioned, gender norms weigh heavily on and urban-based children experienced the greatest women—beginning as early as adolescence, when reductions in child stunting over time (Nene 2018). 22 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal MAP 2: Regional Divides of Prevalence of Stunting and Wasting in Senegal, 2015 a. Stunting b. Wasting Source: Based on DHS Program STATcompiler (database), USAID, Washington, DC (accessed 2016), http://www.statcompiler.com/en/. Wasting prevalence, on the other hand, is less de- lowest prevalences of child stunting, are those most pendent on poverty and more heavily influenced by affected by wasting, with prevalence estimates rang- external shocks, many of which are environmental and ing from 10–14 percent (Nene 2018). Conversely, the geographical. Interestingly, the regions of Saint-Louis, extremely poor region of Kolda, which has a high prev- Louga, and Tambacounda, which exhibit some of the alence of stunting, consistently performs better than The Case for Investment in Nutrition in Senegal 23 Saint-Louis and Louga on the prevalence of wasting by stunting and wasting in Senegal in 2015, respec- (Nene 2018). tively. An understanding of both the number and the prevalence of children suffering from various types of Figure 4 shows the estimated regional distributions undernutrition is critical for planning purposes, as a of the prevalence and number of children affected high prevalence or burden of undernutrition does not FIGURE 4: Prevalence and Absolute Number of Stunted and Wasted Children in Senegal by Region PLEASE PROVIDE DATA IN EXCEL, IN THE a. Children stunted DESIRED ORDER FOR BOTH FIGURES 4A AND 4B 35 50,000 45,000 30 40,000 25 35,000 30,000 20 Number Percent 25,000 15 20,000 10 15,000 10,000 5 5,000 0 0 Dakar Diourbel Fatick Kaffrine Kaolack Kedougou Kolda Louga Matam Saint-Louis Sedhiou Tambacounda Thies Ziguinchor b. Children wasted 18 40,000 16 35,000 14 30,000 12 25,000 Number 10 Percent 20,000 8 15,000 6 4 10,000 2 5,000 0 0 Dakar Diourbel Fatick Kaffrine Kaolack Kedougou Kolda Louga Matam Saint-Louis Sedhiou Tambacounda Thies Ziguinchor Prevalence among children under 5 years Number of children under 5 years Source: Calculations based on the national-level percentage of children under five as reported in ANSD (2016) (16.6 percent). Population data are based on the 2013 census. 24 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal always equate with a high number of children. This is CLs and local service providers (Deussom N. et al. highlighted in the region of Kedougou, for instance, forthcoming). which exhibits a high prevalence of both wasting and stunting but low numbers of children affected. On the The analysis of risks associated with the implemen- contrary, the regions of Dakar and Thies, which ex- tation of the PSMN further highlights the significant hibit relatively low prevalence of stunting, have large risk posed by the instability of critical nutrition per- numbers of stunted children because of the size of the sonnel at the highest levels of government, especially population in each of these regions. within the CLM (Deussom N. et al. forthcoming; Ba forthcoming). Strengthening human resource capacity by improving remuneration and investing in capacity Gaps in Human Resource Capacity to Deliver building and research efforts are among the actions Nutrition Services that are recommended to strengthen the organization- al and leadership capacity of the CLM to enable it to Perhaps the biggest gap in the implementation of the effectively carry out its mandate (Deussom N. et al. PSMN is the gap in human resource capacity to main- forthcoming; Ba forthcoming). stream nutrition throughout relevant sectors of health, agriculture, commerce, fisheries and livestock, educa- Capacity at the local midgovernmental level in Senegal tion, and social protection. Despite the existence of a is especially important given the operational schematic university-level curriculum and training (Master of Sci- for the PRN, which is coordinated by the CLM but de- ence and Ph.D.) for nutrition at the University of Cheikh pends on a highly decentralized arrangement in which Anta Diop in Dakar since 1998, there continues to be a CLs are the entry point and responsible for the PRN dearth of skilled people who are adequately trained in (Deussom N. et al. forthcoming). Although much of the both nutrition and their sectoral specialty (Fox 2018). responsibility for financing and implementing the PRN, This widespread absence of skilled individuals who through partnerships with local nongovernmental or- are able to sensitize their sectors to more strongly ganizations (NGOs), has been transferred to the CLs, support nutrition poses a significant challenge to main- it is widely accepted that their capacity to self-finance streaming nutrition, both vertically (at all administrative and implement nutrition initiatives remains weak, for levels) and horizontally (across sectors) (Fox 2018; many of the reasons described above, including in- Deussom N. et al. forthcoming; Ba forthcoming). sufficient or inadequate training in nutrition (Deussom N. et al. forthcoming; Ba forthcoming). CLs will need More specifically, the vertical human resource capac- more support, including investments in capacity build- ity gap begins at the highest levels of government ing, to successfully carry out their mandate (Deussom and trickles down to front-line workers at the commu- N. et al. forthcoming; Ba forthcoming). nity level (Deussom N. et al. forthcoming). The lack of capacity beyond sectoral specialties at the minis- At the lowest level, that is, within the communities terial level of government is a barrier not only to the themselves, the PRN depends on front-line staff to implementation of nutrition activities, but also to the deliver effective and individually tailored nutrition championing and raising of funds for nutrition, and messages to mothers, households, and communities, the ability to lead and think creatively to maximize to collectively improve IYCF and caring behaviors. investment in nutrition from within each sector (De- Currently, the program depends on about 12,500 com- ussom N. et al. forthcoming). In addition, the lack of munity volunteers nationwide; according to the CLM explicit attention to nutrition in other sectors’ activities information system, coverage stands at a high level and policy documents could further inhibit the prioritiz- of approximately 80 percent for a basic package of in- ing of nutrition, as the CLM expands its coordination terventions in intervention communes. Nevertheless, role to central-level sector institutions in addition to an expansion and intensification of PRN activities to The Case for Investment in Nutrition in Senegal 25 deliver an extended package of interventions will not nutrition, perhaps the biggest financial risk lies in be feasible without a concerted effort to expand the the lack of engagement of the private sector (Deus- army of front-line workers and build their capacity to som N. et al. forthcoming; Ba forthcoming). To date, deliver individualized nutrition services and messages the private sector has not made significant financial to target communities on a monthly basis. contributions to nutrition despite its potential role in increasing the availability, processing, and market- ing of foods with high nutritional value (Offosse N. Institutional, financial, and operational risks 2017; Ba forthcoming). Advocacy for increased private to the implementation of the PSMN sector engagement has been insufficient; the formal establishment of public-private partnerships should be Additional threats or risks to the implementation of the considered (Ba forthcoming). PSMN, which constitute barriers to good nutrition in Senegal, were identified in the risk analysis conducted Although the PSMN has taken important steps to in- by Ba (2017). In addition to the human resource ca- volve relevant sectors and