Children at the public primary school in the village Amoronimania, in Madagascar. © Mohamad Al-Arief/World Bank
In the commune of Ambohimidasy Itaosy, just outside Madagascar’s capital, six-year-old Sitraka waits for his friends to go play after school. Soon, a group of boys his age gathers and forms a circle to kick around their football. As they play, it is apparent that Sitraka is notably shorter and looks much younger than the others.
Sitraka is stunted, a condition caused by chronic malnutrition during a child’s earliest days of development. In Madagascar, nearly 47 percent of children under the age of 5 suffer from chronic malnutrition, putting at risk their growth and development. As a result, it is not uncommon to find children there whose heights are notably below average for their age.
Yet, stunting is not just a simple growth issue. It is a visible expression of potential slowed development that can impact a child for the rest of his or her life. Sitraka, for example, lags behind his friends in schooling and shows other signs of impaired development.
As a consequence of potentially irreversible cognitive damage, stunted children may be slower to learn and less likely to reach their full potential as adults.
For these reasons, there is increasing recognition that stunting is also a long-term economic problem for countries. World Bank research suggests that, on average, countries lose 7 percent of the per capita GDP because they did not eliminate stunting when their current workers were children. It is higher for Madagascar: the losses due to stunting are estimated at 7 to 12 percent of GDP annually.
Recognizing that the social and economic effects of stunting and malnutrition are dire, the world has made progress. Senegal, for example, has succeeded in reducing stunting prevalence from 30 percent in 2000 to 19 percent today, while Peru more than halved its rates of stunting in less than a decade, from 28 percent in 2008 to 13 percent in 2016. However, stark differences remain between regions and countries.
In 2012, amidst a volatile time for the country, the Bank’s Emergency Support to Critical Education, Health, and Nutrition Services project helped Madagascar maintain and expand their long-running National Community Nutrition Program. This program established community nutrition sites, each run by a community nutrition agent selected by her community. These sites supplied a host of different services from providing information for improving nutrition to helping increase the number and quality of systematic household visits conducted by nutrition agents. With the help of this program, more than 425,000 children under the age of two benefited from improved nutrition, and over 515,000 children between the ages of two and five years were regularly monitored at the community nutrition sites.
Around the same time, emerging evidence from a long-term impact evaluation by the Bank of the National Community Nutrition Program as well as emerging global evidence suggested that a shift was needed from focusing only on wasting (weight for age) to shifting more attention to the very prevalent problem of child stunting (height for age). Within the Bank-supported program, pilot initiatives and innovations to address stunting were carried out to test the efficacy of different interventions. With some positive results from this testing, and additional evidence supporting the importance of focusing programs on the first 1,000 days of a child’s life, Madagascar and the Bank charted a path forward for the country.
It’s clear that the complexity of stunting requires sustained multi-year efforts to substantially reduce the number of children impacted. Yet, finding an effective way to phase in the various interventions needed is also crucial, particularly in a challenging environment like this.
The World Bank continually works to develop better solutions to critical development challenges. Recently, the Bank has been actively testing and rolling out ideas to increase efficiencies and improve its operations to provide better results for clients. In this context, a new structure for long-term operational support has emerged: the Multiphase Programmatic Approach (MPA).
Building on the World Bank’s established financial tools, the MPA allows countries to structure long, large, or complex engagements into a set of smaller, linked operations under one umbrella program. This long-term, tailored approach offers more chances to evaluate a program’s successes and shortcomings, and make expedient adjustments that best fit a country’s context and respond to changing circumstances. Lessons and experiences from a program’s early phases can be more quickly integrated into later phases, which are prepared as separate operations as the program progresses. For complex development issues or operations in challenging environments, the MPA’s long-term, but flexible structure may be a better option for achieving results.
“We think that the new [multiphase programmatic] approach gives us a great opportunity to adapt, learn, be fast, less costly, use our resources in a smart way, and provide the best possible solutions to our clients,” says Otaviano Canuto, one of the World Bank’s Executive Directors. “This is what the clients ask from us and this is what the Bank is committed to doing.”
In Madagascar, the Bank’s team recognized that the country’s stunting crisis could benefit from the MPA’s systematic, but flexible and adaptive process.
“Stand-alone operations work fine in many contexts, but if you are grappling with an issue as complex as stunting, the MPA is great because it allows you to mitigate the risks associated with a stop-and-go approach—a huge loss of investment, and stalled or reversed progress toward an outcome,” said Jumana Qamruddin, senior health specialist and task team leader of the program.
The embrace of the approach by the Bank and government in Madagascar culminated in the Bank’s first approved MPA operation—the Improving Nutrition Outcomes Program. Providing up to $200 million over 10 years, the program signals the Bank’s long-term commitment to provide sustained resources to the country. The programmatic structure of the project also ensures that work on chronic malnutrition is systematically and effectively scaled-up across the country.
The program’s first phase, an $80 million grant from the International Development Association—the World Bank’s fund for the poorest—co-financed by a $10 million grant from the Power of Nutrition Trust Fund, stretches over five years. It will scale up the use of a high-impact interventions known to reduce stunting, such as micronutrient supplementation and the promotion of breastfeeding as part of an integrated health and nutrition package, and focus on introducing behavioral changes known to reduce stunting.
Targeting close to 75 percent of children under 5, this program will be rolled out in the eight regions of Madagascar with the highest stunting rates under the first phase, before expanding to 15 regions by the end of the program. It will prioritize activities that promote good nutrition for the 1,000 days from a child’s conception through two years of age. The program seeks to reduce the number of stunted children in the targeted regions by 30 percent by 2028 and offer a brighter future to some 600,000 children.
© Ramatoulaye George-Alleyne
“Given the strong consensus that chronic malnutrition is the top obstacle to growth in the country, I am glad the Bank is standing by children for the long haul, and helping awaken more interest in human capital as a driver of development,” notes Coralie Gevers, the World Bank’s Country Manager in Madagascar.
Good nutrition has a positive impact on the capacity of children to grow, learn, and thrive, and the evidence base for achieving results is growing. Madagascar has set reducing stunting in children under 5 years of age as one of its main goals, and its partnership with the World Bank will help the country promote good nutrition and development from the earliest days of children’s lives.
Looking to the future, establishing a solid foundation of human capital will not only help people take advantage of economic opportunities and fulfill their potential.