Annual Trends and Outlook Report 20 15 ACHIEVING A NUTRITION REVOLUTION FOR AFRICA: The Road to Healthier Diets and Optimal Nutrition Edited by Namukolo Covic Sheryl L. Hendriks About ReSAKSS | www.resakss.org Established in 2006 under the Comprehensive Africa Agriculture Development Programme (CAADP), the Regional Strategic Analysis and Knowledge Support System (ReSAKSS) supports efforts to promote evidence and outcome-based policy planning and implementation. In particular, ReSAKSS provides data and related analytical and knowledge products to facilitate CAADP benchmarking, review, and mutual learning processes. The International Food Policy Research Institute (IFPRI) facilitates the overall work of ReSAKSS in partnership with the African Union Commission, the NEPAD Planning and Coordinating Agency (NPCA), leading regional economic communities (RECs), and Africa-based CGIAR centers. The Africa-based CGIAR centers and the RECs include: the International Institute of Tropical Agriculture (IITA) and the Economic Community of West African States (ECOWAS) for ReSAKSS–WA; the International Livestock Research Institute (ILRI) and the Common Market for Eastern and Southern Africa (COMESA) for ReSAKSS–ECA; and the International Water Management Institute (IWMI) and the Southern African Development Community (SADC) for ReSAKSS–SA. ReSAKSS is funded by the United States Agency for International Development (USAID), the Bill & Melinda Gates Foundation, the International Fund for Agricultural Development (IFAD), and the Ministry of Foreign Affairs of Netherlands (MFAN). Earlier, ReSAKSS also received funding from the UK Department for International Development (DFID) and the Swedish International Development Cooperation Agency (SIDA). Editors Namukolo Covic and Sheryl L. Hendriks DOI: http://dx.doi.org/10.2499/9780896295933 ISBN: 978-0-89629-593-3 Citation Covic, N. and S. L. Hendriks (Eds). 2016. Achieving a Nutrition Revolution for Africa: The Road to Healthier Diets and Optimal Nutrition. ReSAKSS Annual Trends and Outlook Report 2015. International Food Policy Research Institute (IFPRI). Copyright Except where otherwise noted, this work is licensed under a Creative Commons Attribution 4.0 license (CC-BY-NC-ND), available at http://creativecommons.org/licenses/by-nc-nd/4.0/. Contributors: Olutayo Adeyemi, National Consultant, Nutrition Education and Capacity Strengthening, Food and Agriculture Organization (FAO) | Mohamed Ag Bendech, Senior Nutrition Officer, FAO | Dickson Amugsi, Postdoctoral Research Fellow, African Population and Health Research Center (APHRC) |Richmond N. O. Aryeetey, Senior Lecturer, School of Public Health, University of Ghana | Amare Ayalew, Program Manager, Partnership for Aflatoxin Control in Africa (PACA), African Union Commission (AUC) | Godfrey Bahiigwa, Office Head and Africawide ReSAKSS Coordinator, Eastern and Southern Africa Office, International Food Policy Research Institute (IFPRI) | Anna-Marie Ball, Senior Research Fellow and Head, Africa Strategic Alliances, HarvestPlus, IFPRI | Samuel Benin, Research Fellow, Development Strategy and Governance Division, IFPRI | Leah Bevis, Assistant Professor of Sustainable Food and Farm Policy, Department of Agricultural, Environmental and Development Economics, Ohio State University | Komal Bhatia, Data Analyst, Institute of Development Studies | Ekin Birol, Senior Research Fellow and Head, Impact Research, HarvestPlus, IFPRI | Erick Boy, Senior Research Fellow and Head, Nutrition, HarvestPlus, IFPRI | Ruth Butao Ayoade, Food Security and Nutrition Advisor, FAO | Mercy Chikoko, Nutrition Officer, FAO | Esi Colecraft, Lecturer Nutrition and Food Science Department, University of Ghana | Namukolo Covic, Research Coordinator, Poverty, Health and Nutrition Division (PHND), IFPRI | Andrew Dillon, Assistant Professor, Department of Agriculture, Food, and Resource Economics, Michigan State University | Charlotte Dufour, Food Security, Nutrition and Livelihoods Advisor, FAO | Olivier Ecker, Research Fellow, Development Strategy and Governance Division (DSGD), IFPRI | Kamilla Eriksen, Public Health Nutritionist and PhD candidate, University of Cambridge | Chibundu N. Ezekiel, formerly Technical Advisor, PACA, AUC and Senior Lecturer, Department of Microbiology, Babcock University| Peixun Fang, Senior Research Assistant, DSGD, IFPRI | Jessica Fanzo, Bloomberg Distinguished Professor, School of Advanced International Studies, Berman Institute of Bioethics, Johns Hopkins University| Samuel Gameda, Soil Scientist, International Maize and Wheat Improvement Center (CIMMYT) | Stuart Gillespie, Senior Research Fellow, PHND, IFPRI and CEO, Transform Nutrition Research Programme Consortium | Lawrence Haddad, Executive Director, Global Alliance for Nutrition| Tesfaye Hailu, Nutritionist, Ethiopian Public Health Institute (EPHI) | Sheryl L. Hendriks, Professor in Food Security and Director of the Institute for Food, Nutrition and Well-being, University of Pretoria | Kalle Hirvonen, Research Fellow, DSGD, IFPRI | Vivian Hoffmann, Research Fellow, Markets, Trade, and Institutions Division (MTID), IFPRI | Michelle Holdsworth, Professor of Public Health, School of Health and Related Research-Public Health section, University of Sheffield | Isatou Jallow, Senior Nutrition and Partnership Advisor, New Partnership for Africa's Development (NEPAD) | Johann Jerling, Professor, Centre of Excellence for Nutrition, North-West University, South Africa | Elizabeth Kimani-Murage, Research Scientist, African Population and Health Research Center (APHRC) | Patrick Kolsteren, Professor, Department of Food Safety and Food Quality, Ghent University | Carl Lachat, Professor, Department of Food Safety and Food Quality, Ghent University | Natasha Ledlie, Research Analyst, PHND, IFPRI | Jef L. Leroy, Senior Research Fellow, PHND, IFPRI | Johanna Lindahl, Scientist, International Livestock Research Institute (ILRI) and Swedish University of Agricultural Sciences| Laila Lokosang, CAADP Advisor for Food and Nutrition Security, Department of Rural Economy and Agriculture, AUC | Teresia Macharia, APHRC and Department of Food, Nutrition and Dietetics, Kenyatta University | Tekalign Mamo, Senior Director, Agricultural Commercialization Cluster Initiative, Ethiopian Agricultural Transformation Agency (ATA) | Anina Manganhela, DAP Analyst, Mozambique Ministry of Agriculture and Food Security | Rabe Mani, Assistant Representative in Nigeria, FAO |Peninah Masibo, Training Coordinator, APHRC and School of Public Health, Moi University | Bho Mudyahoto, Senior Monitoring, Learning and Evaluation Specialist, HarvestPlus, IFPRI | Eunice Nago, Lecturer-Researcher, Faculty of Agricultural Sciences, University of Abomey-Calavi | Jennifer Nielsen, Senior Nutrition Advisor, Helen Keller International | Deanna Olney, Senior Research Fellow, PHND, IFPRI | Akoto Osei, Former Nutrition Specialist, Department of Social Affairs, AUC | Felicidade Panguene, Focal point for the National School Meals Programme, FAO | David Pelletier, Professor, Division of Nutritional Sciences, Cornell University | Marie Ruel, Director, PHND, IFPRI | Mawuli Sablah, Chief Technical Advisor-CAADP Nutrition, FAO | Amy Saltzman, Senior Program Analyst, HarvestPlus, IFPRI | Betty Samburu, Programme Manager, Maternal Infant and Young Child Nutrition, Kenyan Ministry of Health | Louise Lobisa Setshwaelo, Representative in Nigeria, FAO| Hailu Shiferaw, GIS Analyst, ATA | Eliab Simpungwe, Country Manager-Zambia, HarvestPlus, IFPRI | Christine Taljaard, Postdoctoral fellow, Centre of Excellence for Nutrition, North-West University, South Africa | Wondwosen Tefera, Research Officer, Eastern and Southern Africa Office, IFPRI | Masresha Tessema, Associate Researcher, Food Science and Nutrition Directorate, EPHI | Zainab Towobola, Desk Officer, Nigeria Ministry of Agriculture and Rural Development | Acanda Ubomba-Jaswa, Market Development Manager-Africa, HarvestPlus, IFPRI | Roos Verstraeten, Scientific Researcher, Nutrition and Child Health Unit, Institute of Tropical Medicine | Marjorie Volege, Scaling-Up Nutrition Coordinator, UNICEF | James Warner, Research Coordinator, MTID, IFPRI | Manfred Zeller, Senior Research Fellow and Head, Policy Research, HarvestPlus, IFPRI | Cover design: Shirong Gao/IFPRI ACHIEVING A NUTRITION REVOLUTION FOR AFRICA: The Road to Healthier Diets and Optimal Nutrition Annual Trends and Outlook Report 20 15 2015 ReSAKSS Annual Trends and Outlook Report iii Contents LIST OF TABLES VII LIST OF FIGURES VIII LIST OF BOXES IX ABBREVIATIONS XI ACKNOWLEDGMENTS XIII FOREWORD XIV EXECUTIVE SUMMARY XVII 1| INTRODUCTION 1 Namukolo Covic and Sheryl L. Hendriks 2| THE AFRICAN UNION POLICY ENVIRONMENT TOWARD ENABLING ACTION FOR NUTRITION IN AFRICA 5 Laila Lokosang, Akoto Osei, and Namukolo Covic 3| AFRICA’S PROGRESS TOWARD MEETING CURRENT NUTRITION TARGETS 12 Lawrence Haddad, Mohamed Ag Bendech, Komal Bhatia, Kamilla Eriksen, Isatou Jallow, and Natasha Ledlie 4| ECONOMIC DEVELOPMENT AND NUTRITION TRANSITION IN GHANA: TAKING STOCK OF FOOD CONSUMPTION PATTERNS AND TRENDS 28 Olivier Ecker and Peixun Fang iv resakss.org 5| MAKING AFRICAN AGRICULTURE AND FOOD SYSTEMS WORK FOR NUTRITION: WHAT HAS BEEN DONE, AND WHAT NEEDS TO BE DONE? 51 Stuart Gillespie and Charlotte Dufour 6| LESSONS LEARNED FROM THE EVALUATION OF HELEN KELLER INTERNATIONAL’S ENHANCED HOMESTEAD FOOD PRODUCTION PROGRAM 67 Deanna Olney, Andrew Dillon, Marie Ruel, and Jennifer Nielsen 7| THE ROLE OF BIOFORTIFICATION AS PART OF MORE DIVERSE DIETS IN AFRICA: PROGRESS, CHALLENGES, AND OPPORTUNITIES 82 Ekin Birol, Amy Saltzman, Anna-Marie Ball, Erick Boy, Bho Mudyahoto, Eliab Simpungwe, Acanda Ubomba-Jaswa, and Manfred Zeller 8| THE ROLE OF MYCOTOXIN CONTAMINATION IN NUTRITION: THE AFLATOXIN STORY 98 Amare Ayalew, Vivian Hoffmann, Johanna Lindahl, and Chibundu Ezekiel 9| THE CHALLENGES, OPPORTUNITIES, AND LESSONS LEARNED IN EVIDENCE-INFORMED DECISION MAKING IN AFRICA 115 Michelle Holdsworth, Richmond N. O. Aryeetey, Johann Jerling, Christine Taljaard, Eunice Nago, Esi Colecraft, Carl Lachat, Patrick Kolsteren, Tesfaye Hailu, and Roos Verstraeten 10| EVALUATING NUTRITION-SENSITIVE PROGRAMS: CHALLENGES, METHODS, AND OPPORTUNITIES 130 Jef L. Leroy, Deanna K. Olney, and Marie Ruel 11| SUPPORTING MULTISECTORAL ACTION: CAPACITY AND NUTRITION LEADERSHIP CHALLENGES FACING AFRICA 147 Johann Jerling, David Pelletier, Jessica Fanzo, and Namukolo Covic 12| TRACKING KEY CAADP INDICATORS AND IMPLEMENTATION PROCESSES 170 Godfrey Bahiigwa, Samuel Benin, and Wondwosen Tefera Contents Continued 2015 ReSAKSS Annual Trends and Outlook Report v Contents Continued 13| SUMMARY AND POLICY RECOMMENDATIONS: TOWARD A NUTRITION REVOLUTION FOR AFRICA 179 Sheryl L. Hendriks and Namukolo Covic FEATURED CASE STUDIES CASE STUDY 1: KENYA’S STATUS ON MEETING WORLD HEALTH ASSEMBLY CHILD NUTRITION TARGETS BY 2025 22 Elizabeth Kimani-Murage, Teresia Macharia, Peninah Masibo, Dickson Amugsi, Marjorie Volege, and Betty Samburu CASE STUDY 2: POTENTIAL LINKAGES BETWEEN ZINC IN SOILS AND HUMAN NUTRITION IN ETHIOPIA 96 Samuel Gameda, Kalle Hirvonen, James Warner, Leah Bevis, Tekalign Mamo, Hailu Shiferaw, and Masresha Tessema CASE STUDY 3: MAINSTREAMING NUTRITION IN THE NATIONAL AGRICULTURE PROGRAMS AND INVESTMENT PLANS IN MOZAMBIQUE AND NIGERIA 168 Mozambique: Felicidade Panguene, Anina Manganhela, Ruth Butao Ayoade, and Mercy Chikoko Nigeria: Olutayo Adeyemi, Zainab Towobola, Rabe Mani, Louise Setshwaelo, Mawuli Sablah, and Mohamed Ag Bendech ANNEXES| CORE CAADP M&E AND SUPPLEMENTARY INDICATORS 185 Annex 1a: Level 1—Agriculture’s Contribution to Economic Growth and Inclusive Development, Indicator 1.1.1 188 Annex 1b: Level 1—Agriculture’s Contribution to Economic Growth and Inclusive Development, Indicator 1.1.2 189 Annex 1c: Level 1—Agriculture’s Contribution to Economic Growth and Inclusive Development, Indicator 1.2.1 190 Annex 1d: Level 1—Agriculture’s Contribution to Economic Growth and Inclusive Development, Indicator 1.2.2A 191 Annex 1e: Level 1—Agriculture’s Contribution to Economic Growth and Inclusive Development, Indicator 1.2.2B 192 