create sectoral plans and pacity risks discussed above, other issues that were accompanying budgets for the integration of nutrition identified as constituting severe threats to the success- into their activities, the lack of clarity in the articulation ful implementation of the PSMN included institutional, of each sector’s activities renders the implementation financial, operational, and organizational risks. of a coordinated response more difficult, especial- ly given the human resource gaps in those sectors There is a risk that prioritization of the PSMN may be (Deussom N. 2017; Ba forthcoming). The CLM is the limited by the lack of political engagement at the high- institutional home for intersectoral coordination for nu- est institutional levels, thereby rendering inadequate trition, but many see it as an operational, rather than a the capacity to mobilize relevant actors to implement coordinating, entity. Links between sectors are indeed it (Ba forthcoming). Specifically, nutrition does not fea- facilitated by the CLM, but the absence of nutrition ture strongly in the discourse of political leaders, other representatives within each sector makes communi- than in extreme and highly visible situations such as cation between sectors and the CLM more challenging those involving famine (Ba forthcoming). (Deussom N. 2017; Ba forthcoming). Furthermore, the variability of skills and nutrition knowledge ham- A later section discusses the financial needs for the pers the effectiveness with which nutrition can be implementation of the PSMN. In addition to gener- addressed within each sector (Deussom N. 2017; Ba al insufficiency of public and donor investments for forthcoming). 26 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal 4 What is Needed? Tailored Nutrition Intervention Schematic efficiency of available resources for nutrition, each re- gion is first asked to describe its “nutrition profile.” A As described above, the nutrition profile of women and nutrition profile brings to light the region’s performance children varies widely across the country, with some on key nutrition indicators and populations affected regions bearing a higher burden of stunting while oth- and analyzes the determinants contributing to those ers are more challenged by wasting, and yet others are indicators, to provide guidance for prioritizing the in- challenged by both, in addition to a high prevalence of terventions that are well-targeted and most likely to micronutrient deficiencies and persistent overweight provide results. Following the example of the PSMN, and obesity among certain population groups. Where regional plans should also be costed, with interven- malnutrition does not affect all equally, the broad goal tions linked to specific goals, timelines, and lines of is to strengthen community and household resilience accountability. to malnutrition with very specific actions developed on the basis of each region’s epidemiological, sociode- Using regional and tailored plans for nutrition, the mographic, and geographical profile. PRN can deliver the chosen interventions: All regions of the country are covered by the PRN and have an Despite variations in methodology and representa- entry point with local leaders, giving them the ability tiveness, the frequent reporting of nutrition and child to convene actors across all sectors. With a clear defi- health statistics through large-scale national surveys nition of the region-specific nutrition challenges, key like the DHS and Multiple Indicator Cluster Survey determinants, and populations affected, locally rele- (MICS) in Senegal provides a continuous picture of vant and tailored plans of action can be designed and the changing nutritional landscape, which further pro- implemented using existing structures and programs. vides the opportunity for informed decision-making at Progress toward nutrition goals can be accelerated the regional level. when human and financial resources are allocated based on evidence and existing programs are lev- To implement a tailored and multisectoral nutrition eraged to maximize the scope and reach of nutrition intervention schematic, as well as to maximize the activities. The Case for Investment in Nutrition in Senegal 27 Strategic Approaches community levels, will become essential for tracking nutrition progress across sectors, as well as across The DPNDN lays out a conceptual framework for geographic regions and populations. acting multisectorally in nutrition; both the policy’s strategic objectives and the PSMN are built upon this The four pillars of nutrition-specific and nutrition-sen- framework (figure 5). Of note in the framework is the sitive activities are: (1) production of foods with high integration not only of the four pillars, or categories, of nutritional value; (2) processing, distribution, and tar- intervention that support optimal nutritional status, but ification; (3) education, hygiene, and sanitation; and also of transversal, cross-cutting issues at the base of (4) essential nutrition and health services. each pillar: local governance and territorial develop- ment; adequate and sustainable financing; advocacy Beyond the four pillars and their base are three stra- communication and social and behavior change com- tegic objectives that are meant to guide actors in the munication; multisectorality through community development and implementation of key interventions participation and equity; and research, monitoring, that will contribute to the final seven targets that repre- and evaluation and capacity building. Operationally, sent optimal nutritional status, as laid out in the PSMN. the institution of a common results framework that The three strategic objectives apply to each of the four translates national targets to the regional, district, and pillars of intervention and include: FIGURE 5: Conceptual Framework of the Multisectoral Approach for Nutrition Human Development Nutritional surveillance Optimal Nutritional Status Adequate Utilization Interventions specific to the Production of Processing, Education, Essential four pillars of foods with high Distribution & Hygiene & nutrition & nutrition nutritional value Tarification Sanitation health services Local Governance and Territorial Development Cross-cutting Adequate & Sustainable Financing interventions that support the Advocacy communication & SBCC four pillars Multisectiorality – Community participation and equity Research – Monitoring – Evaluation & Capacity building Source: République du Sénégal forthcoming. 28 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal ®® Mainstreaming of nutrition across sectors: Multi- social justice; good governance; and contracting. sectorality is at the crux of Senegal’s new era for These principles constitute ethical, legal, and mor- nutrition. It is understood that the mainstreaming of al guidance for nutrition interventions implemented nutrition within each sector is at the foundation of across all sectors. policy dialogue and program planning, especially within sectors that directly affect the determinants of nutrition. Further, the multisectoral approach de- Governance and Management mands a shift in public service delivery mechanisms, in which horizontal, community-based management The governance and management of nutrition activ- of nutrition activities is used to strengthen delivery. ities in Senegal are unique not only because of the ®® Decentralization of program delivery: Among the highly visible and central placement of the CLM, but many innovative and unique features of Senegal’s also because of the level of decentralization and cor- nutrition program is the highly decentralized ap- responding systems that are in place to extend service proach to the delivery of nutrition services. The delivery to communities and individuals across the multisectoral approach to nutrition intervention, as country. well as the reinforcement of local electorates, pres- ents a new opportunity for