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

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Executive Summary

The Cost of Hunger in Africa (COHA) study 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. In March 2012, the regional COHA study was presented to African Ministers of Finance, Planning and Economic Development at the 5th Joint African Union (AU) and Economic Commission for Africa (ECA) Conference of Ministers of Economic Planning and Finance held in Addis Ababa,
Ethiopia. At the meeting, the Ministers issued a resolution affirming the importance of the Study and recommending that it should progress beyond the initial stage. Eighteen countries have so far completed the study and The Gambia is among eight countries in the second phase that are embarking on the study.
Over the past decade, the Gambia has registered some progress in improving the nutritional status of children, particularly the reduction of the prevalence of stunting, wasting and underweight among children under five years of age. According to the recently published Gambia Micronutrient Survey (GMNS) conducted in 2018, stunting among children under five years was 15.7 %, down from 24.5 % according to the 2013 Gambia Demographic and Health Survey (GDHS). Underweight and wasting were 10.6 % and 5.8 % down from 16.2 and 11.5 % respectively. Despite this overall progress, child undernutrition remains unacceptably high in The Gambia. It is evident that positioning nutrition interventions as a top priority for development and poverty reduction is often challenging, partly due to the lack of credible data on both short- and long-term returns. Indeed, there is not enough country-specific evidence to demonstrate how improved nutrition can have a direct impact on school performance, and thereby improving opportunities in the labour market and physical work. Additionally, nutrition is too often regarded as a health issue and is highly medicalied in many countries, disregarding the ripple social and economic effects it has on other areas of development.
The specific objectives of undertaking the COHA Gambia Study included estimating the social and economic impacts of child undernutrition, generating policy evidence to justify the need to increase investment in nutrition, and recommending actions to inform human capital development that will help bolster implementation of The Gambia's NDP and other commitments.
The findings of the study give policy insights that shall be key in the development and revision of key policies and strategies geared towards reducing child undernutrition in The Gambia.
The Study was spearheaded by Government Ministries, Departments and Agencies (MDAs) including the National Nutrition Agency under the Office of the Vice President, The Gambia Bureau of Statistics, Ministry of Finance and Economic Affairs,
Ministry of Health, Ministry of Basic and Secondary Education, Ministry of Agriculture, Ministry of Women, Children and Social Welfare, National Population Commission Secretariat in collaboration with various development partners including WFP, FAO and UNICEF. Several other national and development partners representing the interest of the Government also participated in the Study.
The COHA model is used to estimate the additional cases of morbidity, mortality, school repetitions, dropouts and reduced physical capacity that can be associated with a person’s undernutrition status before the age of five. In order to estimate these social impacts for a single year, the model focuses on the current 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 year of analysis. Using this information and the data provided by the NIT, the model estimates the associated economic losses incurred by the country in health, education and labour productivity in a single year. The reference year used in the analysis of the study model is 2018, which is referred throughout the text as ‘base year’. The data for The Gambia COHA study was collected from national data sources which include: GDHS (2013), GMNS (2018) and MICS 2006 and 2010, the SMART Surveys 2012 and 2015 and the National Health Account (NHA) 2015. Additional data was obtained from the World Health Organization and the United Nations Department of Economic and Social Affairs (UNDESA). Primary data was collected by conducting a survey and interviews at the Kanifing General Hospital.
The report outlines the social and economic costs of child undernutrition affecting three sub sectors namely; health, education and labour and productivity. The study estimated that in 2018, there was an increase of 64,094 episodes of illnesses related to diseases that are associated with underweight. In addition, pathologies related to calorie and protein deficiencies and low birth weight associated with Intrauterine Growth Retardation (IUGR), totalled to more than 4,462 episodes. As a result, The Gambia had to address 68, 557 illnesses in children that required medical attention and generated costs both to families and to the health sector.
Between 2013 and 2018, it is estimated that 6,316 child deaths in The Gambia were directly associated with undernutrition.
These deaths represent 20.3 % of all child mortalities for this period. Thus, it is evident that undernutrition significantly exacerbates the rates of death among children and limits The Gambia’s capacity to reduce child mortality. In the last five years precedings 2018, it is estimated that 68,557 illnesses in children that required medical attention in The Gambia were directly associated with the incremental risk to illnesses associated with children being underweight. This generated an estimated cost of GMD 280.7 million. The model estimates that an equivalent of 35.3 % of the current workforce has been lost due to the contribution of undernutrition to child mortality rates. This represents 48,066 people who would have been 15-64 years old by 2018, and part of the working age population of The Gambia.