Annex 1f: Level 1—Agriculture’s Contribution to Economic Growth and Inclusive Development, Indicator 1.2.2C 193 Annex 1g: Level 1—Agriculture’s Contribution to Economic Growth and Inclusive Development, Indicator 1.2.3 194 Annex 1h: Level 1—Agriculture’s Contribution to Economic Growth and Inclusive Development, Indicator 1.3.1 195 Annex 1i: Level 1—Agriculture’s Contribution to Economic Growth and Inclusive Development, Indicator 1.3.3 196 Annex 1j: Level 1—Agriculture’s Contribution to Economic Growth and Inclusive Development, Indicator 1.3.4 197 Annex 1k: Level 1—Agriculture’s Contribution to Economic Growth and Inclusive Development, Indicator 1.3.5 198 Annex 2a: Level 2—Agricultural Transformation and Sustained Inclusive Agricultural Growth, Indicator 2.1.1 199 vi resakss.org ANNEXES| CORE CAADP M&E AND SUPPLEMENTARY INDICATORS continued Annex 2b: Level 2—Agricultural Transformation and Sustained Inclusive Agricultural Growth, Indicator 2.1.2 200 Annex 2c: Level 2—Agricultural Transformation and Sustained Inclusive Agricultural Growth, Indicator 2.1.3 201 Annex 2d: Level 2—Agricultural Transformation and Sustained Inclusive Agricultural Growth, Indicator 2.1.4 202 Annex 2e: Level 2—Agricultural Transformation and Sustained Inclusive Agricultural Growth, Indicator 2.1.5A 203 Annex 2f: Level 2—Agricultural Transformation and Sustained Inclusive Agricultural Growth, Indicator 2.1.5B 204 Annex 2g: Level 2—Agricultural Transformation and Sustained Inclusive Agricultural Growth, Indicator 2.1.5C 205 Annex 2h: Level 2—Agricultural Transformation and Sustained Inclusive Agricultural Growth, Indicator 2.1.5B 206 Annex 2i: Level 2—Agricultural Transformation and Sustained Inclusive Agricultural Growth, Indicator 2.1.5E 207 Annex 2j: Level 2—Agricultural Transformation and Sustained Inclusive Agricultural Growth, Indicator 2.2.1A 208 Annex 2k: Level 2—Agricultural Transformation and Sustained Inclusive Agricultural Growth, Indicator 2.2.1B 209 Annex 2l: Level 2—Agricultural Transformation and Sustained Inclusive Agricultural Growth, Indicator 2.2.2 210 Annex 3a: Level 3—Strengthening Systemic Capacity to Deliver Results, Indicator 3.5.1 211 Annex 3b: Level 3—Strengthening Systemic Capacity to Deliver Results, Indicator 3.5.2 212 Annex 3c: Level 3—Strengthening Systemic Capacity to Deliver Results, Indicator 3.5.3 213 Annex 3d: Level 3—Strengthening Systemic Capacity to Deliver Results, Table 3(A) 214 Annex 3d: Level 3—Strengthening Systemic Capacity to Deliver Results, Table 3(B) 217 Annex 4: Distribution of countries by Year of Signing CAADP Compact and Level of CAADP Implementation Reached by End of 2015 220 Annex 5: Supplementary Data Tables 221 REFERENCES 229 Contents Continued 2015 ReSAKSS Annual Trends and Outlook Report vii List of Tables T2.1 Examples of Nutrition-Sensitive and Nutrition-Specific Interventions 8 T2.2 The Eleven Principles of the CAADP Pillar III Framework for African Food Security (FAFS) 9 T3.1 Countries Ranked According to Stunting (%), Lowest to Highest Prevalence, with Assessment of Progress toward Malabo Target 16 T3.2 Countries Ranked According to Stunting (%), Lowest to Highest Prevalence, with Assessment of Progress toward WHA 2025 Target 17 T3.3 Countries Ranked According to Wasting (%), Lowest to Highest Prevalence, with Assessment of Progress toward WHA Target 18 T3.4 Countries Ranked According to Anaemia (%), Lowest to Highest Prevalence, with Assessment of Progress toward WHA Target 19 T3.5 Countries Ranked According to Percentage of Infants Younger than Six Months Exclusively Breastfeeding, Highest to Lowest Prevalence, with Assessment of Progress toward WHA Target 19 T4.1 Poverty and Child Undernutrition in Ghana 33 T4.2 Shares of Own-produced Foods in Total Food and Food Group Consumption (percentages) in Southern Ghana 37 T4.3 Shares of Own-produced Foods on Total Food and Food Group Consumption (percentages) in Northern Ghana 38 T4.4 Household Food Consumption (Ghanian cedi) and Food Consumption Shares (percentages) in Southern Ghana 41 T4.5 Household Food Consumption (Ghanian cedi) and Food Consumption Shares (percentages) in Northern Ghana 42 T4.6 Food Consumption Elasticity Estimates 48 T5.1 Mapping the Linkages of Agriculture and Nutrition along Identified Pathways in Ethiopia, Kenya and Uganda 59 T5.2 Policies with Potential to Address Nutrition Multisectorally 61 T5.3 Perceptions of Key Factors Preventing Nutrition from Being Prioritized in Agriculture 61 T6.1 Overview of Selected Methods and Numbers of Participating Households from Health Committee, Older Women Leader, and Control Villages 72 T7.1 Status of Biofortified Variety Testing and Release in Africa (August 2016) 85 T7.2 Number of Households (in thousands) Reached in Target Countries in Africa, 2012–2015 86 T8.1 Recent Studies Showing Aflatoxin M1 in Dairy Products in Some African Countries 107 viii resakss.org T9.1 EVIDENT Achievements to Date (September 2016) 125 T11.1 Requirements for an Effective and Sustainable Multisectoral Nutrition (MSN) System 152 T11.2 Illustration of the Accomplishments of the Africa Nutrition Security Partnership, using Mali as an Example 155 CASE STUDY TABLE TC1.1 Kenya’s Supportive Legal and Policy Environment 24 List of Figures F3.1 The Multiple Burdens of Malnutrition in African Countries 14 F3.2 The Annual Cost of Undernutrition, Seven African Countries 15 F3.3 Number of African Countries at Various Stages of Progress against Global Targets on Nutrition 20 F4.1 Economic Growth and Reduction in Poverty and Child Undernutrition, Ghana, 1984–2014 32 F4.2 Calorie and Protein Availability (per capita per day), Ghana, 1984–2011 34 F4.3 Composition of Household Food Consumption in Southern Ghana 43 F4.4 Composition of Household Food Consumption in Northern Ghana 44 F4.5 Engel Curves for the Consumption of Main Food Groups in Southern Ghana 46 F4.6 Engel Curves for the Consumption of Main Food Groups in Northern Ghana 47 F5.1 Mapping the Linkages between Agriculture and Nutrition Outcomes 54 F6.1 Program Theory Framework for HKI’s EHFP Program in Burkina Faso 69 F6.2 Unadjusted Mean Prevalence of Wasting (WHZ < -2 SD) at Baseline and After 2 y Among Children 3–12.9 Months of Age at Baseline, by Group 75 F6.3 Unadjusted Mean Prevalence of Anemia (Hb < 11.0 g/dL) at Baseline and After 2 y Among Children 3–5.9 of Age at Baseline, by Group 75 F6.4 Unadjusted Total Mean Score of Women’s Empowerment at Baseline and After 2 y, Among Beneficiary and Nonbeneficiary Mothers 76 Tables Continued 2015 ReSAKSS Annual Trends and Outlook Report ix F6.5 Reported Changes between 2010 and 2012 Related to Views of Ownership and Use of Land for Agricultural Purposes, Among Women and Men, by Group 78 F7.1 Percentage of Population with Selected Micronutrient Deficiencies 83 F7.2 Biofortification Priority Indexes for Vitamin A Maize and Vitamin A Cassava, Africa Map 92 F7.3 Biofortification Priority Indexes for Vitamin A Sweet Potato and Iron Beans, Africa Map 93 F8.1 Risk Factors contributing to the Aflatoxin Problem in Africa 108 F9.1 EVIDENT Conceptual Framework for Evidence-Informed Decision Making 123 F9.2 Adult Overweight and Obesity Prevalence for Morocco and Tunisia 127 F10.1 Estimating Program Impact Using the Double Difference Follow-up With-and-Without Intervention and the Before-and-After Intervention Group Only Approaches 137 F10.2 Hypothesized Pathways Through Which Homestead Food Production Programs May Improve Maternal and Child Health and Nutrition 140 F11.1 One Version of a Multisectoral Nutrition Structure 150 F11.2 A Framework for Technical, Managerial, and Leadership Capacities Needed for the Dynamic Nutrition Landscape 158 F13.1 The Elements and Connectivity of the Food System at National or Regional Scale 182 CASE STUDY FIGURES FC1.1 Progress toward World Health Assembly Nutrition Indicators, Kenya, 1998–2014 23 FC1.2 Underlying Determinants of Malnutrition in Kenya, 1990–2014 26 List of Boxes B.1.1 2014 Malabo Declarations: Nutrition Commitments 3 B2.1 2025 Nutrition Targets of the Africa Region Nutrition Strategy 2015–2025 7 B2.2 Nutrition-Related Indicators included in the Comprehensive Africa Agriculture Development Programme 9 Figures Continued x resakss.org B3.1 The Scale of Malnutrition in Africa 13 B.3.2 World Health Assembly Indicators and 2025 Targets 16 B5.1 Key Recommendations for Improving Nutrition through Agriculture and Food Systems 57 B5.2 Leveraging Agriculture for Nutrition in East Africa Study Methods 58 B5.3 Zimbabwe’s Food and Nutrition Security Information System 64 B5.4 NEPAD’s Food and Nutrition Security Knowledge-Sharing and Monitoring Platform 64 B8.1 Key Action Items to Address the Problem of Mycotoxins in Africa 113 B9.1 Some Initiatives to Advance Evidence-informed Decision Making in Africa 121 B9.2 Summary of the Aims of EVIDENT 122 B10.1 Nutrition-Specific and Nutrition-Sensitive: What’s the Difference? 131 B10.2 Examples of Standardized Approaches Available for the Measurement of Select Outcomes in Nutrition-Sensitive Programs 138 B.10.3 Definitions of Program Inputs, Processes, Outputs, Outcomes, and Impacts 141 B11.1 Leadership Compared to Management 162 B11.2 Some Elements of Transformational Leadership that Can Be Developed 163 B11.3 Transforming Multisectoral Action Plans into Action—An Illustrative Case Study 165 B11.4 Generic Requirements for an Effective Nutrition Leadership Capacity Building Program—Sharing Experience from the African Nutrition Leadership Programme 166 Boxes Continued 2015 ReSAKSS Annual Trends and Outlook Report xi A4NH CGIAR Research Program on Agriculture for Nutrition and Health AAPPI average annual percentage-point increase AARR average annual rate of reduction ABC-I activity-based costing ingredients AEZ agroecological zone AFB1 aflatoxin B1 AFM1 aflatoxin M1 AfricaAIMS Africa Aflatoxin Information Management System ANLP African Nutrition Leadership Programme ANSP Africa Nutrition Security Partnership APRG Association d’Appui et de Promotion Rurale du Gulmu (Burkina Faso) APTECA Aflatoxin Proficiency Testing and Control in Africa ARNS African Regional Nutrition Strategy ATFFND African Task Force for Food and Nutrition Development ATOR Annual Trends and Outlook Report AU African Union AUC African Union Commission BCC behavior change communication BCURE Building Capacity to Use Research Evidence BMI body mass index BPI Biofortification Priority Index CAADP Comprehensive Africa Agriculture Development Programme CAEWR Commission of Agriculture, Environment, and Water Resources CHANGE Creating Homestead Agriculture for Nutrition and Gender Equity CHW community health worker CIP International Potato Center CRF common results framework DHS Demographic and Health Survey EBF exclusive breastfeeding ECOWAP ECOWAS Agricultural Policy ECOWAS Economic Community of West African States EDHS Ethiopia DHS EHFP Enhanced Homestead Food Production EIDM evidence-informed decision making EIPM evidence-informed policy making ENAs essential nutrition actions EthioSIS Ethiopian Soil Information System FAFS Framework for African Food Security FAO Food and Agriculture Organization of the United Nations FBS Food Balance Sheets FNC Food and Nutrition Council (Zimbabwe) FNSC food and nutrition security committee (Zimbabwe) FNSIS Food and Nutrition Security Information System (Zimbabwe) FSN food security and nutrition FtF Feed the Future GDP gross domestic product GLSS Ghana Living Standards Survey GNR Global Nutrition Report HAZ height-for-age z-score Hb hemoglobin HBV hepatitis B virus Abbreviations xii resakss.org HC health committee HCC hepatocellular carcinoma HFP Homestead Food Production HHN health, hygiene, and nutrition HINI high-impact nutrition interventions HKI Helen Keller International ICN2 Second International Conference on Nutrition IFPRI International Food Policy Research Institute IMAM integrated management of acute malnutrition IYCF infant and young child feeding LAC Latin America and the Caribbean LANEA Leveraging Agriculture for Nutrition in East Africa LANSA Leveraging Agriculture for Nutrition in South Asia LMIC low- to middle-income country LNS lipid-based