the decentralization of Figure 6 shows the institutional arrangements for the nutrition. This strategic objective calls for the de- delivery of nutrition services in Senegal. The CLM was velopment of partnerships among local authorities created in 2001 by Presidential decree and is under to coordinate the implementation of nutrition activi- the authority of the Prime Minister. Its main role is to ties to promote synergy and complementarity, while support the Prime Minister in technical matters relating encouraging dynamic exchanges and interactions to nutrition, in particular in the development of nutrition among relevant partners and stakeholders. Decen- policy and strategies, and the implementation, moni- tralization also implies increased support for local toring, and evaluation of action plans and activities for initiatives, which have until now been suppressed nutrition at the national level. Line (technical) ministries by limitations in knowledge, motivation, and bud- fall under the CLM, which highlights the CLM’s addi- getary support. tional role of coordinating and maintaining synergy for ®® Use of a community-based approach: The use of nutrition activities across sectors and mainstreaming a community-based approach has long been un- relevant nutrition activities into each of them. The CLM derstood as essential for increasing ownership, is led by the Director of the Cabinet (Chief of Staff) investment, and participation in any initiative or for the Prime Minister and comprises representatives movement, with nutrition no exception. As a stra- from the technical ministries of economy and finance, tegic orientation, the community-based approach health, education, agriculture, fisheries, livestock, emphasizes community engagement as fundamen- commerce, industry, interior, youth, water, sanitation tal to the process of sustainably optimizing both and hygiene, social protection, and CLs. This arrange- individual and community-wide nutritional status. ment allows for direct input, technical discussion, and Capacity building of individuals and local authorities planning with the support and coordination of the CLM. will enable communities to become both partners as well as active participants in the improvement of the Also under the guidance, leadership, and coordination health and nutrition of their constituents, promoting of the CLM but responsible for the operationalization shared responsibility and mutual accountability. and management of community-level nutrition activ- ities, is the BEN. All community-level activities are Finally, Senegal recognizes four principles of engage- managed directly by CLs, which operate to reach ment that are aligned with those used for all its public communities and individuals through 18 AECs, each service delivery: proximity and subsidiarity; equity and of which varies in form (for example, local NGO, inter- The Case for Investment in Nutrition in Senegal 29 FIGURE 6: Institutional Arrangements for the Delivery of Nutrition Services in Senegal Office of the Prime Minister Nutrition Coordination Unit (CLM) National Executive Bureau (BEN) Line (technical) ministries Local Government Collectives (CLs) Decentralized Community Execution Private sector services Agencies (AEC) THE COMMUNITY Source: CLM. national NGO, civil society organization, and specific on a monthly basis, and more than one million children interest association) and operate across the country’s under five on a quarterly basis, with essential nutrition 14 regions. The AECs are directly responsible for the services at the community level. recruitment, capacity building, monitoring, and super- vision of direct service providers and service delivery Given the existence and widespread reach of this sys- to communities, households, and individuals. tem, the main challenges moving forward are: (1) the amplification of the breadth of services that are offered The evolution of this institutional arrangement for nu- and delivered under the PRN, from basic to more com- trition in Senegal over more than a decade enables prehensive; (2) the expansion of service coverage the country to “think multisectorally, and act sectoral- to the remaining 171 communes and possibly con- ly” by mainstreaming nutrition across sectors (World tracting with new AECs to do so; (3) streamlining the Bank 2013). Sectors have the freedom and mandate to communication, collaboration, and implementation of implement relevant nutrition activities sectorally (ver- nutrition activities among key actors and sectors work- tically), while benefitting from the CLM’s transversal ing in nutrition toward a common results framework; view and coordination across all sectors (horizontal- and (4) building public-private partnerships with the ly). In parallel, the PRN has developed over a similar private sector to increase the availability, processing, period the foundation for a well-functioning service de- and marketing of foods with high nutritional value. livery platform for maternal and child nutrition services at the community level, through partnerships between CLs and AECs. This platform is operational in all 14 The Role of Relevant Sectors under the PSMN regions and 69 health districts, and involves 400 com- munes (72 percent of which are rural) out of a total of Senegal is uniquely positioned to implement and scale 571, reaching 223,000 children under the age of two up a renewed multisectoral effort toward addressing 30 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal malnutrition as a result of its long evolution toward The agriculture sector plays a central role in the fight nutrition championship, institutional ownership, mul- against malnutrition by promoting food production and tisectoral coordination and collaboration, community processing, both of which are necessary to fulfill the ownership, integrated services and delivery platforms, caloric and micronutrient needs of the population. The and partner engagement (Spray 2018). The strategic opportunity to encourage the year-round production placement of the CLM under the Prime Minister’s office and availability of nutritious and varied foods, through supports the operationalization of the PSMN in accor- activities such as crop diversification and homestead dance with its direct mandate to coordinate nutrition gardens, render the agriculture sector an obvious activities throughout the country and across ministries. means of implementing nutrition-sensitive interven- Under this arrangement, the CLM directly finances min- tions. More distal to food production, but still relevant isterial activities for nutrition as well as community-level because of the significant involvement of women in activities through CLs and NGOs. Moving forward, the agriculture, are gender-sensitive activities focused on CLM carries the heavy burden of enabling the synergy income generation, such as microcredit programming, of interventions and investments across relevant sec- time-saving technologies in production and transfor- tors, which it is poised to do in today’s environment of mation, and food transformation training and initiatives. renewed enthusiasm to address malnutrition. Equally important, however, is the clear definition of the CLM’s Increasing access to and ownership of livestock and role as a coordinator rather than an implementer; too fisheries can have important implications not only for much reliance on the CLM as an implementer may re- improving the nutritional quality of the household diet, sult in the CLM’s being overburdened and unable to but for increasing a household’s resilience to external keep up with its coordinating responsibilities. shocks. Animal-sourced foods are excellent sources of essential micronutrients (such as vitamin A, iron, zinc, The PSMN, which serves as the rubric for the op- and calcium), protein, and fat, filling an important nu- erationalization of the DPNDN, is well under way to tritional gap, especially among vulnerable