The study showed that in The Gambia, it is estimated that in 2018 families bear 38% of the costs associated with undernutrition, while the remaining 62% are borne by the health system. Although the families of undernourished children incur a high percentage of the health costs related to undernutrition, the burden of this phenomenon is still an important expenditure component in the public sector. In 2018, the annual estimated cost to the public sector was equivalent to 9.7% of the total budget allocated to health. In summary, the economic impact of undernutrition in health-related aspects was equivalent to 0.4 % of total GDP in 2018.
A total number of 23,429 children repeated grades one to twelve in 2018 (representing 4.6% repetition rate in 2018). Using data on increased risk of repetition among stunted students, the model estimated that out of the 23,429 children of grades one to twelve who repeated in 2018, the repetition rate for stunted children was 8.3 %, while the repetition rate for nonstunted children was 3.4 %. Thus, given the proportion of stunted students, the model estimates that 8,106 students, or 34.6 % of all repetitions in 2018 were 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 (Households). Of the overall costs, a total of GMD 37 million (USD 780,261) are being covered by the caretakers, while GMD 22.6 million (USD 476,592) 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 and lower secondary education, the families respectively cover - 58.4 % and 56.7 % of the associated costs of repeating a year, whereas in upper secondary education the burden on the families is increased to 71.2 %. In both cases, the households cover a larger proportion of the burden.
For the education sector, the model estimated that 35.3 % of the working-age population in The Gambia were stunted as children. Research shows that adults who suffered from stunting as children are less productive than non-stunted workers and are less able to contribute to the economy. This represents 399,694 people whose potential productivity is affected by undernutrition.
The model estimated that 537,268 people in The Gambia are engaged in manual activities, of which 446,088 were stunted as children. This represented an annual loss in potential income that surpasses GMD 1.305 billion or USD 27.5 million equivalent to 1.7 % of the GDP in potential income lost due to lower productivity. Overall, The Gambia is estimated to have lost an equivalent of about GMD 3.956 billion in 2018, which represented 5.1 % of the GDP. Productivity related losses contributed the largest costs at 4.7 % of GDP followed by Health and Education at 0.4 % and 0.002 % respectively.
In addition to calculating a retrospective cost for 2018, the model also highlighted potential savings, based on different scenarios.
These scenarios are constructed based on the estimated net present value of the costs associated with undernutrition of the children born in each year, from 2018 to 2030. The methodology follows each group of children and, based on each scenario, estimates a progressive path towards its achievement. The following four scenarios and their potential gains were constructed Baseline: The Cost of Inaction. Progress in reduction of stunting and underweight children stops.
Scenario #1: Cutting by half the prevalence of child undernutrition by 2025.
Scenario #2: The ‘Goal’ Scenario. Reduce stunting and underweight in children to 10% and 5% respectively by 2025.
Scenario #3: Gambia Policy Scenario 2030, based on the National Development Plan and National Nutrition Policy.
With the different scenarios, it is expected that stunting will reduced to different levels and rates. It is also expected that annual average savings and possible economic returns that can be gained if appropriate investments in nutrition are undertaken based on the different scenarios ranged from GMD 3.146 billion to GMD 4.957 billion by 2030.
The report underscores the importance of nutrition in human capital development and by extension the socio-economic transformation of The Gambia. It particularly demonstrates that for children, undernutrition has adverse implications for school performance, health and for workers it reduces productivity and ultimately earnings. The Gambia COHA report estimates the associated cost of undernutrition to the economy through health, education and labor productivity in a single year. In 2018, an estimated GMD 3.956 billion (or USD 83.4 million) equivalent to 5.1 % of GDP was lost to the economy as a result of child undernutrition. The report finds that positioning nutrition interventions as a top priority for human capital development has a lasting effect on the socio-economic development of a country.
The Report strongly recommends an increase investment in nutrition, strengthening of multi-sectoral coordination and collaboration mechanisms for nutrition, mobilizing resources for sustainable provision of nutrition, health and education services through an Innovative Financing Strategy and enhancing the implementation of the National Development Plan, Zero Hunger Strategy and the Comprehensive Multi-Sectoral Nutrition Action Plan.