nutrient supplement MCM multicriteria mapping MDD-W minimum dietary diversity of women MDG Millennium Development Goal MIYCN maternal, infant, and young child nutrition MOOC massive open online community MP malaria prevention MSN multisectoral nutrition NAFSIP National Agriculture and Food Security Investment Plan NAIP National Agriculture Investment Plan NARS national agricultural research system NCD noncommunicable disease NEPAD New Partnership for Africa’s Development NNAP National Nutrition Action Plan (Kenya) OSP orange sweet potatoes OWL older women leader PACA Partnership for Aflatoxin Control in Africa PLAN Le Programme de Leadership Africain en Nutrition ppb parts per billion RAIP regional agriculture investment program REC Regional Economic Community REU Reaching End Users SAA strategic action area (Malabo Declaration) SD standard deviation SDG Sustainable Development Goal SMART specific, measurable, achievable, relevant, and time bound SNNP Southern Nations, Nationalities, and Peoples’ Region SSI semi-structured interview SUN Scaling Up Nutrition SUNLEAD Scaling Up Nutrition Leadership in Africa SUNRAY Sustainable Nutrition Research for Africa in the Years to Come SURE Supporting the Use of Research Evidence U5 children younger than five years UN United Nations VFL village farm leader WASH water, sanitation, and hygiene WHA World Health Assembly WHO World Health Organization WHZ weight-for-height z-score WRA women of reproductive age Abbreviations Continued 2015 ReSAKSS Annual Trends and Outlook Report xiii Acknowledgments The 2015 Annual Trends and Outlook Report (ATOR) has benefited from the research and efforts of the many authors and contributors whose work is presented here. We express our gratitude to all the authors and coauthors. ReSAKSS Coordinators and their teams collected, updated or compiled data on the various CAADP indicators tracked in chapter 12 of this report. We are also grateful to the valuable and thorough reviews and feedback provided by several reviewers as part of our blind review process. We thank Samuel Benin who managed the peer-review process and the processing of data on CAADP indicators. We are also very grateful to Ousmane Badiane and Tsitsi Makombe for their guidance, feedback, and coordination of the production process. Excellent research assistance from Julia Collins and administrative support from Pamela Dogbe are gratefully acknowledged. Sincere thanks go to IFPRI’s Communications and Knowledge Management Division, which provided thorough editorial support. Finally, we would also like to acknowledge the organizations that provided financial support for the 2015 ATOR: the United States Agency for International Development (USAID) and the Bill & Melinda Gates Foundation. xiv resakss.org Foreword A frica's political commitment to nutrition is growing. Increasingly, African leaders recognize the critical role nutrition plays in fostering economic growth, food security, and poverty reduction. Because agriculture remains the main source of livelihood for the poor, agricultural policies and interventions need to be designed to maximize their nutrition and health benefits. The twenty-third assembly of African Union heads of state and government in Malabo, Equatorial Guinea, in 2014 passed three declarations with specific commitments on nutrition. The commitments include ending hunger by 2025, improving nutritional status, reducing child stunting to 10 percent and underweight to 5 percent by 2025, and accelerating progress on preventing child and maternal deaths. In recent years, the African Union Commission (AUC) and the NEPAD Planning and Coordinating Agency (NPCA) have spearheaded several initiatives to improve nutrition outcomes including the African Regional Nutrition Strategy for 2015–2025, the African Task Force on Food and Nutrition Development, and the Comprehensive Africa Agriculture Development Programme (CAADP) Agriculture Nutrition Capacity Development Initiative (2011–2013). The latter helped to strengthen countries’ capacity for mainstreaming nutrition in their CAADP processes and national agriculture and food security investment plans (NAIPs). These initiatives complement country-led efforts to deal with malnutrition, such as those through the Scaling Up Nutrition Movement. For Africa as a whole, levels of hunger and malnutrition have been on the decline. The chapter on tracking CAADP indicators shows that the prevalence of undernourishment in the entire population and the prevalence of underweight, stunting, and wasting in children under five years of age have all decreased since the launch of CAADP in 2003, although rather slowly. Thus millions remain malnourished and hungry. Drastically reducing hunger and malnutrition will require concerted efforts to make agriculture more nutrition sensitive. 2015 ReSAKSS Annual Trends and Outlook Report xv Ousmane Badiane Director for Africa International Food Policy Research Institute H. E. Rhoda Tumusiime Peace Commissioner for Rural Economy and Agriculture African Union Commission Efforts are currently underway to do just that, especially in light of the Malabo Declaration and the CAADP Results Framework 2015–2025, by appraising existing NAIPs, and where needed, formulating second generation NAIPs, in a manner that ensures that nutrition issues are effectively addressed and mainstreamed. This will also help ensure that Malabo nutrition targets are met and that nutrition-sensitive agriculture interventions and best practices are in place. The 2015 Annual Trends and Outlook Report contributes to our understanding of the important role of nutrition in achieving sustainable development outcomes. The report examines the current status of nutrition in Africa, including progress in meeting Malabo nutrition targets, and highlights the importance of dietary quality and diversity, the need to increase the nutrition sensitivity of agriculture, and the importance of strengthening capacities for nutrition mainstream- ing, monitoring, and evaluation. We hope the report will highlight challenges and opportunities that need to be urgently addressed and stimulate action that leads to improved nutrition outcomes at the national, regional, and continental levels. xvi resakss.org 2015 ReSAKSS Annual Trends and Outlook Report xvii Never before has so much attention been paid to nutrition in development dialogues and planning. In the early design of the Comprehensive Africa Agriculture Development Programme (CAADP), the important role nutrition plays in achieving development goals was recognized, but little thought was given to how to integrate nutrition into agriculture and development investment plans. However, several key international events and commitments following the 2007– 2008 food price crisis raised awareness of the need to improve nutrition in order to achieve international, regional, and national development and growth targets. This awareness is articulated in the Sustainable Development Goals and echoed in various strategic African Union policies, strategies, and plans, including the African Union (AU) Agenda 2063, the AU 2014–2017 Strategic Plan, and the three Malabo Declarations (2014) relating to nutrition. Other African Union Commission (AUC) initiatives support this commitment, including the CAADP Nutrition Initiative that commenced in 2011, and the African Regional Nutrition Strategy 2015–2025 (ARNS 2015–2025). In addition, 37 African countries are involved in the Scaling Up Nutrition (SUN) Movement. While many first generation CAAPD programs included food security and nutrition (FSN) programs and activities, nutrition was not well integrated, and monitoring and evaluation systems for assessing the impact of these interventions on nutrition of vulnerable groups were not always included. Some nutrition indicators have now been incorporated in the CAADP Results Framework and can be monitored as part of CAADP implementation progress; CAADP indicators can also complement monitoring that countries are conducting in relation to SUN movement activities. Some countries have already developed common results frameworks for this purpose. Focusing the 2015 Annual Trends and Outlook Report (ATOR) on nutrition will contribute to a broader understanding of the critical role of nutrition in achieving international, continental, and national economic growth targets through agriculture, food security, and nutrition. This report presents information and analysis in support of evidence-based policy making that should inform the second generation of CAADP national investment plans now being developed. This is an important moment for shaping the region’s future and ensuring that the much-needed agriculture-led growth and development agenda can simultaneously deliver on improving nutrition, saving lives, improving productivity and health, and curbing nutrition-related diseases and the associated public health expenditures. These investment plans should address not only the usual elements of undernutrition but also widespread micronutrient deficiencies (termed “hidden hunger”) and the growing problem of overweight and obesity that is associated with economic growth. Executive Summary xviii resakss.orgxviii resakss.org Key Findings Agenda 2063 prioritizes healthy and well-nourished African citizens as an overarching goal for realizing a prosperous Africa that is based on inclusive growth and sustainable development, 2). In January 2014, African Leaders adopted the Common Africa Position (CAP) on the post-2015 development agenda with six priority areas for development and implementation of the Sustainable Development Goals (SDGs). These priority areas include striving for inclusive economic growth that reduces inequality and ensures sustainable agriculture, food self-sufficiency, and nutrition security for all. The Malabo Declaration on CAADP reaffirmed the commitment of African governments to allocate at least 10 percent of their national budgets to agriculture and seek to achieve an annual agricultural growth rate of at least 6 percent. The Declaration commits to using agriculture as a strategy to eradicate undernutrition (stunting and underweight), a goal which in the past was solely the responsibility of the health sector. The post-Malabo Implementation Strategy and Roadmap (2014) emphasizes agriculture-sector activities that have direct links to nutrition, particularly stabilization of food availability and prices and diversification of available nutritious foods for local consumption to improve dietary diversity. This agriculture-based approach is reinforced by a broad range of nutrition policies and frameworks at continental, regional, and national levels, including the ARNS 2015–2025, which is aligned to World Health Assembly nutrition targets. The CAADP Results Framework integrates key nutrition targets, affording an opportunity to measure the impact of national agriculture and food security investment programs on nutrition. Good nutrition provides a vital foundation for human development that is central to meeting our full potential. Improvements in nutrition status lead to a host of positive outcomes for individuals and families. Yet the current statistics and trends in nutritional status in Africa indicate a need for more concerted effort in tackling a triple burden of malnutrition that includes undernutrition, micronutrient deficiencies, and overweight and obesity. Far too many children in Africa are not growing and developing in ways that ensure the future productivity and health of the population. Fifty-eight million children below five years of age are too short for their age (described as stunted); 13.9 million weigh too little for their height (described as wasted); and 10.3 million are overweight. Over 220 million people do not consume enough calories. Moreover, 163.6 million children and women of reproductive age are anemic. Eight percent of adults over 20 years of age are obese. Adult obesity in all 54 African countries rose between 2010 and 2014. Malnutrition is a burden on national budgets and could cost countries between 3 percent (in