populations becoming active in 2017. As part of the process of such as pregnant women and young children, whose defining institutional and operational arrangements, needs are disproportionately high and difficult to meet. two preliminary activities were required of the relevant sectors: (1) the elaboration of sectoral action plans for The importance of health for nutrition is well known. nutrition; and (2) the integration of nutrition-sensitive Good nutrition is not possible without good health and and nutrition-specific activities into those action plans vice versa. The health sector’s role in preventing dis- in a way that ensures that all activities are equitably ease and promoting optimal health through improved covered. As suggested by the CLM, sectoral action access to and quality of health services contributes plans include: strategic objectives; essential nutrition to improved nutrition. Moreover, and given the health interventions identified by the sector and how they sector’s access to populations at important life stages, will be implemented; estimated costs of these activ- the health sector is also well-placed to use those con- ities; and a results framework that includes nutrition tacts to deliver nutritional services. indicators. All of these activities are underway and are expected to be finalized in 2017. Although the suggest- Education and nutrition are inextricably linked; good ed nutrition activities for each sector are presented nutrition is important for cognitive and physical devel- “vertically” below, readers are urged to recognize the opment, both of which contribute to improved learning critical role of the CLM in coordinating each of the capacity, beginning at a very young age, and school listed activities so that they complement one another performance. Higher education among women con- and effectively reach the goals of a common results tributes to better nutrition outcomes through improved framework, while addressing transversal issues such IYCF knowledge and practices, care during illness as vulnerability, gender, and communication. (including care-seeking behaviors), and increased The Case for Investment in Nutrition in Senegal 31 decision-making power and gender equity. The edu- (including negative taxation and subsidies), consumer cation sector’s goals of providing universal access to safety, and special exceptions or considerations that primary and secondary education contribute indirect- favor food provision for marginalized populations. In ly to improvements in nutrition. Less explicit, but of this role, the commerce sector contributes to nutri- equal or perhaps stronger importance for nutrition, is tional status through the oversight and enforcement the sector’s role in reaching children in their preschool of industrial food production and food fortification that years with early child development services that sup- complies with national policies, laws, and regulations. port adequate nutrition, stimulation, and responsive care during this critical period of brain development. The industry sector prolongs the life of food products, Finally, the education sector can also play an import- whether through the reduction of food waste or loss or ant role in the provision of life skills development and conservation and preservation of foods, which allows literacy training for adolescent girls and adult women. households greater protection from external shocks. Water, sanitation, and hygiene have an increasingly In countries like Senegal, which are beginning a better understood role in nutrient absorption and nutri- nutrition transition, the sporting sector can make im- tional status through environmental enteric dysfunction portant contributions to the prevention of overweight and inflammation, even in the absence of clinical and obesity and the management of adequate weight symptoms or illness. Thus, individuals and house- among at-risk populations. Physical activity has also holds that lack access to proper hygiene facilities and been associated with lifelong health benefits, including potable water suffer a greater burden of intestinal pa- the reduction of noncommunicable diseases, such as thologies that contribute to increased susceptibility to hypertension and diabetes, for which overweight and diarrhea, with dire consequences for nutritional status, obesity are important risk factors. especially among children. This sector—by improving the access to and use of practices related to improved water, sanitation, and hygiene—can greatly contribute Stakeholders to a reduction in malnutrition. The well-established and far-reaching service delivery The link between nutrition and social protection is platform is an attractive mechanism to enable stake- especially relevant given the targeting mechanisms holders to deliver nutrition interventions. However, that are central to social protection programming and concerns remain regarding the myriad stakeholders that allow for the provision of services to households intervening in nutrition, whose interventions, monitor- and individuals identified as being nutritionally vulner- ing and evaluation activities, and financing schemes able, such as pregnant women and young children. are not always well coordinated, which can lead to du- Beyond targeting, the integration of nutrition into so- plication of effort and inefficiencies in the provision of cial protection programs, such as growth monitoring, services. nutrition education, and behavior change communi- cation, or other health-related conditionalities among In this section, we briefly describe the various stake- beneficiaries, can contribute to gains in nutrition. Fur- holders—communities, service providers, AECs, CLs, thermore, social protection programs have a role to and development partners—all of which have a unique play in facilitating access for vulnerable populations to and essential role to play in not only maintaining, but basic social services, including health, water, sanita- also strengthening, the delivery of nutrition services to tion, and hygiene, and education. households and individuals across Senegal. The clear definition of roles, collaboration, and communication The commerce sector facilitates access to foods among these stakeholders is the key to effective, equi- through mechanisms of economic regulation, taxation table, and sustainable implementation at all levels; this 32 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal task is facilitated by the CLM, which builds the bridges CLs are especially critical, as they are responsible for among these entities. all community-level development activities, and thus constitute the entry point for the delivery of nutrition Communities represent both the recipients of ser- services through AECs, both operationally and finan- vices and the service providers who enable and cially. Under the country’s decentralization scheme, drive sustained, nutrition-related behavioral change CLs are the direct recipients of nutrition-related fund- at the community, household, and individual levels. ing from the CLM, which is used to finance service Service providers require the proper tools as well as delivery contracts with AECs. Although an important the knowledge of how to use them to communicate proportion of the CLM’s budget is funded internally, messages, all of which fall under the capacity-build- development partners also contribute, both financial- ing efforts discussed in this report. Both communities ly and technically, to the delivery of nutrition services, and service providers are directly supported by AECs, through the CLM and the respective community imple- which work in partnership with, and on behalf of, mentation mechanisms described herein. CLs through service delivery contracts. AECs bear the greatest responsibility for the mobilization, orga- The diverse number of partners working toward im- nization, monitoring, supervision, and evaluation of proved nutrition in Senegal represent