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The Cost of Hunger: The Social and Economic Impact of Child Undernutrition in Sudan

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Executive Summary

The Cost of Hunger in Africa (COHA) is an African Union Commission (AUC) led initiative through which countries are able to estimate the social and economic impact of child undernutrition in a given year. About 16 countries are initially participating in the study. Sudan is part of the phase VI countries.
The COHA study shows that undernutrition among children is a social issue that affects the whole economy, because countries are losing significant sums of money as a result of current and past cases of child undernutrition. It is with this background that in March 2012, a regional COHA study was presented to African Ministers of Finance, Planning and Economic Development, in Addis Ababa, Ethiopia. From this meeting the Ministers issued a resolution confirming the importance of the study and recommending that the COHA study be replicated across African countries.
The COHA study in Sudan is led by the National Council of Child Welfare , with support from the Central Bureau of Statistics (CBS); Federal Ministry of Health (FMOH); Ministry of Education; Ministry of Labour; Ministry of Agriculture; Ministry of Finance and Economic Planning; Ministry of Industry; Central Bank of Sudan; Development partners namely World Food ProgrammeSudan. At regional level, the COHA project is led by the African Union Commission (AUC) with technical leadership from World Food Program- Africa Office (WFP).
During the process, all data for the study were collected from national data sources including Multiple Indicators Cluster Survey (MICS) 2014; the Sudan Household survey 2014; Sudan National Bureau of Statistics - Economic Survey and Statistical Abstracts various years, Sudan Labour Force Survey; Central Bank of Sudan 2014; and primary data collected from selected public hospitals, and relevant data from international sources, such World Health Organization, United Nation International Children Emergency Fund and World Bank Data bases.
Methodology The study is concerned with the construction and estimation of composite indicators that reflect the cost of malnutrition on the populace and the economy. The process delineates the measurable indicators of malnutrition, and then measures the performance of child development through adulthood prospectively and retrospectively taking into consideration the performance in the key domains of livelihood, i.e., education, health, economy and the environment. The methodology uses these key domains as reference domains for data collection. The philosophy underlying the methodology is to measure how malnutrition is triggered by the performance failure in each and every domain of these key domains, and how all that impacts the national economy. The ultimate cost of malnutrition as measured by the failure in the performance in the key domains, is termed ‘Cost of Hunger’; and the cost is generalized for the whole economy.
The COHA model estimates the additional cases of morbidity, mortality, school repetitions, school dropouts and reduced physical capacity that can be directly associated with undernutrition in children under the age of five. In order to estimate these social impacts for a single year, the model focuses on the current1 population, identifies the percentage of that population who were undernourished before the age of five, and then estimates the associated negative impacts experienced by the population in the study year. Using this information and economic data provided by the National Implementation Team (NIT), the model then estimates the associated economic losses incurred by the economy in health, education, and in potential productivity in a single year.
Social and economic impacts of undernutrition The current levels of child undernutrition illustrate the continuing challenges for reduction of child hunger. It is estimated that 1.8 million of the 7.1 million children under the age of five in Sudan were affected by stunting in 2014 and 767,927 children were underweight. This situation is especially critical for children between 12 and 23 months, where 26 percent of children are affected by stunting.
Sudan has made progress in reducing stunting in children; nevertheless, stunting rates remain high. It is estimated that 7.9 million population, in the working-age population suffered from growth retardation before reaching five years. In 2014, this represented 25.2 percent of the population aged 15-64 who were in a disadvantaged position as compared to those who were not undernourished as children. Undernutrition can also be associated with low progression in education system with only 3 out of every 10 learners enrolled in grade 1 progressing (pass level) to form four. This can be attributed to low cognitive skills.
In the last 5 years alone, it is estimated that 172,866 child deaths in Sudan were directly associated with undernutrition.
These deaths represent 37.7 percent of all child mortalities for this period. Thus, it is evident that undernutrition significantly exacerbates the rates of death among children and limits the country’s capacity to achieve the SDGs, especially goal 3 which is good health and wellbeing to reduce child mortality.
These historical mortality rates will also have an impact on national productivity. The model estimates that an equivalent of 5.2 percent of the current workforce has been lost due to the impact of undernutrition in increasing child mortality rates.
This represents 1,077,671 people who would have between 15-64 years old, and part of the working age population of the country. It is estimated that 3,244,243 clinical episodes in Sudan in 2014, were associated with the higher risk present in underweight children. These episodes generated an estimated cost of SDG 4,616 Million.
Based on official information provided by the Ministry of Education, 218,533 children repeated grades in 2014. Using data on increased risk of repetition among stunted students, the model estimated that the repetition rate for stunted children was 5.4 percent, while the repetition rate for non-stunted children was 2.2 percent. Thus, given the proportion of stunted students, the model estimates that 63,215 students, or 28.9 percent of all repetitions in 2014 were associated with stunting.
The costs associated with school dropouts are reflected in the productivity losses experienced by individuals searching for opportunities in the labour market. As such, the impact is not reflected in the school age population, but in the workingage population. Hence, in order to assess the social and economic costs in 2014, the analysis focuses on the differential in schooling levels achieved by the population who suffered from stunting as children and the schooling levels of the population who was never stunted.
In 2014, the 63,215 students who repeated grades (and whose repetitions are considered to be associated with undernutrition) incurred a cost of SDG 140.2 million. The largest proportion of repetitions occurred during primary school, where the cost burden falls mostly on the public education system. The following chart summarizes the public and private education costs associated with stunting.
As in the case of health, the social cost of undernutrition in education is shared between the public sector and the families.
Of the overall costs, a total of SDG 92.7 million (66.1 percent) are being covered by the care takers, while SDG 47.5 million (33.9 percent) is borne by the public education system. Nevertheless, the distribution of this cost varies depending on whether the child repeated grades in primary or secondary education. In primary education, the families cover 68.4 percent of the associated costs of repeating a year, where as in secondary the burden on the families is reduced to 51.6 percent. In both cases, the government covers a larger proportion of the burden.
The cost estimates in labour productivity were estimated by identifying differential income associated with lower schooling in non-manual activities, as well as the lower productivity associated with stunted people in manual work, such as agriculture.
The opportunity cost of productivity due to mortality is based on the expected income that a healthy person would have been earning, had he or she been part of the workforce in 2014.
Based on information from the Sudan Labour force survey 2011,1it is estimated that the educational gap between the stunted and non-stunted population is 1.6 years. It is important to note that over time there has been an improvement in the average years of schooling among the working population. Whereas, the cohort from 60-64 years shows an average level of school education of 1.8 years, the cohort aged 20-24 shows an average of 7.2 years of education.
The lower educational achievement of the stunted population has an impact on the expected level of income a person would earn as an adult. The model estimates that 6,055,543 people engaged in non-manual activities suffered from childhood stunting.
This represents 29.5 percent of the country’s labour force that is currently less productive due to lower schooling levels associated to stunting. The estimated annual losses in productivity for this group are SDG 1.018 billion (USD 176.5 million) equivalent to 0.23 percent of the GDP in 2014.