Swaziland) and 16 percent (in Ethiopia) of national budgets in health costs and productivity losses. However, the calamity of malnutrition is not inevitable. It results from choices we make or fail to make. As African countries review their past performance and draft investment plans for the next 5 to 10 years, they can make strategic policy choices that will improve the trajectory of development by ensuring that development programs lead to widespread and significant improvements for nutrition. The many links between agriculture and nutrition suggest that agricultural policies, interventions, and practices can be better designed to enhance nutrition and health benefits. We can turn agriculture into a powerful lever for raising people’s health and nutritional status, while at the same time contributing to 2015 ReSAKSS Annual Trends and Outlook Report xix other outcomes such as food security, income, equity, and sustainability. Efforts to scale up nutrition-specific interventions need to be paired with investments in nutrition-sensitive development programs and policies. The most direct pathway for improving nutrition is through agricultural production—when production translates directly into consumption for households cultivating crops. However, we need to stimulate the demand for nutritious foods to ensure increased demand for, and consumption of, nutritious food, and reducing excessive demand for foods that lead to undesirable health consequences in order to curb the acceleration of rates of overweight, obesity, and noncommunicable diseases. Doing so will require the transformation of agriculture value chains to increase the nutritional value of foods. Improving the “basket” of food that households produce or can access economically can create multiple benefits for producers and consumers. The nutrient content and safety (lack of contamination risk) of foods should be enhanced. Like other productive sectors, agriculture is a source of household income (raised through wages earned by agricultural workers or through the sales of food produced) and expenditure on nutrition-enhancing goods and services (including health, education, and social services). Agriculture is known to be a more important source of income for the poor and undernourished in Africa than other economic sectors. But as the continent and its countries develop, transformation from a rural and agriculture-based society can lead to problems associated with more developed food systems, including increasing levels of overweight and obesity. The potential nutritional impact of existing food policies (including agricultural subsidies) should be reviewed, and reforms should be initiated for those policies that are likely to have adverse effects on people’s dietary quality and health. Increasing risks of overweight, obesity, and related noncommunicable diseases (NCDs) are normal symptoms of a progressing nutrition transition, but public policy can do a great deal in setting appropriate economic incentives to reduce these adverse impacts. The food and agriculture sector is central to addressing not only undernutrition, but also to containing and preventing the spread of diet-related NCDs. Achieving these goals requires action throughout the food system, from sustainable natural resource management and input supply to enabling consumption of healthy diets and promoting gender equity. Delivering and promoting the consumption of safe food that is affordable and of good nutritional quality on a year-round basis requires working with a broad range of stakeholders—governments, farmers, agribusiness, retailers, and consumers. Agricultural production needs to be diversified to include more nutrient-dense foods that can improve micronutrient intake. This would include fruits and vegetables as well as biofortified crops, which can make an important contribution in addition to animal source foods that remain too expensive for many. More attention to food value chains is needed to prevent postharvest losses; contamination and exposure to hazardous substances like mycotoxins due to mold growth across the value chain; and increases in consumption of high-energy foods that are contributing to the rise in obesity. Examples of ways scientific knowledge can be used to solve critical nutrition problems include biofortification and the use of zinc fertilizer in Ethiopia to improve dietary zinc intake. But more research and innovation is necessary to reduce losses of nutrients across the food system and to find ways of increasing the nutrient content of a variety of foods to improve nutrition. xx resakss.org Innovation is also needed in other areas to make CAADP investment plans deliver impact for nutrition more efficiently from production through processing and storage of food. But innovation in institutional design is also essential. The successes showcased in this report relate to institutional innovation in mainstreaming and integrating nutrition concerns into national policies, priorities, and coordination structures. Doing this requires building the necessary capacity for comprehensive, multisectoral approaches to coordination across sectors and stakeholders as well as vertical coordination within sector or stakeholder institutions. Both the human and financial resources as well as technical and managerial skills to support program planning, implementation, monitoring, and evaluation are critical. Stronger national systems of policy mapping and analysis are essential to making the best choices in policy formulation and decision making. Supporting countries in developing the capacity to collect, analyze, and communicate this information to inform food system and agricultural policy and program design and monitor their impact is key. Comprehensive monitoring and evaluation systems, complete with key nutrition indicators and contextualized evidence, are needed to evaluate the impact of comprehensive investment plans on nutrition and attainment of the international, continental, and national commitments for growth, development, and nutrition. Building a strong body of evidence from rigorous, theory-based, comprehensive evaluations of different program models that bring together interventions from a variety of sectors (for example, health, education, agriculture, social protection, women’s empowerment, water and sanitation) is essential to guiding future investments for better nutrition. Such evidence is necessary to assess what works and does not work in terms of strengthening the nutrition impact of agriculture and food security investment activities, the pathways to impact, and the cost-effectiveness of such programs. Championing the integration of such evidence will require well-developed leadership capabilities and a variety of leadership orientations. The multisectoral nature of such programs requires working with and interacting with multiple sectors and stakeholder actors, for which leadership is critical. Notable improvement has been recorded in Africa on a number of indicators during the CAADP implementation period. Africa as a whole has experienced robust economic growth in GDP per capita and household consumption expenditure per capita during the last 20 years. Measures of hunger and malnutrition (overall undernourishment as well as underweight, stunting, and wasting in children) are improving across Africa, albeit slowly. The incidence of poverty has been declining in Africa as a whole, along with its depth. Agriculture value-added and public agri- culture expenditures have increased, but not enough to meet the CAADP growth and expenditure targets for Africa as a whole. Overall, the analysis of CAADP indicators shows that countries that have been in the CAADP process the longest and those that have gone through most of the levels of the CAADP process have tended to register better outcomes in most of the indicators reviewed, thus highlighting the positive impact of CAADP. Conclusion and Recommendations Malnutrition in all its forms (undernourishment, micronutrient deficiencies, and overweight) is robbing Africa of much-needed productivity and growth potential. Addressing nutrition is an investment with high potential returns 2015 ReSAKSS Annual Trends and Outlook Report xxi in terms of reduced health costs, increased productivity, and improved human resource capacity and economic growth. Although nutrition interventions have been seen as belonging in the health sector, integrated programs that include agriculture and other sectors can create synergies and added value. The agriculture sector needs to become more nutrition sensitive so that it can work in tandem with other sectors to drive a much- desired nutrition revolution for Africa. Achieving the goals of the Malabo Declarations on (1) accelerated agricultural growth and transformation for shared prosperity and improved livelihoods and (2) nutrition security through inclusive economic growth and sustainable development will require efforts from agriculture, social agriculture, social protection, educa- tion, water and sanitation, and more to implement high-impact, integrated interventions at scale. Achieving these goals requires a comprehensive food systems approach to agricultural development. Although the AU and CAADP have not deliberately adopted a food systems approach, the four pillars of CAADP cover key elements of the food system. Therefore, refinement of current CAADP frameworks to deliberately adopt a food systems approach offers tremendous opportunities to deliver more nutritious, healthier diets to the population at large, thus helping to overcome malnutrition in all its forms. In this report we have dealt with opportunities for making Africa’s food system deliver healthier and more nutritious foods, making these foods more available and affordable to all people, and promoting better food consumption patterns as African economies develop. Clearly, the choices we make for agriculture and other sectors now will shape the future food system and in turn, the health and productivity of the continent. To achieve a nutrition revolution for Africa, we recommend the following: 1. At all levels, make the political choice to position nutrition as a priority at the highest level of governance within an integral element of funded comprehensive growth and development strategies. 2. Make deliberate efforts to increase the nutrition sensitivity of current and future agriculture programs and projects by incorporating nutrition components, including, leveraging agricultural extension networks at the country level, and providing a nutrition workforce within the agriculture sector to support nutrition action. It will also be critical to integrate nutrition objectives and indicators into the design and monitoring mechanisms of all future programs seeking to achieve priority national development objectives, as well as the Malabo Declarations and Sustainable Development Goal targets. 3. Establish strong institutional structures to coordinate efforts and ensure that existing resources in agriculture, social protection, education, and water and sanitation are leveraged to scale up nutrition impact. 4. Create national growth and development strategies that include a blend of nutrition-specific and nutrition-sensitive programs that seek to increase the overall supply and distribution of healthy nutrient-dense foods at affordable prices through agricultural value chains that support sustainable livelihoods for rural households. This calls for a food systems approach. xxii resakss.org 5. Make agricultural policy and practice more nutrition-sensitive and, therefore, more effective in improving nutrition and agriculture. This can be achieved through review of agriculture, food, and trade policies to identify reforms necessary to stimulate the local supply and demand of healthy nutritious foods and discourage the consumption of unhealthy foods and food waste. This will also help ensure that unfavorable food policies do not aggravate nutritional challenges, especially in rapidly transforming food systems. 