both a challenge service delivery by community workers at the com- and an opportunity. The building blocks needed to en- munity level, while CLs oversee their implementation sure efficient and coordinated programming, such as and activities with technical and operational support policies, protocols, monitoring and evaluation frame- from the CLM and BEN. Working in parallel—under works, and a network to implement activities are largely a tripartite arrangement with CLs and AECs to sup- in place. However, other critical elements, such as cost- port community nutrition development activities—are ed sectoral plans, partners’ use of the PRN’s network sector-specific public service providers (for health, and structures rather than the development of parallel agriculture, education, and livestock), who have an systems, and strengthening of systems to enable coor- indirect impact on nutrition through their activities, dination and collaboration across partners and sectors, which include: (1) the provision of essential services, are still needed. Given the significant task that lies ahead including immunizations, vitamin A supplementation, as Senegal enters its new nutrition era, development deworming, and veterinary services; (2) the training partners have an even greater mandate and opportunity and supervision of community workers; and (3) their to support the country in expanding the coverage and advisory role to CLs. breadth of nutrition activities in the coming decade. The Case for Investment in Nutrition in Senegal 33 Photo: Adama Cissé/CLM 5 Economic Analysis S ignificant and increasing financial resources— 2013, 2). They broadly encompass interventions that both from the government and from external address “food security; adequate caregiving resourc- donor agencies—have been invested in nu- es at the maternal, household and community levels; trition in Senegal over the last two to three decades, and access to health services and a hygienic envi- especially since the establishment of the CLM in 2001. ronment” (Ruel and Alderman 2013, 2). In the case Although 88 percent of funding for nutrition in Sene- of Senegal, funding for nutrition-sensitive activities gal comes from external sources, nutrition funding is focused largely on food security programming and represents only 2 percent of total development assis- interventions. Nutrition-specific activities, those that tance to Senegal (Offosse N. 2017). The remaining “address the immediate determinants of fetal and 12 percent comes from the Senegalese government, child nutrition and development” (Ruel and Alderman of which nutrition similarly represents only approxi- 2013, 2), incurred an annual cost of US$17 million, mately 2 percent of total national annual expenditures equivalent to US$1.30 per person per year (Offosse (Offosse N. 2017). N. 2017). Nutrition-specific interventions in Senegal include community-based nutrition interventions (such A budgetary analysis of recent commitment to nutri- as promotion of improved food and nutrient intake, tion indicates that total spending for nutrition reached child feeding, caregiving, and parenting practices), US$195 million for the period from 2012 to 2015, support to the health system to deliver essential child equivalent to approximately US$49 million per year, health and growth monitoring services, micronutrient or US$4 per person per year (Offosse N. 2017). More supplementation, and fortification of staple foods. than half (58 percent) of this funding comes from other sectors, which have larger budgets, for the im- As stated in the PSMN, to operationalize the DPNDN plementation of nutrition-sensitive activities (Offosse over the five years from 2017 to 2021, the budget to N. 2017). Nutrition-sensitive activities are those that implement nutrition-specific and nutrition-sensitive in- “address the underlying determinants of fetal and terventions across all sectors in Senegal will need to child nutrition and development and incorporate spe- grow to an estimated average of US$71 million per year. cific nutrition goals and actions” (Ruel and Alderman This number is derived from a total budget of US$355 The Case for Investment in Nutrition in Senegal 35 million shown in table 1. This translates to an investment ning workshops for their respective action plans for that averages US$5 per person per year (assuming a nutrition. These estimates include funding for the im- total population of 15.1 million people), or US$29 per plementation of a full package of nutrition-specific and child under five per year (assuming a population of 2.51 nutrition-sensitive activities from the following sectors: million children). The US$71 million estimated average health; water, sanitation, and hygiene; social protec- and the total budget of US$355 million for nutrition rep- tion; agriculture; fisheries; livestock; education; higher resent increases not only in the breadth of activities, education and research; CLs (which are responsible but also of a country-wide scale-up of a more compre- for the delivery of most nutrition-specific interventions); hensive and intensive package of nutrition activities industry; environment; and commerce. Table 2 shows from the current 30 percent coverage rate to the target the distribution of costs by type of nutrition intervention of 80 percent. An analysis of returns on investment for (nutrition-specific or nutrition-sensitive), by sector and implementing a package of nutrition-specific (30 per- as a proportion of the total required budget. For details cent of total budgetary needs) and nutrition-sensitive regarding specific types of activities that each sector (70 percent of total budgetary needs) activities (smaller has accounted for in their budgetary preparations and in scope than that proposed by PSMN) demonstrates that generated the numbers referenced in this invest- that increasing coverage to 100 percent would prevent ment case, please refer to appendix A. As shown in 5,280 child deaths, 159,398 DALYs, and 101,587 cas- table 1, the highest costs over the five-year period es of stunting (Yao forthcoming). We can expect that from 2017 to 2021 are accrued by the health sector the cost-effectiveness of increasing the full package of (US$105.2 million) and CLs, which are responsible for activities as outlined and budgeted in the PSMN would the delivery of essential nutrition services (US$88.5 only increase the impact on these indicators. million), followed by social protection (US$81.5 mil- lion) and water, sanitation, and hygiene (US$38.7 A breakdown of costs required to finance nutrition ac- million). Estimated costs for each sector, by category tivities in the next five years is shown in table 1, which of activity, are broken down further, by sector and ac- shows costs estimated by each sector during plan- tivity in table 3. TABLE 1:  Estimated Costs by Sector and Year for Nutrition in Senegal, 2017–21 US$, millions Cost per Sector 2017 2018 2019 2020 2021 sector Agriculture 1.4 2.3 4.5 5.3 4.2 17.6 Commerce 0.1 0.1 0.09 0.09 0.09 0.5 Education 0.8 0.8 1.1 1.2 0.8 4.6 Environment 0.5 0.5 0.6 0.6 0.6 2.8 Fisheries 0.1 0.3 0.2 0.2 0.01 0.8 Health 27.8 22.4 19.2 18.2 17.5 105.2 High-level education and research 0.1 0.5 0.6 1.0 1.0 3.1 Industry 0.5 0.1 0.08 0.04 0.04 0.8 Livestock 1.4 4.1 1.8 1.8 1.9 11.0 Local government collectives 15.3 19.1 18.8 17.4 17.9 88.5 Social protection 16.2 16.3 16.3 16.3 16.4 81.5 Water, sanitation, and hygiene 23.0 8.4 5.8 0.7 0.8 38.7 Total 355.2 Source: CLM. 36 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal TABLE 2:  Budget Breakdown by Type of Nutrition Intervention by Sector and as a Proportion of the Total Budget, 2017–21 Percent Budget HTH AGR FSH LVS EDU HLE CL IND COM SP WSH ENV total Nutrition-specific 56 0 0 0 34 0 52 0 0 0 0 0 30 Nutrition-sensitive 44 100 100 100 66 100 48 100 100 100 100 100 70 Source: CLM. Note: HTH: health; AGR: agriculture; FSH: fisheries; LVS: livestock; EDU: education; HLE: high-level