The model estimated that 7.3 million people in Sudan are engaged in manual activities, of which 3.2 million were stunted as children. This represented an annual loss in potential income that surpasses SDG 655.9 million (USD 113.7 million), equivalent to 0.15 percent of the GDP in potential income lost due to lower productivity.
The total losses in productivity for 2014 are estimated at approximately SDG 6.9 billion (USD 1.2 billion), which is equivalent to 1.5 percent of Sudan’s GDP. As presented in Figure 4.12, the largest share of productivity loss is due to reduced productivity due to undernutrition-related mortality which represents 75.6 percent of the total cost. The lost productivity in non-manual activities represents 14.8 percent of the costs. The income differential in manual labour, due to the lower physical and cognitive capacity of people who suffered from growth retardation as children represents 9.5 percent of the total costs.
For Sudan, the total losses associated with undernutrition are estimated at SDG 11.6 billion, or USD 2 billion for the year 2014. These losses are equivalent to 2.6 percent of Sudan 2014 GDP. The highest element in this cost is the loss in potential productivity as a result of undernutrition-related mortalities

Future scenarios

The model generates a baseline that allows development of various scenarios based on nutritional goals established in each country using the prospective dimension. These scenarios are constructed based on the estimated net present value of the costs of children born in each year between 2014 – 2025 and 2014 – 2030.
The scenarios developed for this report are as follows:

  1. Scenario #1: Cutting by half the prevalence of child undernutrition by 2025. In this scenario, the prevalence of underweight and stunted children would be reduced to half of the 2014 values corresponding to the reference year. In the case of Sudan this would mean a constant reduction of 1.2 percent points annually in the stunting rate from 38.2percent (estimate for 2014) to 19.1percent in 2025. A strong effort has to be carried-out to complete this scenario that would require a revision of the effectiveness of on-going interventions for the reduction of stunting as the average rate of reduction for stunting between 2005 and 2010 was estimated at 4.7 percent.

  2. Scenario #2: The ‘Goal’ Scenario. Reduce stunting to 10 percent and underweight children to 5 percent by 2025. In this scenario, the prevalence of stunted children would be reduced to 10 percent and the prevalence of underweight children under the age of five, to 5 percent. Currently, the global stunting rate is estimated at 26 percent, with Africa having the highest prevalence at 36 percent. This Goal Scenario would require a true call for action and would represent an important regional challenge, in which countries of the region could collaborate jointly in its achievement. The progress rate required to achieve this scenario would be 4.7 percent annual reduction for a period of 12 years, from 2014 to 2025. cutting undernutrition by half by 2025 would represent a reduction in costs of over 30.31 billion SDG, equivalent to $US2.5 billion for the period of 11 years, from 2014 to 2025. Although the tendency of savings would not be linear, as they would increase over time with the achieved progress, a simple average of the annual savings would represent $US 344.79 million per year. In the case of the Goal Scenario, the savings would increase to 62.7 billion SDG, or $USD 713.34 million, which represent a simple average of $US 59.44 million per year.


• Sudan must review its national development frameworks to ensure that the reduction of the stunting prevalence is an outcome indicator of the its social and economic development policies.

• Ambitious targets should be set in Sudan for the reduction of stunting that go beyond proportional reduction, and to establish an absolute value as the goal at 10 percent. More specifically, investment should be increased in combating undernutrition during the first 1000 days of a child’s life.

• Sudan should put in place a comprehensive multisectoral nutrition policy, strategy and plan of action, with strong political commitment and allocation of adequate resources for its implementation across all line ministries.

• Promote the delivery of nutrition services integrated with other essential services and utilization of essential health services should be increased and nutrition services should be delivered at all contact points • Promote optimal complementary feeding practices: Best practices should be observed in some area regarding improving the complementary feeding practice, through improved local food processing should be scaled up and interventions should be employed to enrich food with micronutrients.

• Mandatory fortification of staple foods (flour, oil, salt) with multiple micronutrients should be initiated and scaled up.

• Improve monitoring and evaluation systems and clearly link these to prevention interventions.

• Schools can serve as good platform for behaviour change communication for future generations through nutrition and health education, as well as for health check-ups and screening.

• Increase awareness and advocacy of key stakeholders at all levels on the social and economic impacts of child under nutrition to ensure that nutrition, with a focus on addressing stunting, receives the highest possible level of commitments.