6. Create and strengthen institutional and policy environments that enable agriculture to support nutrition and health goals. 7. Harness the potential for science, technology, and innovation to reduce postharvest losses and food waste; promote product diver- sification with nutritious foods; improve processing to extend shelf life and make healthy foods easier to prepare; and improve storage and preservation to retain nutritional value, ensure food safety, and extend seasonal availability. 8. Accelerate efforts to reduce exposure to mycotoxins, such as afla- toxins, in the food value chain in support of nutrition, health, and economic objectives. 9. Develop capacity and leadership to use evidence-informed decision making to enhance the impact of agriculture on nutrition and health. 10. Accelerate current efforts to develop transformational leadership capabilities, which are needed to manage the change processes required to effectively coordinate and implement nutrition programs and interventions amid competing priorities and demands. 11. African academic institutions must work to develop the needed nutrition workforce to leverage current momentum on nutrition and sustain it into the future, including providing attention to frontline staff. 12. Make commitments that count—specific, measurable, achievable, relevant, and time bound (SMART), as well as ambitious and aligned to the efforts of others. More needs to be invested in more and better data. Inclusive annual national and subnational reporting mechanisms need to be developed and implemented to assess progress on commitments, nutrition outcomes, and actions in a timely way. 2015 ReSAKSS Annual Trends and Outlook Report 1 CHAPTER 1 Introduction Namukolo Covic and Sheryl L. Hendriks 2 resakss.org N ever before has so much attention been paid to nutrition in development dialogues and planning. The early design of the Comprehensive Africa Agriculture Development Programme (CAADP) recognized the important role nutrition plays in achieving development goals, but little thought was given to how to integrate nutrition into agriculture and related development investment plans. Following the guidance of the Global Plan of Action (HLTF 2010) and drawing inspiration from Millennium Development Goal 1, the African Union/CAADP Framework for African Food Security (FAFS) (AU/NEPAD 2009) set out policy and program options for African governments to consider in the design of programs, including their comprehensive growth and development plans. The FAFS was launched at a meeting of 16 African governments at the height of the 2007–2008 world food crisis. Following the first Nutrition for Growth Summit, held in London in 2013 (DFID 2013), signatories committed their political will and financial resources to work in partnership to accelerate progress toward achieving World Health Assembly targets by 2025 (WHO 2014). Other commitments have been made through the Scaling Up Nutrition (SUN) movement and the 2014 Rome Declaration on Nutrition from the Second International Conference on Nutrition (ICN2) (FAO and WHO 2014). These efforts con- tributed to informing the drafting of the Sustainable Development Goals (SDGs), especially SGD2 but, more broadly, at least 12 of the 17 SGDs contain indicators that track important nutrition elements (IFPRI 2016). The recent decision of the UN General Assembly to endorse the ICN2 Framework of Action and declare 2016–2025 the UN Decade of Action on Nutrition is a major step toward mobilizing action around reducing hunger and improving nutrition (IFPRI 2016). The food price crisis of 2007–2008 and recent global attention to nutri- tion have demonstrated the need to focus more on nutrition—especially in the first 1000 days window of opportunity to reduce the long-term negative impacts of malnutrition. While the evidence in support of invest- ment in nutrition has existed in health and nutrition circles for a long time, the need for integrating nutrition objectives and deliberately considering nutrition through the human life cycle in agriculture and development decisions has only recently become topical. The importance of nutrition in the African economic and develop- ment agenda is articulated in the African Union’s (AU’s) Agenda 2063 (AUC 2015a), its First 10 Year Implementation Plan (AUC 2015b), and the three Malabo Declarations (2014) relating to nutrition. The latter are the Declaration on Nutrition Security through Inclusive Economic Growth and Sustainable Development, the Declaration on Accelerated Agricultural Growth and Transformation for Shared Prosperity and Improved Livelihoods, and the Declaration on Ending Preventable Child and Maternal Deaths in Africa (Box 1.1) (AU 2014). Other AUC initiatives support this commitment, including the CAADP Nutrition Initiative being implemented by the New Partnership for Africa’s Development (NEPAD) (FAO 2016), and the African Regional Nutrition Strategy 2015–2025 (AUC undated), In addition, 37 African countries are involved in the Scaling Up Nutrition movement (SUN 2016). While some first-generation CAADP programs included food security and nutrition (FSN) programs and activities, nutrition received little attention in programs and monitoring systems for assessing the impact of these interventions on the nutrition of specific vulnerable groups. Some nutrition indicators have now been incorporated in the CAADP Results 2015 ReSAKSS Annual Trends and Outlook Report 3 Framework (NEPAD 2015) and can thus now be part of monitoring CAADP implementation progress, which can lend synergy to efforts being made by countries in tandem with SUN movement activities. Some coun- tries have already developed common results frameworks for this purpose. Focusing the 2015 Annual Trends and Outlook Report (ATOR) on nutrition will contribute to a broader understanding of the role and impor- tance of nutrition in achieving international, continental, and national economic growth targets through agriculture, food security, and nutrition. This report presents information and analysis in support of evidence- based policy making at the moment when the second-generation CAADP national investment plans are being developed. This is an important moment for shaping the region’s future and ensuring that the much-needed agriculture-led growth and development agenda can simultaneously deliver on improving nutrition and health, saving lives, improving the productivity of Africa’s population, and curbing public health expenditure on nutrition-related diseases. This includes addressing not only the usual elements of undernutrition but also widespread micronutrient deficiencies (termed “hidden hunger”) and the growing problem of overweight and obesity that is increasing across the African continent. While nutrition has traditionally been the domain of the health sector, there are multiple ways of addressing malnutrition in all its forms (under- nutrition, hidden hunger, and overweight and obesity) through smarter design of agriculture and food security–related programs. This report seeks to demonstrate different avenues for addressing malnutrition to unlock and multiply the efforts of countries in breaking the cycle of poverty, mal- nutrition, and inequality. BOX 1.1—2014 MALABO DECLARATIONS: NUTRITION COMMITMENTS Declaration on Nutrition Security through Inclusive Economic Growth and Sustainable Development in Africa 1. Ending hunger by 2025 through strengthening development policies 2. Ending child stunting and bringing down stunting to 10 percent and underweight to 5 percent by 2025 a. Focusing on the first 1000 days of a child’s life b. Prioritizing this goal in national development plans and strategies c. Establishing long-term targets that give all children an equal chance for success 3. Continuing dialogue and strengthening advocacy in support of improved nutrition Declaration on Ending Preventable Child and Maternal Deaths in Africa 1. Ending preventable child and maternal deaths by the year 2035 in line with Post 2015 Sustainable Development Framework 2. Developing and implementing country-led roadmaps to accelerate ending preventable deaths among children and mothers Declaration on Accelerated Agricultural Growth and Transformation for Shared Prosperity and Improved Livelihoods 1. Ending hunger by 2025 2. Improving nutritional status and eliminating child undernutrition by bringing down stunting to 10 percent and underweight to 5 percent by 2025 Source: AU (2014). 4 resakss.org To this end, the report is organized around key focus areas relevant to current efforts on nutrition by the African Union. The AU policy context for nutrition is addressed in Chapter 2. The current status of malnutrition on the continent is addressed in Chapters 3 and 4. Chapter 3 sets out the current status of malnutrition on the continent and the costs associated with not acting, while Chapter 4 complements this by presenting insight into the impact of economic development in driving the nutrition transition across Africa, focusing on Ghana.The need to make agriculture more nutrition sensitive and some examples of what is being done to address different aspects of this on the continent are covered in Chapters 5 through 8. This includes an in-depth consideration of how agriculture can become more nutrition sensitive (Chapter 5); lessons that have been learned on using homestead food production to impact nutrition (Chapter 6); the role that biofortification can play to improve micronutrient intakes from staple foods, especially among the poor who may be hard to reach through other interventions (Chapter 7); and the importance of mitigating against exposure to mycotoxins like aflatoxins across the food value chain in support of improved nutrition, health, and economic outcomes (Chapter 8). Chapter 9 highlights the capacity needs, challenges and opportunities related to bringing about more effective evidence-informed policy and program processes at the national level. Important considerations toward monitoring and evaluation of nutrition sensitive programs are covered in Chapter 10 in support of the strong drive for multisectoral nutrition action to which agriculture needs to play its full potential. Chapter 11 focuses on capacity needs for multisectoral nutrition systems in addition to technical and managerial capacities for different types of program and research staff under different categories of the nutrition workforce. Leadership is highlighted as a cross-cutting capacity need that must also be addressed. The ATOR is the official monitoring and evaluation report for CAADP at the continental level and in this regard Chapter 12 tracks progress on CAADP indicators outlined in the CAADP Results Framework 2015–2025. The chapter also reviews progress in the CAADP implementation process in African countries. To complement the information in the chapters, some case studies (CS) drawing attention to specific areas form part of the ATOR. CS-1 looks at how Kenya has made significant progress on nutrition policy and interventions toward achieving nutrition targets. CS-2 puts forward the use of zinc fertilizers as a potential intervention that can play a dual function of increasing productivity of cereals and increasing intake of zinc, a micronutrient of public health significance. And in light of the ongoing efforts to increase the nutrition sensitivity of agriculture by mainstreaming nutrition into National Agricultural Investment Plans, CS-3 examines how this process has unfolded for Mozambique and Nigeria. The ATOR concludes with Chapter 13, which provides a summary and policy recommendations. The information included in this ATOR does not imply these are the only areas of nutrition focus on the continent. With 37 out of the 54 AU member states involved in the SUN movement, among many initiatives aiming to address nutrition, much is happening on nutrition in Africa. A strong multisectoral emphasis is increasingly evident in many countries. Agriculture needs to play its role, and this ATOR points to areas where this applies so that agriculture can contribute to bringing about a nutrition revolution toward “The Africa We Want” as indicated by Agenda 2063. 