education and research; CL: local government collectives; IND: industry; COM: commerce; SP: social protection; WSH: water, sanitation, and hygiene; ENV: environment. TABLE 3:  Financial Analysis of Sector-Specific Budgetary Needs and Sources, 2017–21 US$, millions HTH AGR FSH LVS EDU HLE CL IND COM SP WSH ENV Goods and services 104.7 0.06 0.06 0.1 4.6 3.1 86.8 0.8 0.5 0 3.9 0.8 Internal investments 0.3 14.2 0.2 9.6 0 0 1.7 0 0 78.1 34.8 2.0 Personnel 0.2 0 0.5 0 0 0 0 0 0 0 0 0 Current and capital transfers 0 3.4 0 1.3 0 0 0 0 0 3.4 0 0 Total 105.2 17.6 0.8 11.0 4.6 3.1 88.5 0.8 0.5 81.5 38.7 2.8 Source: CLM. Note: HTH: health; AGR: agriculture; FSH: fisheries; LVS: livestock; EDU: education; HLE: high-level education and research; CL: local government collectives; IND: industry; COM: commerce; SP: social protection; WSH: water, sanitation, and hygiene; ENV: environment. Further analysis of current and future operations in es of funding for nutrition activities include the national the sectors of agriculture, fisheries and livestock, re- budget, CL budgets, national and international part- search, and education, also present opportunities for ners and NGOs, and innovative financing mechanisms the expansion of nutrition services with relatively mini- through foundations and the private sector. mal added costs. These expansions require additional investment in capacity building not only for nutrition, In addition, innovations in financing mechanisms, such but for multisectoral programming and governance, as results-based financing, have already been piloted none of which should be underestimated. in Senegal as well as in other parts of Africa and have the potential to improve both nutrition and health out- Financing for multisectoral activities in nutrition can comes through increasing both the demand for, and the quickly become complicated. This is especially true in supply of, essential services for mothers and children. Senegal, where the technical and financial needs to The results-based financing pilot project in Senegal address nutrition differ significantly by region, not only is targeted toward mothers in four regions, with the as a result of varying patterns and trends in undernu- objective of reducing neonatal, infant, and maternal trition, but also due to differences in demographics, mortality by increasing the use and quality of health local economy, and consumption behaviors. The main and nutrition services among the poorest and most challenge is the development of a financing mecha- vulnerable mothers and children. Similar, innovative nism that includes multiple channels and inputs but is financing schemes in the health sector and beyond, still accountable to and based on a common results which have the common objective of improving nutri- framework. The responsibility of finding and managing tion either by nutrition-specific or nutrition-sensitive funding extends beyond that of the CLM to involve all approaches, are encouraged given the known absorp- sectors and regions. Nevertheless, the targeted sourc- tive capacity of the CLM. The Case for Investment in Nutrition in Senegal 37 Photo: Adama Cissé/CLM 6 Summary and Conclusions: A Call to Action T he rationale for investing in nutrition in Senegal ®® Expand the delivery of nutrition services from has been well established in this investment the current coverage of 400 to 571 communes case. Good nutrition is essential for ensuring (municipalities); good health, saving lives, and building human capi- ®® Intensify and reach full coverage of nutrition ser- tal for a prosperous and economically productive vices for all children under five in the 400 communes Senegal. The timing for intervening in nutrition in Sen- in which the PRN is already operational; egal is equally critical: The country has entered into ®® Support the integration of nutrition activities into its nutrition transition, with an unfinished agenda in other sectors, as dictated by the DPNDN and PSMN undernutrition that is parallel to a rising threat of over- ®® Adequately prepare for additional nutritional chal- weight, obesity, and their associated consequences lenges that lie ahead, such as the growing burden on health, well-being, and longevity. Most important- of overweight and obesity. ly, and to tackle these double and triple burdens of malnutrition, Senegal is embarking on a new, multisec- toral approach that deviates from business as usual to Senegal has a history of unprecedented commitment achieve its ambitious nutrition goals. to nutrition at the highest political levels, beginning with its coordination of nutrition activities under the In the context of increased attention to nutrition and of Office of the Prime Minister, which increased visibility the central role nutrition plays in global initiatives such and involvement of all sectors in improving nutrition. as the World Bank’s Investing in the Early Years, as Furthermore, the decentralization of nutrition activities well as in meeting the ambitious WHA and SDG tar- to CLs has increased ownership at all levels, as have gets, there is no better time to invest in nutrition than long-standing and increasing national budgetary com- now. The next decade marks a new era for nutrition mitments to nutrition. in Senegal, where continued and renewed efforts are needed to: The Case for Investment in Nutrition in Senegal 39 This investment case urges the global community to because of persistent leadership of nutrition champi- support and contribute to Senegal’s momentum in ons, institutional ownership, multisectoral coordination redefining its nutrition policies and operations, and and collaboration, establishment of a well-functioning, to sustain longstanding efforts in nutrition, not only community-based system for delivery of integrated to prevent a stagnation—or worse, a deterioration— services, partner engagement and responsible lever- in progress that has been made in nutrition in recent aging of donor investments. decades, but also to increase the ability of even the most vulnerable members of society to be nutrition se- Today, Senegal is at yet another critical stage of cure. Although the determinants of nutritional status ramping up key nutrition interventions to scale in are complex and multifaceted, there is a growing body an unconventional way that engages multiple, rele- of evidence that outlines the effectiveness and cost of vant sectors, with a focus on capacity building that nutrition-specific and nutrition-sensitive interventions. will yield sustained changes in behaviors and im- Senegal has demonstrated its ability to move the proved nutrition for all of Senegal’s people. The time needle on stunting not only because of its scaled im- to invest in the country’s new, exciting era for nutri- plementation of efficacious nutrition interventions, but tion is now. 40 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal APPENDIX A Nutrition Activities Included in Budgetary Projections, by Sector The Case for Investment in Nutrition in Senegal 41 Sector Types of activity and services Health Governance and management: protocol and policy development; product supply chain management; advocacy; central and local coordination activities; capacity building; nutrition surveys and research; enforcement of food safety rules and regulations; routine monitoring and evaluation; routine local and national meetings Provision of essential health services: management of acute malnutrition (surveillance and treatment); growth monitoring and promotion; nutrient supplementation for vulnerable groups (pregnant women, adolescents, young children); nutrition education; management of acute and chronic illnesses; mobilization activities Health referral services: advocacy and support for use of health and other social services Agriculture Governance and management: integration of agricultural and nutritional initiatives in public policy; communication and advocacy Agricultural productivity: increase