Similarly, in urban areas, the lowest PCER decile (1st) has an average calorie intake of 669 kcal, slightly lower than in rural areas. The highest decile (10th) in urban areas has a significantly higher intake of 3,451 kcal, which is considerably lower than the highest decile in rural areas. This indicates a disparity in calorie consumption between the least and most impoverished individuals in urban settings, albeit less pronounced than in rural areas. Looking at the overall figures for Madagascar, the average calorie intake is 2,112 kcal in rural areas and 2,227 kcal in urban areas. But also, more than 70 percent of the population do not meet the required caloric intake of 2,133 as recommended by local health authorities, highlighting the high prevalence of food insecurity and the inequality in access to food.

# Malnutrition – Stunting

Malnutrition, specifically stunting, poses a significant barrier to alleviating extreme poverty in Madagascar, as the overall stunting rate among children 0-5 years old is approximately 40 percent (INSTAT and ICF, 2022). Madagascar grapples with high rates of micronutrient deficiencies, stemming from inadequate intake of essential vitamins and minerals crucial for growth, development, and immune function, such as iodine, Vitamin A, and iron. These deficiencies are predominantly linked to inadequate diets in terms of both quality and diversity, alongside insufficient quantity, contributing to stunted growth and adverse health outcomes. Moreover, a concerning 8 percent of children aged 0-5 experience wasting, heightening their vulnerability to illness and mortality. On a global scale, malnutrition is responsible for 45 percent of child deaths, with anemia alone contributing to about 20 percent of maternal fatalities (UNICEF, WHO, World Bank, 2020). Stunted growth also correlates with cognitive delays and reduced educational achievement, limiting long-term earning potential and workforce productivity. The annual economic burden of malnutrition in Madagascar is estimated to range from 7 to 12 percent of the Gross Domestic Product (GDP)<sup>1</sup> .

The "first 1,000 days," spanning from conception to the age of two, represent a critical period for ensuring adequate nutrition due to the rapid pace of physical and cognitive development. Stunting during this timeframe indicates potentially irreversible effects on children's health and well-being. Notably, in Madagascar, a significant portion of children, around 40 percent, already experience stunted growth by the age of just 12 months, much earlier than in other countries, with growth impairment beginning as early as in utero due to high rates of early pregnancies and maternal malnutrition. Micronutrient deficiencies are also widespread, with 50 percent of children aged 6-59 months and 35 percent of women of reproductive age experiencing anemia, and 52 percent of children suffering from Vitamin A deficiency.

Global evidence emphasizes the potential of implementing a set of 10 high-impact nutrition interventions, centered on the critical "first 1,000 days," to significantly reduce stunting (Martorell, 2017). Ensuring access and utilization of these interventions through well-coordinated communitybased and primary care services integrated into a robust maternal and child health program is a pivotal starting point. Additionally, effective prevention and management of infectious diseases play a crucial role in reducing the contribution of illness to malnutrition and stunting. Strengthening the foundational health and nutrition service delivery platform can also generate synergies with other sectors, expediting progress in reducing stunting. As a result, adopting a more targeted approach to

> 1 UNICEF, 2017. Madagascar Nutrition Investment Case. UNICEF: Antananarivo.

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