2015 ReSAKSS Annual Trends and Outlook Report 5 CHAPTER 2 The African Union Policy Environment toward Enabling Action for Nutrition in Africa Laila Lokosang, Akoto Osei, and Namukolo Covic 6 resakss.org T he levels of undernourishment (underweight and stunting) in Africa have dropped in recent years, although progress across countries is uneven. African countries have demonstrated their commitment to improving nutrition in that at least 37 of 54 African countries (69 percent) are currently involved in the Scaling Up Nutrition (SUN) movement (SUN 2016). Both SUN and the Comprehensive Africa Agriculture Development Programme (CAADP) are primarily country led according to common principles of coordinated action and multisectorality, recognizing the need to include multiple stakeholders in order to achieve the desired food security and nutrition outcomes. There is also increasing socioeconomic integration with growing intra-Africa trade and investment, especially within African Union (AU) Regional Economic Communities (RECs) (AfDB, OECD, and UNDP 2015). Movement of labor, on the other hand, has remained more constrained, despite having AU and REC frameworks that should facilitate freer movement of labor in support of economic development (UNDP 2011). The RECs make efforts to promote trade relations among countries, and there is often overlap among countries belonging to different RECs. This arrangement calls for greater harmony of policy instruments, which would contribute to a supportive or enabling environment across the continent toward achieving shared goals of attaining sustained food and nutrition security over time. The AU policy environment is an important part of the enabling environment for nutrition on the continent. AU policy direction and instruments are agreed upon by the heads of state and governments of member states and thus are useful rallying points for advocacy and action at the regional and national levels. This chapter provides an overview of the food security and nutrition–related policies at the level of the AU. It is by no means an exhaustive review but seeks to highlight key nutrition-related policies and show how they may contribute to creating an enabling environ- ment for achieving nutrition targets. Key African Union Policy Frameworks Related to Nutrition The political will for nutrition has improved in many African countries, and the momentum among policy makers to tackle the nutrition problems on the continent has never been stronger. This is evident in numerous statements, decisions, and declarations that commit Africa’s leaders to real- izing the continent’s aspiration for equitable growth and socioeconomic development through improving human nutrition. The African Regional Nutrition Strategy (ARNS) and the CAADP Pillar III Framework for African Food Security (FAFS) are strongly reinforced by the African Union’s Agenda 2063 (AU 2015b), which is a blueprint for the continent’s development over the next 50 years (2014–2063) and was reiterated in the three Malabo Declarations. Agenda 2063 prioritizes healthy and well-nourished African citizens as an overarching goal for realizing a “prosperous Africa that is based on inclusive growth and sustainable development” (AU 2015b, 2). In January 2014, African leaders adopted the Common Africa Position on the post-2015 development agenda, which includes six priority areas for developing and implementing the Sustainable Development Goals (SDGs) in a manner that adequately supports the broader development of the continent (AU 2014b). 2015 ReSAKSS Annual Trends and Outlook Report 7 These priority areas include striving for inclusive economic growth that reduces inequality and ensures sustainable agriculture, food self-sufficiency, and nutrition security for all (AU 2014b). The Malabo Declaration on CAADP reaffirmed the commitment of African governments to allocate at least 10 percent of their national budgets to agriculture and seek to achieve an annual agricultural growth rate of at least 6 percent (AU 2014a). The dec- laration deliberately commits to using agricultural growth for eradicating undernutrition (stunting and underweight), rather than leaving achieve- ment of this goal solely to the health sector as in the past. The Malabo Declarations also recognize and call for investment in social protection (with a special focus on women and youth) and agribusi- ness programs as integral elements of national investment plans. The post-Malabo Implementation Strategy and Roadmap (2014) emphasizes implementing agriculture-based activities that have direct links to nutri- tion, particularly through stabilization of food availability and prices, as well as diversification of available nutritious foods for local consumption to improve dietary diversity. The above strategies are reinforced by a broad range of nutrition policies and frameworks at the continental, regional, and national levels. This includes ARNS 2015–2016 (AU 2015a), mentioned above, which includes specific nutrition targets (Box 2.1) that are aligned to World Health Assembly nutrition targets. ARNS 2015–2025 advocates concrete, evidence-based interventions consistent with the globally agreed-upon Comprehensive Implementation Plan for Maternal, Infant and Young Child Nutrition that was adopted at the 2012 World Health Assembly (WHO 2014) and by the 23rd AU ordinary session through the Malabo Declaration on Ending Preventable Child and Maternal Deaths in Africa (Doc. Assembly/AU/18(XXIII)Add.3). ARNS 2015–2025 spells out four strategic areas to guide the AU Commission and member states in the governance of nutrition: • Definition of standards, norms, policies, and frameworks for AU member state adoption and ratification • Convening and facilitation of consensus on matters regarding nutrition security in Africa • Nutrition security policy and program advocacy and promotion • Establishment of decision-making architecture for the implementation of the strategy BOX 2.1—2025 NUTRITION TARGETS OF THE AFRICA REGION NUTRITION STRATEGY 2015–2025 • A 40% reduction in the number of children younger than five who are stunted • A 50% reduction in anemia in women of child-bearing age • A 30% reduction in low birth weight • No increase in overweight for children younger than five • An increase in exclusive breastfeeding rates during the first six months of life to at least 50% • A reduction in childhood wasting, maintaining it at less than 5% Source: African Union (2015a). Over the years, the AU has advocated for African countries to develop national nutrition policies through the Africa Task Force for Nutrition and Development. Almost all the RECs, other regional institutions, and 8 resakss.org8 resakss.org countries in Africa have nutrition policies. The majority of these policies lean toward the global call for multisectoral nutrition action in implement- ing both nutrition-specific and nutrition-sensitive interventions across sectors. Examples of these interventions are given in Table 2.1. TABLE 2.1 —EXAMPLES OF NUTRITION-SENSITIVE AND NUTRITION-SPECIFIC INTERVENTIONS Nutrition-specific interventions Nutrition-sensitive interventions Adolescent health and pre-conception nutrition Agriculture and food security Micronutrient supplementation or fortification Social safety nets Breastfeeding and complementary feeding Early childhood development Dietary supplementation Maternal mental health Feeding behaviors and stimulation Women’s empowerment Treatment of severe acute malnutrition Child protection Treatment of moderate acute malnutrition Classroom education Disease prevention and management Water and sanitation Nutrition interventions in emergencies Health and family planning services Source: Black et al. (2013). Most nutrition policies in Africa focus on addressing undernutrition (stunting, wasting, and underweight, as well as deficiencies in key micronutrients such as iron, zinc, iodine, and vitamin A). However, few pay attention to the growing problem of overweight and obesity now associated with developing economies (Steyn and Mchiza 2014; IFPRI 2016a). ARNS 2015–2025 includes a target to arrest or reduce overweight in children younger than five to less than 5 percent (AU 2015a). CAADP is the overarching policy framework for attaining food security and nutrition and sustainable development through agriculture-led investment at the national and regional levels within Africa. CAADP actions are structured under four interrelated pillars (FARA et al. 2009): • Pillar I: Extending the area under sustainable land management and reliable water control systems • Pillar II: Improving rural infrastructure and trade-related capacities for market access • Pillar III: Increasing food supply, reducing hunger, and improving responses to food emergency crises • Pillar IV: Improving agriculture research and technology dissemination and adoption CAADP sought to achieve Millennium Development Goal 1 (MDG 1), to reduce by half the levels of extreme poverty and hunger by 2015 (UN 2015), but also took into account the importance of responding to emergencies and disasters with food and agricultural responses involving safety nets and resilience building for the long term. The CAADP-FAFS provides a framework for the implementation of CAADP Pillar III. The framework was developed as a deliberate attempt to ensure that the CAADP agricultural growth agenda targeted the chronically poor and vulnerable directly, instead of hoping for a trickle-down effect (NEPAD and AU 2009). The framework sought to provide guidance to countries on the design of their national plans to address structural, systemic, and long-term aspects of chronic food insecurity challenges on the continent. It set out four specific strategic intervention areas for improving Africa’s food security and nutrition status: • Improving risk management and resilience • Increasing the supply of affordable food • Increasing the incomes of the vulnerable • Improving the quality of diets through diversification of food among target groups 2015 ReSAKSS Annual Trends and Outlook Report 9 CAADP-FAFS also underscores that failure to address food insecurity, including undernutrition, while large sections of the African population face severe poverty, hunger, and marginalization from gainful employment and markets, could put countries at risk for social instability and conflict (NEPAD and AU 2009). Table 2.2 presents the 11 principles of Pillar III as given in the CAADP-FAFS document. The given principles include atten- tion to the right to food for all Africa’s citizens, specifically focusing on the more vulnerable groups of society, those chronically affected by hunger and malnourishment, with particular attention to women and children in addressing both long- and short-term effects. TABLE 2.2—THE 11 PRINCIPLES OF THE COMPREHENSIVE AFRICA AGRICULTURE DEVELOPMENT PROGRAMME PILLAR III FRAMEWORK FOR AFRICAN FOOD SECURITY 1. Protect the right to food for all citizens of Africa. 2. Focus on the chronically hungry and malnourished, particularly women and children, in order to address short-term crises and, in the long term, integrate this population into broad agricultural development. 3. Ensure that all parties and players automatically seek to understand and address hunger and malnutrition. 4. Mainstream considerations of human diseases such as HIV/AIDS, malaria, and TB. 5. Ensure that emergency responses promote growth and reduce chronic hunger (that is, do no harm to the overall CAADP agenda). 6. Protect and promote the resilience of the livelihoods of the vulnerable. 7. Ensure that gender dimensions of hunger and malnutrition are addressed. 8. Promote intraregional trade, particularly in food staples, to raise food supply and quality, and to moderate price volatility. 9. Integrate regular review and broad-based dialogue to ensure successful implementation of this pillar. 10. Be in coherence with the MDGs, especially MDG 1, to cut extreme poverty and hunger. 