in production, transport, and processing of agricultural products; homestead, community, and microgardens; training activities for agricultural producers on both nutrition and agricultural practices; pesticide management; proper handling of food products and food safety; seed production Research: financing; capacity building and training; biofortification Fisheries Governance and management: training and capacity building on fishery development and maintenance; monitoring and evaluation of fishery activities; food safety control; integration of fishery education into school curricula; research program on edible algae and micronutrient qualities of fish and algae; mobilization and advocacy Development of fisheries: stock-taking of fish species; construction and maintenance of fisheries; installation and rehabilitation of refrigeration complexes; fish repopulation in natural habitats; construction and maintenance of edible algae farms; rehabilitation of docks and fish processing and production points Livestock Governance and management: training and capacity building Livestock development and maintenance: livestock vaccination and deworming; animal feed production; construction and maintenance of stables; livestock and poultry purchasing and reproduction; purchase and distribution of transport, conservation, and quality control materials; dairy production Education Governance and management: development of education materials; support, management, supervision, and monitoring of capacity building; development of school feeding nutritional standards and requirements policies; updating of school feeding recipes; management and oversight of school feeding activities Nutrition education: capacity building for nutrition education at all levels of the education system; community mobilization for utilization of school-based nutrition services and initiatives School-based interventions: reinstatement of preschool and primary school gardens; physical activity; nutrient supplementation (such as iron folate) and deworming for school-aged children; support to early childhood centers with provision of equipment, materials, and capacity building; school feeding and links with local, smallholder producers High-level Nutrition education: strengthening of nutrition education, research, and innovation programs in upper-level education and education; promotion of improved feeding and physical activity practices in upper-level education facilities research Local government Governance and management: contracting with, and management of local NGOs for delivery of collectives community-based nutrition services; motivation of community volunteers; baby-friendly hospital and community initiatives; sensitization and mobilization of local leaders; financial and budgetary management and oversight Community-based nutrition activities: identification, establishment, and functioning of nutrition community centers; social mobilization for nutrition; implementation of nutrition-sensitive approaches (such as homestead gardens and aquaculture); processing of food products; establishment and management of local flour fortification production; point-of-use fortification (such as micronutrient powders) Other community-based activities: birth registration; construction of latrines; construction and maintenance of wells and boreholes; construction or rehabilitation of health posts for the delivery of essential health services; financing of water, sanitation, and hygiene (WASH) microprojects Industry Governance and management: supervision and support for adherence to food fortification legislation; policy development and review for food fortification for specific population groups; quality assurance; capacity building Nutrition activities: establishment of salt iodization plants in areas of local production; development of local quality-control groups Research: feasibility of expansion of various food fortification initiatives (continued on next page) 42 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal (continued) Sector Types of activity and services Commerce Governance and management: quality control and verification of adherence to fortification policies and guidelines; capacity building; support for breastmilk-substitute policy process; updating of policies as needed; food content regulations Operations and research: maintenance of food fortification equipment; routine analysis of fortified foods to ensure compliance; support of local food processing, transport, and marketing initiatives; implementation of a food information network (detailing geographically driven food prices and stocks); food labeling research and guidelines Social protection Governance and management: capacity building for community-based personnel involved in social protection programs and child care; provision of nutrition communication supplies and materials Community-based nutrition activities: provision of supplies and financial scholarships for women’s organizations; nutrition training for female scholarship recipients, including processing of locally available and nutritious food products; construction and maintenance of child care centers; microcredit and income generation activities for women; cash transfer programs, food vouchers, and agriculture insurance for pregnant and lactating women and vulnerable households; growth monitoring and promotion and school feeding for children from birth to three years in early child care centers; provision of nutrition support kits for malnourished children under five in daaras (traditional Koranic schools) Research: census of the number of children under five in daaras Water, sanitation, Governance and management: capacity building for community-based WASH and other personnel and hygiene involved in nutrition-sensitive WASH promotion; provision of nutrition communication supplies and materials Community-based nutrition activities: improved access to sanitation through building of latrines (public and household), pump stations, water and sludge treatment plants, and household connections to piped water; use of the Total Sanitation approach to promote essential hygiene actions (such as household handwashing stations, household-level water treatment, and latrine use); provision of “WASH kits” to health facilities, Foyers d’Amélioration et de Récupération Nutritionnelle (Nutrition Improvement and Recovery Homes), and Centers of Recovery and Nutritional Education; celebration of WASH day The Case for Investment in Nutrition in Senegal 43 Endnotes 1. Joint Child Malnutrition Estimates, UNICEF (Unit- 6. World Bank calculations based on ROS MSAS ed Nations Children’s Fund), WHO (World Health (2016) and Onehealth-LiST. The OneHealth tool Organization) and World Bank (accessed 2018), (http://www.avenirhealth.org/software-onehealth. http://datatopics.worldbank.org/child-malnutrition/. php) is new software created to strengthen the 2. For more information on nutrition trends, see Nene analysis of health systems and their cost, and to (2018) in this series. develop different funding scenarios at the country 3. This investment case emphasizes a transition from level. The primary purpose of this tool is to as- the current business-as-usual approach to a new, sess health-related investment needs in low- and innovative, and resolute shift toward a multisec- middle-income countries for the medium and long toral approach for nutrition. As detailed below, the term. The Lives Saved tool (http://www.livessa- new approach expands the coverage and reach vedtool.org/) uses linear modeling to estimate the of nutrition services, comprehensively through effects of nutrition-specific and nutrition-sensitive relevant and multiple sectors, and adequately pre- interventions on malnutrition (number of cases of pares the country for additional and unforeseen stunting avoided) and infant mortality (number of nutritional challenges that may lie ahead, such as lives saved). the growing burden of overweight and obesity and 7. STATcompiler (database), USAID, Washington, external shocks. Yao forthcoming in this series, DC (accessed 2017), http://www.statcompiler. describes what is meant by “business as usual.” com/en/. 