11. Integrate lessons from success stories in cutting hunger and malnutrition. Source: NEPAD and AU (2009). The CAADP-FAFS further articulates a number of options for improving food access, principally including investment to provide incentives for local processing and marketing of nutrient-rich foods, as well as public procurement programs to enhance market demand for nutritious foods. It also advocates rationalization of food price policies to improve incentives for production, processing, and marketing of food favored by vulnerable populations. Other equally important options the framework gives include development of community or homestead vegetable and fruit gardens; production of fish, poultry, and small animals (rabbits, goats, and guinea pigs); reduction of postharvest losses and loss of the nutritional value of micronutrient-rich foods, such as fruits and vegetables; improvement of food storage and preservation; implementation of school-based gardening programs; and improvement of food safety. These aspects of the framework point to the need for a more deliberate food-systems approach to addressing BOX 2.2 —NUTRITION-RELATED INDICATORS INCLUDED IN THE COMPREHENSIVE AFRICA AGRICULTURE DEVELOPMENT PROGRAMME RESULTS FRAMEWORK • Prevalence of national undernourishment • Prevalence of underweight for children under five • Prevalence of stunting for children under five • Prevalence of wasting for children under five • Minimum dietary diversity among women • Minimum acceptable diet for children 6–23 months old Source: NEPAD (2015). 10 resakss.org food security and nutrition on the continent in order to bring on board the additional dimensions needed. CAADP has been instrumental in bringing about increased food production on the continent. However, it is also widely accepted that this increased food production has not equitably resulted in the levels of reduction in undernutrition that would be expected. Effective implementation of the CAADP Pillar III principles with adequate nutrition sensitivity would contribute to attaining better nutrition outcomes. These outcomes, however, would further depend on how effectively other issues that impact nutrition are addressed, including the nutrition-specific interventions required and the nutrition sensitivity of social protection, health, water and sanitation, and so on. Mainstreaming Nutrition into the Comprehensive Africa Agriculture Development Programme Being a key strategy for attaining food and nutrition security for Africa, CAADP now includes the CAADP Nutrition Initiative, which aims at mainstreaming nutrition into national agriculture investment plans (NAIPs). Inclusion of nutrition indicators (Box 2.2) in NAIPs introduces a require- ment to monitor nutrition progress on the continent as an integral part of monitoring progress in the agriculture sector. Besides the accountability and governance aspects this inclusion provides for nutrition on the continent, it is expected to create an opportunity to measure and improve the nutrition sensitivity of agricultural development programs implemented as part of CAADP. Monitoring and Evaluation of Progress toward Commitments and Targets Agenda 2063, the Malabo Declarations, the CAADP Results Framework, and the ARNS 2015–2025 all make reference to accountability and gover- nance mechanisms as a necessary aspect of transforming the agriculture-led economic development and nutrition progress that the AU is promoting. As the continent sets out to implement Agenda 2063, the Malabo Declaration intentions, and the ARNS 2015–2015 strategy aligned to global commitments and continental goals (those set by the UN’s Sustainable Development Goals and the World Health Assembly), deliberate action will be required to make sure that the second generation of CAADP NAIPs and regional strategies recognize and integrate actions to improve the impact of various agriculture, social protection, and health strategies on nutrition across the human life cycle. The future potential of Africa is dependent on the nutrition, health, and productivity of its people. Addressing nutrition is a vital element to ensure Africa’s economic development. For agriculture to reach its full potential role in the development agenda, nutrition needs to improve and the scourge of overweight and obesity that are possible outcomes of such development need to be curbed through careful policy planning and implementation. 2015 ReSAKSS Annual Trends and Outlook Report 11 Conclusion The current AU policy environment supports efforts by African countries to address malnutrition and can be a rallying point for different interventions at the continental, REC, and country levels. In addition, the accountability processes incorporated into the various declarations create opportunities for monitoring nutrition progress across the continent. The chapters in this report reflect on the current status of nutrition in Africa and offer insight into some of the different approaches being used to improve nutrition outcomes as part of agriculture interventions. The ATOR also always includes a chapter (Chapter 12) that reports current progress on CAADP indicators. 12 resakss.org CHAPTER 3 Africa’s Progress toward Meeting Current Nutrition Targets Lawrence Haddad, Mohamed Ag Bendech, Komal Bhatia, Kamilla Eriksen, Isatou Jallow, and Natasha Ledlie 2015 ReSAKSS Annual Trends and Outlook Report 13 I n the era of the Sustainable Development Goals, the world faces many seemingly intractable problems. Malnutrition should not be one of them. The incentives to improve nutrition are strong, and determined countries can make rapid advances in malnutrition reduction. Good nutrition provides a vital foundation for human development that is central to meeting our full potential. When nutrition status improves, a host of positive outcomes can follow for individuals and families. Improved nutrition in Africa means many more children will live past the age of five, their growth will be less disrupted, and they will gain in height and weight. Their cognitive abilities will develop more fully, allowing them to learn more both in and outside of school. As a result of sufficient nourishment and a positive early environment, children are more likely to get better jobs and suffer fewer illnesses as adults—aging healthily and living longer to support the African Union Agenda 2063 vision of a prosperous and united Africa (AU 2015b). The Scale and Nature of Malnutrition in Africa The extent of malnutrition in Africa is large. Box 3.1 summarizes the current state of malnutrition on the continent. As in many other regions, the nutrition problems Africa is facing are multiple and overlapping. Figure 3.1 shows that 8 of the 54 African coun- tries (Botswana, Egypt, Equatorial Guinea, Lesotho, Libya, Namibia, South Africa, and Swaziland) are facing serious public health issues on three key dimensions: stunting, women’s anemia, and overweight/obesity—a triple burden.1 Thirteen countries are facing a double burden of undernutrition and overweight/obesity. Only 4 countries are facing serious single burdens of stunting (Ethiopia and Rwanda) and women’s anemia (Ghana and Senegal). BOX 3.1—THE SCALE OF MALNUTRITION IN AFRICA While the number of people affected by malnutrition is difficult to calculate—because a person can suffer from more than one type of malnutrition simultaneously—the scale of malnutrition in Africa is staggering: • 58 million children younger than five are too short for their age (stunted), 13.9 million weigh too little for their height (wasted), and 10.3 million are overweight. None of these children are growing healthily. • 163.6 million children and women of reproductive age are anemic. • 220 million people are estimated to be calorie deficient. • 8 percent of adults older than 20 are obese. • Adult obesity is on the rise in all 54 African countries (2010–2014). • 13 countries in Africa have to manage serious levels of stunting in children younger than five or anemia in women of reproductive age and adult overweight (Figure 3.1). • In eight African countries, only a minority of children are growing healthily. In Burundi, Chad, Democratic Republic of the Congo, Djibouti, Ethiopia, Guinea-Bissau, Niger, and Somalia, the percentage of children younger than five who are not stunted or wasted ranges between 43 and 48 percent. Source: UNICEF, WHO, and World Bank (2015); WHO (2015a, 2015b, 2015c); FAO (2015); IFPRI (2016). 1 These indicators are chosen, first, because they are a subset of the eight global goals that the World Health Assembly has set and, second, because they represent undernutrition, micronutrient deficiency, and a diet-related risk factor for noncommunicable disease. 14 resakss.org The burdens in terms of human suffering, mortality, and disease are large (IFPRI 2016), but so too are the economic burdens. As the presidents of the African Development Bank and the World Bank have recently stated, early child malnutrition undermines “grey matter infrastructure” (cited in Rice 2016, p 59).The data bear them out. The African Union and World Food Programme estimates of the monetary cost of hunger for seven countries are summarized in Figure 3.2. Recognizing the extent and conse- quences of these burdens, African leaders made a bold commitment within the 2014 Malabo Declaration on Accelerated Agricultural Growth and Transformation for Shared Prosperity and Improved Livelihoods: “to improve nutritional status, and in particular, [to eliminate] child undernutrition in Africa with a view to bringing down stunting to 10 percent and underweight to 5 percent by 2025” (African Union 2014, 4). In addition, African leaders have signed on to the Under 5 Stunting Women’s Anemia Adult Overweight (BMI ≥ 25) Ethiopia, Rwanda Ghana, Senegal Angola, Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Comoros, Congo (Republic of The), Côte d’Ivoire, Democratic Republic of the Congo, Djibouti, Eritrea, Gambia, Guinea, Guinea-Bissau, Kenya, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Niger, Nigeria, Sao Tome and Principe, Sierra Leone, Somalia, Sudan, Togo, Uganda, Tanzania, Zambia, Zimbabwe Algeria, Gabon, Morocco, Seychelles, Tunisia Botswana, Egypt, Equatorial Guinea, Lesotho, Libya, Namibia, South Africa, Swaziland FIGURE 3.1—THE MULTIPLE BURDENS OF MALNUTRITION IN AFRICAN COUNTRIES Source: IFPRI (2016); data on stunting and overweight based on Joint Malnutrition Estimates of UNICEF, WHO, and World Bank (2015); data on anemia in women of reproductive age from Stevens et al. (2013). Note: Analysis includes 54 African countries, listed according to the United Nations’ naming and regional classification. BMI = body mass index. 2015 ReSAKSS Annual Trends and Outlook Report 15 World Health Assembly’s key targets for six nutrition outcomes by 2025, and the Africa Regional Nutrition Strategy has adopted them as well (African Union 2015a, 20). Leaders have also signed on to the Sustainable Development Goals, the second of which is to “end hunger, achieve food security and improved nutrition, and promote sustainable agriculture” (UN 2016). And as part of the United Nations General Assembly Decade of Action on Nutrition 2016–2025, African governments endorsed the Rome Declaration on Nutrition and the Framework for Action adopted by the Second International Conference on Nutrition in November 2014. African Progress in Meeting Nutrition Targets This section assesses the progress of African countries in meeting the Malabo 2025 targets for stunting among children younger than five and the World Health Assembly (WHA) 2025 targets for under-five stunting, wasting and overweight, exclusive breastfeeding rates (for infants younger than six months), anemia in women, adult overweight and obesity, and adult diabetes (Box 3.2). The Malabo 2025 Target for Stunting To assess whether a country will attain the Malabo stunting target2 by 2025, we calculate the average annual rate of reduction (AARR) required for a country to get to 10 percent stunting from where it currently stands. We then compare the required AARR with the country’s recent performance in reducing rates (the current AARR as determined by the Joint Child Malnutrition Estimates from UNICEF, WHO, and World Bank 2015). If the current AARR ≥ the required AARR, then the country is “on course.” If the current AARR is > 0 but < the required AARR, then the country is designated as “off course but making progress,” and if the current AARR is ≤ 0 (that is, stunting rates are static or increasing), then the country is designated as “off course, no progress.” FIGURE 3.2—THE ANNUAL COST OF UNDERNUTRITION, SEVEN AFRICAN COUNTRIES Source: African Union Commission et al. (2014). Note: GDP = gross domestic product. 16.5 11.5 10.3 7.7 6.3 5.6 3.1 Ethiopia Rwanda Malawi Burkina Faso Ghana Uganda Swaziland Annual cost of undernutrition (% of GDP) 2 The World Health Organization does not assess the rate of progress on underweight because it is not a WHA indicator; hence we are unable to comment on it here. 16 resakss.org Table 3.1 lists countries by their latest stunting estimate, with colors that designate whether they are on or off course. Of the 54 countries, 49 have sufficient data to make the comparison while 5 do not. Of the 49 with data, only 4 are on course to meet the Malabo Declaration target, 39 are off course but making some progress, and only 6 are making no progress. BOX 3.2—WORLD HEALTH ASSEMBLY INDICATORS AND 2025 TARGETS STUNTING: Reduce by 40 percent the number of children younger than five who are stunteda WASTING: Reduce and maintain childhood wasting at less than 5 percent UNDER-FIVE OVERWEIGHT: Halt the increase in childhood overweight ANEMIA: Reduce anemia in women of reproductive age by 50 percent LOW BIRTH WEIGHT: Reduce by 30 percent EXCLUSIVE BREASTFEEDING: Increase rate of exclusive breastfeeding in first six months of life to at least 50 percent ADULT OVERWEIGHT: Halt the rise in prevalence ADULT OBESITY: Halt the rise in prevalence ADULT DIABETES (raised blood glucose): Halt the rise in prevalence Source: WHO (2016a, 2016b). Note: a For more on the methods behind the World Health Assembly stunting target, see de Onis et al. (2013). TABLE 3.1—COUNTRIES RANKED ACCORDING TO STUNTING PERCENTAGE, LOWEST TO HIGHEST PREVALENCE, WITH ASSESSMENT OF PROGRESS TOWARD MALABO TARGET Rank Country Stunting percentage   Rank Country Stunting percentage 1 Seychelles 7.9   28 Comoros 32.1 2 Tunisia 10.1   29 Liberia 32.1 3 Algeria 11.7   30 Cameroon 32.6 4 Morocco 14.9   31 Burkina Faso 32.9 5 Gabon 17.5   32 Nigeria 32.9 5 Ghana 18.8   33 Lesotho 33.2 7 Senegal 19.4   34 Djibouti 33.5 8 Libya 21.0   35 Benin 34.0 9 Mauritania 22.0   36 Uganda 34.2 10 Egypt 22.3   37 Tanzania 34.7 11 Namibia 23.1   38 Rwanda 37.9 12 South Africa 23.9   39 Sierra Leone 37.9 13 Gambia 24.5   40 Sudan 38.2 14 Congo 25.0   41 Mali 38.5 15 Swaziland 25.5   42 Chad 38.7 16 Somalia 25.9   43 Zambia 40.0 17 Kenya 26.0   44 Ethiopia 40.4 18 Equatorial Guinea 26.2 45 Central African Republic 40.7 19 Togo 27.5 46 Malawi 42.4 20 Guinea-Bissau 27.6 47 DRC 42.6 21 Zimbabwe 27.6 48 Niger 43.0 22 Angola 29.2 49 Mozambique 43.1 23 Côte d’Ivoire 29.6 50 Madagascar 49.2 24 South Sudan 31.1 51 Eritrea 50.3 25 Guinea 31.3 52 Burundi 57.5 26 Botswana 31.4 Cape Verde No data 27 Sao Tome and Principe 31.6   Mauritius No data Source: Based on IFPRI (2016). Stunting percentage is the most recent estimate from UNICEF, WHO, and World Bank (2015), September 2015 update. Note: Analysis includes 54 African countries, listed according to the United Nations’ naming and regional classification. Congo = Republic of the Congo; DRC = Democratic Republic of the Congo; Tanzania = United Republic of Tanzania. For details on the criteria for rating countries, see IFPRI (2016). On course, good progress Off course, some progress Off course, no progress Insufficient data to make assessment 2015 ReSAKSS Annual Trends and Outlook Report 17 The World Health Assembly 2025 Targets Table 3.2 undertakes the same exercise as Table 3.1, but this time in relation to meeting the more modest WHA target3 of a 40 percent reduction in the number of stunted children by 2025. The results show that 9 countries are on course, the same 6 are making no progress, and 34 are off course but making some progress. TABLE 3.2—COUNTRIES RANKED ACCORDING TO STUNTING PERCENTAGE, LOWEST TO HIGHEST PREVALENCE, WITH ASSESSMENT OF PROGRESS TOWARD WORLD HEALTH ASSEMBLY 2025 TARGET Rank Country Stunting percentage   Rank Country Stunting percentage   Rank Country Stunting percentage 1 Seychelles 7.9   19 Togo 27.5   37 Tanzania 34.7 2 Tunisia 10.1   20 Zimbabwe 27.6   38 Sierra Leone 37.9 3 Algeria 11.7   21 Guinea-Bissau 27.6   39 Rwanda 37.9 4 Morocco 14.9   22 Angola 29.2   40 Sudan 38.2 5 Gabon 17.5   23 Côte d’Ivoire 29.6   41 Mali 38.5 6 Ghana 18.8   24 South Sudan 31.1   42 Chad 38.7 7 Senegal 19.4   25 Guinea 31.3   43 Zambia 40.0 8 Libya 21.0   26 Botswana 31.4   44 Ethiopia 40.4 9 Mauritania 22.0   27 Sao Tome and Principe 31.6   45 Central African Republic 40.7 10 Egypt 22.3 28 Comoros 32.1 46 Malawi 42.4 11 Namibia 23.1 29 Liberia 32.1 47 DRC 42.6 12 South Africa 23.9 30 Cameroon 32.6 48 Niger 43.0 13 Gambia 24.5 31 Burkina Faso 32.9 49 Mozambique 43.1 14 Congo 25.0 32 Nigeria 32.9 50 Madagascar 49.2 15 Swaziland 25.5 33 Lesotho 33.2 51 Eritrea 50.3 16 Somalia 25.9 34 Djibouti 33.5 52 Burundi 57.5 17 Kenya 26.0 35 Benin 34.0 Cape Verde No data 18 Equatorial Guinea 26.2   36 Uganda 34.2   Mauritius No data Source: Based on IFPRI (2016). Stunting percentage is the most recent estimate from UNICEF, WHO, and World Bank (2015), September 2015 update. Note: Analysis includes 54 African countries, listed according to the United Nations’ naming and regional classification. Congo = Republic of the Congo; DRC = Democratic Republic of the Congo; Tanzania = United Republic of Tanzania. On course, good progress Off course,some progress Off course, no progress Insufficient data to make assessment 3 The WHA nutrition targets tracked by the Global Nutrition Report are listed in Table 3A.1 and the on/off course rules are specified in Table 3A.2. The Africa Regional Nutrition Strategy 2016–2025 targets are aligned with the WHA targets. The strategy was adopted by the AU in 2015 and can be found here: http://sa.au.int/en/sites/default/files/Africa%20Regional%20Nutrition%20Strategy%202015-2025%20 13.3.2015%20-%20English_0.pdf. 18 resakss.org Table 3.3 summarizes the country rankings and progress status for wasting. Here the WHA 2025 target is less than 5 percent. As the table shows, of 51 countries with data, 17 are on course and 34 are off course. Table 3.4 summarizes the rankings and progress for anemia in women of reproductive age (15–49 years old). Only one country, Burundi, is on track to meet this WHA target. Finally, for exclusive breastfeeding of infants younger than six months, so important for getting infants off to the best possible start in life, Table 3.5 shows that 23 countries are on course, 3 are off course but making some progress, and 12 are off course and making no progress (one of these 12, Egypt, is actually showing a worsening rate of exclusive breastfeeding). Sixteen countries do not have sufficient data on exclusive breastfeeding to make an assessment. TABLE 3.3—COUNTRIES RANKED ACCORDING TO WASTING PERCENTAGE, LOWEST TO HIGHEST PREVALENCE, WITH ASSESSMENT OF PROGRESS TOWARD WORLD HEALTH ASSEMBLY TARGET Rank Country Wasting percentage   Rank Country Wasting percentage   Rank Country Wasting percentage 1 Swaziland 2.0   19 Senegal 5.8   37 Egypt 9.5 2 Rwanda 2.2   20 Cameroon 5.8   38 Guinea 9.9 3 Morocco 2.3   21 Congo 5.9   39 Burkina Faso 10.9 4 Tunisia 2.8   22 Guinea-Bissau 6.0   40 Comoros 11.1 5 Lesotho 2.8   23 Mozambique 6.1   41 Sao Tome and Principe 11.2 6 Equatorial Guinea 3.1   24 Burundi 6.1   42 Gambia 11.5 7 Zimbabwe 3.3   25 Zambia 6.3   43 Mauritania 11.6 8 Gabon 3.4   26 Libya 6.5   44 Somalia 14.9 9 Tanzania 3.8   27 Togo 6.7   45 Eritrea 15.3 10 Malawi 3.8 28 Namibia 7.1 46 Mali 15.3 11 Kenya 4.0 29 Botswana 7.2 47 Chad 15.7 12 Algeria 4.1 30 Central African Republic 7.4 48 Sudan 16.3 13 Seychelles 4.3 31 Côte d’Ivoire 7.6 49 Niger 18.7 14 Uganda 4.3 32 Nigeria 7.9 50 Djibouti 21.5 15 Benin 4.5 33 DRC 8.1 51 South Sudan 22.7 16 Ghana 4.7 34 Angola 8.2 Cape Verde No data 17 South Africa 4.7 35 Ethiopia 8.7 Madagascar No data 18 Liberia 5.6   36 Sierra Leone 9.4   Mauritius No data Source: Based on IFPRI (2016). Wasting percentage is most recent estimate from UNICEF, WHO, and World Bank (2015), September 2015 update. Note: Analysis includes 54 African countries, listed according to the United Nations’ naming and regional classification. Congo = Republic of the Congo; DRC = Democratic Republic of the Congo; Tanzania = United Republic of Tanzania. On course, good progress Off course, no progress Insufficient data to make assessment 2015 ReSAKSS Annual Trends and Outlook Report 19 TABLE 3.4—COUNTRIES RANKED ACCORDING TO ANEMIA PERCENTAGE, LOWEST TO HIGHEST PREVALENCE, WITH ASSESS- MENT OF PROGRESS TOWARD WORLD HEALTH ASSEMBLY TARGET Rank Country Anemia percentage   Rank Country Anemia percentage 1 Rwanda 17.4   27 Tanzania 39.6 2 Ethiopia 19.2   28 Cameroon 41.5 3 Burundi 20.9   29 Somalia 42.6 4 Seychelles 21.2   30 Sao Tome and Principe 42.7 5 Mauritius 23.4   31 Mozambique 44.2 5 Kenya 25.0   32 Guinea-Bissau 44.6 7 Uganda 26.7   33 Angola 44.8 8 Lesotho 26.8   34 Sierra Leone 45.2 9 Djibouti 27.1   35 Gambia 45.3 10 South Africa 27.6   36 Equatorial Guinea 45.4 11 Swaziland 27.8   37 Central African Republic 46.0 12 Libya 27.9   38 Chad 46.6 13 Tunisia 28.0   39 Niger 46.7 14 Zimbabwe 28.4   40 Guinea 48.4 15 Botswana 28.5   41 Nigeria 48.5 16 Malawi 28.8   42 Côte d’Ivoire 48.8 17 Zambia 29.2   43 DRC 49.0 18 Comoros 30.8 44 Liberia 49.3 19 Sudan 31.5 45 Burkina Faso 49.5 20 Madagascar 31.8 46 Benin 49.6 21 Algeria 32.7 47 Congo 50.7 21 Namibia 32.7 48 Gabon 50.8 22 Eritrea 32.8 49 Togo 52.7 23 Morocco 33.1 50 Mali 56.2 24 Egypt 34.5 51 Ghana 56.4 25 Cape Verde 37.9 52 Senegal 57.5 26 Mauritania 39.0   South Sudan No data Source: IFPRI (2016). Anemia percentage is most recent estimate (2011) from Stevens et al. (2013). Note: Analysis includes 54 African countries, listed according to the United Nations’ naming and regional classification. Congo = Republic of the Congo; DRC = Democratic Republic of the Congo; Tanzania = United Republic of Tanzania. On course, good progress Off course, no progress Insufficient data to make assessment TABLE 3.5—COUNTRIES RANKED ACCORDING TO PERCENTAGE OF INFANTS YOUNGER THAN SIX MONTHS EXCLUSIVELY BREAST- FED, HIGHEST TO LOWEST PREVALENCE, WITH ASSESSMENT OF PROGRESS TOWARD WORLD HEALTH ASSEMBLY TARGET Rank Country EBF percentage   Rank Country EBF percentage 1 Rwanda 87.0   27 Egypt 39.7 2 Sao Tome and Principe 73.8   28 Mali 37.8 3 Zambia 72.5   29 Central African Republic 34.0 4 Malawi 70.2   30 Senegal 33.0 5 Burundi 69.3   31 Congo 32.9 6 Eritrea 68.7   32 Sierra Leone 32.0 7 Lesotho 66.9   33 Cameroon 28.2 8 Uganda 63.2   34 Morocco 27.8 9 Kenya 61.4   35 Mauritania 26.9 10 Cape Verde 59.6   36 Algeria 25.7 11 Togo 57.5   37 Niger 23.3 12 Sudan 55.4   38 Mauritius 21.0 13 Liberia 55.2   39 Guinea 20.5 14 Guinea-Bissau 52.5   40 Botswana 20.3 15 Ghana 52.3   41 Nigeria 17.4 16 Ethiopia 52.0   42 Comoros 12.1 17 Burkina Faso 50.1   42 Côte d’Ivoire 12.1 18 Namibia 48.5 43 Tunisia 8.5 19 DRC 47.6 44 South Africa 8.3 20 Gambia 46.8 45 Equatorial Guinea 7.4 21 South Sudan 45.1 46 Gabon 6.0 22 Swaziland 44.1 47 Somalia 5.3 23 Madagascar 41.9 48 Djibouti 1.3 24 Benin 41.4 49 Chad 0.3 25 Tanzania 41.1 Angola No data 26 Mozambique 41.0 Libya No data 26 Zimbabwe 41.0   Seychelles No data Source: Based on IFPRI (2016). Exclusive breastfeeding percentage is most recent estimate from UNICEF (2016), March 2016 update. Note: Analysis includes 54 African countries, listed according to the United Nations’ naming and regional classification. Congo = Republic of the Congo; DRC = Democratic Republic of the Congo; Tanzania = United Republic of Tanzania. EBF = exclusive breastfeeding. On course, good progress Off course, some progress Off course, no progress Insufficient data to make assessment 20 resakss.org Figure 3.3 provides a summary of the eight indicators tracked by the Global Nutrit