4. STATcompiler (database), USAID, Washington, 8. STATcompiler (database), USAID, Washington, DC (accessed 2017), http://www.statcompiler. DC (accessed 2017), http://www.statcompiler. com/en/. com/en/. 5. 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Forthcoming. “Cost and Benefits of Scaling Up Nutrition Interventions in Senegal.” Analysis & ———. 2013. “Improving Nutrition through Mul- Perspective: 15 Years of Experience in the Devel- tisectoral Approaches. Washington, D.C.: opment of Nutrition Policy in Senegal. Washington, World Bank. http://documents.worldbank.org/ DC: World Bank; Dakar, Sénégal: CLM. curated/en/625661468329649726/pdf/75102-RE- VISED-PUBLIC-MultisectoralApproachestoNutri- tion.pdf. The Case for Investment in Nutrition in Senegal 49 Glossary Anemia: often due to a deficiency in iron, but can also trient-specific). Each type of undernutrition has varying be the result of deficiencies of other micronutrients consequences for the health and well-being of the (such as vitamins B9 or B12) or infection (with malaria child, with some holding greater risks for child survival. or intestinal parasites). Anemia occurs when hemo- globin falls below the acceptable level for a person’s Stunting: defined as a length- or height-for-age be- age, sex, and physiological status. The consequenc- low –2 standard deviations from the median length- or es of anemia include reduced physical and cognitive height-for-age of the reference population (children development that can translate to lower school per- of the same age and sex). Stunting often reflects a formance among children and economic productivity chronic deficiency of essential calories and nutrients among adults. or sustained periods of illness that contribute to poor appetite and food consumption over extended periods CLM: the nutrition coordination unit in Senegal, which of time. is under the authority of the Prime Minister and whose main role is to support the Prime Minister in technical Wasting: defined as a weight-for-height or -length matters related to nutrition, including the development below –2 standard deviations from the median of nutrition policies, strategies, and coordination of nu- weight-for-height or -length of the reference popula- trition activities across sectors (horizontally) and down tion (children of the same age and sex). Wasting is to the community level (vertically). categorized by two forms of severity: severe acute malnutrition (below –3 standard deviations from the Child undernutrition: typically broken down into median weight-for-height or -length of the reference three types: stunting, wasting, and underweight. Each population) and moderate acute malnutrition (be- of these indicators is defined using the anthropomet- tween –3 and –2 standard deviations from the median ric measures of height or weight or both, is specific weight-for-height or -length of the reference popula- to the child’s age and sex, and results from various tion). Wasting often reflects an acute shock or acute types of food deprivation (chronic, acute, or micronu- absence of calories. The Case for Investment in Nutrition in Senegal 51 Underweight: defined as a weight-for-age below –2 many consequences for both maternal and birth out- standard deviations from the weight-for-age of the ref- comes, including low birthweight. erence population (children of the same age and sex). Micronutrient deficiency: a deficiency in one or more Complementary feeding: the period during which a child micronutrients, with vitamin A, iron, iodine, and zinc receives age-appropriate foods in addition to breastmilk. the most often studied. Depending on the micronutri- This period typically begins at 6 months, when breast- ent, the severity of the deficiency, and the development milk alone is no longer sufficient to sustain the nutrient stage during which the deficiency occurs, conse- requirements of the infant, and lasts for the duration of quences range from impaired cognitive and physical continued breastfeeding, typically 24 months. development to severe mental retardation and death. Double and triple burden of malnutrition: A term Nutrition-sensitive: interventions or programs that used to describe the coexistence of two or three types address the underlying determinants of fetal and child of malnutrition within one individual, household, or pop- nutrition and development—food security; adequate ulation, throughout life. Typically, the double burden of caregiving resources at the maternal, household, and malnutrition refers to a coexistence of undernutrition community levels; and access to health services and and overweight or obesity; the triple burden adds mi- a safe and hygienic environment—and incorporate cronutrient deficiencies. specific nutrition goals and actions. Nutrition-sensitive programs can serve as delivery platforms for nutri- Exclusive breastfeeding: the provision of breastmilk tion-specific interventions, potentially increasing their only, with no other liquids or foods added to the diet, scale, coverage, and effectiveness. typically from birth to 6 months. Nutrition-specific: interventions or programs that Household food security: when all people within a address the immediate determinants of fetal and household, at all times, have physical, social, and eco- child nutrition and development—adequate food and nomic access to safe, sufficient, and nutritious food nutrient intake, feeding, caregiving, and parenting that meets their dietary needs and food preferences practices, and low burden of infectious diseases. for an active and healthy life. Overweight and obesity: an excess of adipose tis- Infant and young child feeding (IYCF): a set of in- sue, which is measured among children and adults ternationally vetted recommendations that have been using anthropometric measures of height and weight, developed to address the nutritional needs of infants and summarized as a BMI above an age- and sex-spe- from birth to 24 months (that is, from birth through the cific threshold. Overweight and obesity typically result periods of exclusive breastfeeding and complementa- from shifts in diet and physical activity that accompany ry feeding). national-level changes in economic growth and migra- tion. Overweight and obesity also constitute important Low birth weight: defined as a child whose weight at risk factors for many noncommunicable and chronic birth is less than 2,500 grams (5 pounds, 8 ounces). diseases, such as diabetes, heart disease, and certain Low birthweight is typically a consequence of poor nu- cancers. Thus, increases in overweight and obesity trition in utero, which may result from poor maternal at the population level typically are accompanied by nutritional status before and during pregnancy. shifting patterns in disease epidemiology. Maternal thinness: defined as a woman of childbear- Child overweight: defined as a child with a BMI at or ing age (15–49 years) with a body-mass index (BMI) above the 85th percentile and below the 95th percen- of or below 18.5. Maternal thinness has been linked to tile for children of the same age and sex. 52 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal Child obesity: defined as a child with a BMI at or Maternal obesity: defined as a woman of childbearing above the 95th percentile for children of the same age age (15–49 years) with a BMI at or above 30. and sex. Maternal overweight: defined as a woman of child- bearing age (15–49 years) with a BMI at or above 25 and below 30. The Case for Investment in Nutrition in Senegal 53 1818 H Street, NW Washington, DC 20433 Funding for the report was provided by the World Bank and the Japanese Trust Fund for Nutrition. The task force providing oversight of the series was composed of members of the following organizations: