Knowledge Brief Health, Nutrition and Population Global Practice Assessing Public Financing for Nutrition in Bhutan, India, Nepal, and Sri Lanka October 2021 Key Messages • Overall nutrition-specific expenditure in Bhutan, India, Nepal, and Sri Lanka remains low, although substantial variation exists among these countries. • Given the high rates of malnutrition in these countries, it is important to identify more fiscal space for nutrition, and to prioritize funding of proven, high-impact interventions. • The share of spending on nutrition-specific versus nutrition-sensitive interventions should be carefully balanced in relation to the expected impact of the interventions being funded. • The cause of underutilization of nutrition-related allocations should be analyzed to improve utilization or free up funds for interventions that are high-impact and well-executed. • There are substantial limitations to tracking nutrition expenditures within the current budget allocation records. Standardized systems of data collection are recommended for all countries in the region and beyond. • Standardized global guidance is needed for defining nutrition-sensitive and nutrition-specific interventions to enhance comparability between studies in different countries. Introduction of well-nourished children (McDonald et al. 2013; UNICEF, WHO, & World Bank Group 2020). Maternal anemia, Despite rapid economic growth in recent decades, South thinness, and short stature are common in South Asia and Asian countries continue to face a large burden of are critical risk factors for low birthweight, neonatal malnutrition. In 2019, an estimated 56.1 million children (33 mortality, stunting, and wasting among children (Harding, percent) in South Asia were stunted, which places children Aguayo, & Webb 2018; Kim et al. 2017; Rahman et al. at higher risk for infectious disease morbidity and delays in 2016). There is also a growing burden of overweight and cognitive development (Caulfield et al. 2004; Sudfeld et al. obesity in the region, which raises the risk of cardiovascular 2015; UNICEF, WHO, & World Bank Group 2020). A total disease, diabetes, and cancer (Guh et al. 2009; WHO of 25.1 million children (15 percent) were wasted, with 2020). The prevalence of overweight and obesity among wasted children experiencing mortality rates over twice that adults was estimated to vary between countries from 19 to Page 1 HNPGP Knowledge Brief • 29 percent in 2016, but all countries have seen substantial domestic product (GDP), and as a percentage of general growth (61–88 percent increase from 2000 to 2016) (WHO government expenditure (GGE). 2020). Table 1. Nutrition-Specific Expenditures in Four Countries (2018, US$ per capita) Though there is considerable variability between countries 2012 2013 2014 2015 2016 2017 2018 in the region with respect to nutrition outcomes, taken Bhutan — — 2.96 7.94 7.82 8.76 — together, nutritional risk factors are the largest single India Jharkhand — — — — 4.38 6.08 5.46 contributor to the overall burden of morbidity and mortality Madhya Pradesh — — — 4.89 5.30 5.44 5.42 in the region (IHME 2018). Beyond the direct impacts on Tamil Nadu — — — 3.90 3.66 3.84 3.88 health outcomes, nutrition is also an important driver of Nepal 1.45 1.08 1.25 1.62 2.91 1.71 1.27 Sri Lanka — — 3.45 3.90 3.48 3.23 3.79 economic productivity. While estimates of the cost-benefit Source: World Bank. 2020. Assessing Public Financing for Nutrition in Bhutan, ratio for different nutritional interventions vary widely, a Nepal and Sri Lanka. Washington DC. review of studies found a median return value of 17.9 for Notes: —: Not available each currency unit invested (Hoddinott et al. 2013). Expenditure data were used for Bhutan, India (2015–2016), Nepal, and Sri Lanka. Due to unavailability of expenditure data, allocation data were used for India in Many South Asian countries have developed national 2017–18. strategies or plans, aligned with the second Sustainable While nutrition-specific expenditures grew over time for two Development Goal (SDG) to “end hunger, achieve food thirds of countries or states, in only one country (i.e., security and improve nutrition, and promote sustainable Bhutan) did expenditure increase considerably as a agriculture” (Bhutan, MoAF 2014; Sri Lanka, MoHN 2010; proportion of general government expenditure; indicating Nepal, MoH, NPC 2018; NITI Aayog 2017). These that not all gains were due to placing a higher priority on strategies lay out a broad range of interventions, and nutrition. In 2017, nutrition-specific expenditures as a generally include nutrition-specific interventions, such as percentage of GDP ranged from 0.08 percent in Sri Lanka programs to provide nutritional care for pregnant women; to 0.62 percent in Jharkhand (see Figure 1). Expenditures support infant and young child feeding practices; treat as a percentage of GGE in 2017 ranged from 0.42 percent acute malnutrition and include nutrition-sensitive in Sri Lanka to 2.45 percent in Jharkhand. interventions, such as interventions to improve water and sanitation and agricultural outputs. Progress of such Figure 1. Nutrition-Specific Intervention Expenditures, as a Percentage of GDP (Panel A) and Percentage of GGE (Panel B), strategies should be monitored periodically to ensure that 2012-2018. targets are reached and adjustments in the approach are made as necessary. Progress monitoring must necessarily A include assessments of public financing, which provide insight into whether investments are adequate to achieve stated objectives and are aligned with the interventions and population groups prioritized by national nutrition strategies. The objective of this study was to assess financing for nutrition interventions in Bhutan, Nepal, Sri Lanka, and three states in India during the period 2012 to 2018, to highlight challenges and lessons learned from B undertaking the analysis and its policy implications. The approach used in the study was a variant of the Scaling Up Nutrition Movement methodology (Fracassi et al. 2017), and comprised three general steps: identification of nutrition budget line items (programs and interventions); categorization of expenditures; and weighting of expenditures (this last step is optional, and weighting was not done in this study). Key Findings Source: World Bank. 2020. Assessing Public Financing for Nutrition in Bhutan, EXPENDITURE ON NUTRITION INTERVENTIONS Nepal and Sri Lanka. Washington DC. The study found that expenditures by a government on Data on the level of expenditures should be interpreted with nutrition-specific interventions tended to remain relatively caution; it is also important to note that there is no stable over time, with a few short-term increases (see benchmark as to what constitutes an adequate level of Table 1). Expenditures varied widely between countries on expenditure. The level of nutrition spending depends on the basis of spending per capita, as a percentage of gross multiple factors such as nutritional status of the country’s Page 2 HNPGP Knowledge Brief population. For instance, Sri Lanka has the lowest share of more decentralized. In some countries with centralized nutrition-specific expenditure as a percentage of GGE, but resource allocation systems, the distribution of resources the rate of stunting is also lowest among the countries in to provinces and districts was not always accurately and this study. completely recorded. This limited the ability to track nutrition financing at lower administrative levels and NUTRITION-SPECIFIC VERSUS NUTRITION- impaired insight into the level of analysis and targeting, and SENSITIVE INTERVENTIONS how resources are matched to needs at subnational levels. In general, nutrition-sensitive expenditures were substantially higher (without weighting) than nutrition- THE EFFECTIVENESS OF NUTRITION SPENDING specific expenditures. Wide discrepancies were seen in To evaluate the effectiveness of nutrition spending, it is Bhutan (2017), Nepal (2016), and Sri Lanka (2015), with important to monitor whether spending on nutrition is being nutrition-sensitive spending recorded at 2.6, 10.7, and 13.1 allocated to the interventions that yield the greatest impact. times higher, respectively. This difference can be partially The study found nutrition-specific intervention spending to attributed to the fact that the entire expenditures of be heavily concentrated within a few programs. In most nutrition-sensitive interventions have been counted as countries, a significant percentage of spending was on nutrition-related. It must be noted that nutrition-sensitive child health and school feeding programs, though their interventions are typically counted comprehensively while impact on reducing stunting are in fact minimal, since most their impacts on nutrition outcomes are incompletely stunting develops in the first two years of life. Spending is documented and may in fact be overestimated. most likely to impact nutritional status when it is targeted to age groups that are most likely to benefit, particularly Spending on nutrition-specific interventions comprised during the first 1,000 days of life (from pregnancy until the between 4 and 28 percent of overall nutrition spending in child is two years of age). It is important to target programs, Bhutan, Nepal, and Sri Lanka. Evidence shows that and prioritize populations that are sensitive to nutrition nutrition-specific interventions have more immediate interventions and will therefore benefit from impacts. impacts on nutritional outcomes. This suggests that an Comparing spending level and nutrition outcomes could increased emphasis on nutrition-specific expenditures may support subnational analyses to assess if resources are be warranted. Nutrition-specific interventions should, reaching areas and populations where demand is high. however, be complemented with nutrition-sensitive Optimization algorithms like those embedded in the Optima interventions to address underlying and basic causes of Nutrition tool could help formulate the optimal mix of malnutrition (Bhutta et al. 2008). There is, however, no programs for each context. clear benchmark of a recommended proportion between nutrition-specific and nutrition-sensitive interventions. Limitations and Challenges UTILIZATION OF RESOURCES LIMITATIONS IN BUDGET TAGGING PROCEDURES The study found that in most cases, governments did not The data collection process for this study revealed spend the full amount allocated to nutrition-specific limitations in how nutrition-related line items were tagged interventions. Utilization rates for nutrition-sensitive in budget allocations and expenditure records. None of the interventions were generally higher than for nutrition- countries had a preexisting budget tagging mechanism to specific interventions. The underutilization of resources identify nutrition activities, and nutrition activities were often can affect future resource allocation, since it may be bundled with other interventions in health service difficult to convince government officials that increased packages. The involvement of multiple ministries and the spending on nutritional interventions is needed when the frequent restructuring of ministries exacerbated difficulties currently allocated amounts are not being spent. It is thus in extracting nutrition expenditure data. important to identify and address the bottlenecks for utilization. Countries would also benefit from benchmarking LIMITATIONS IN THE ANALYTICAL APPROACH the level of spending needed for a population through The classification of nutrition-specific and nutrition- costing exercises that estimate the required cost for sensitive interventions, and the weighting of nutrition- delivering essential nutrition programs stated in the sensitive interventions underpins the understanding of national policy. Comparing actual spending against the nutrition expenditure. While the lack of documented projected cost will help identify investment gaps (in cases evidence on nutrition outcomes complicates the weighting of inadequate spending) and potential inefficiencies (in of nutrition-sensitive interventions, not assigning weights cases of excess spending). can result in nutrition-sensitive interventions dominating the nutrition expenditure. This in turn could provide DECENTRALIZATION OF EXPENDITURE potentially misleading information that the government is Central government spending was dominant for nutrition- investing sufficient funds in nutrition, or that nutrition- specific interventions in Bhutan (90.7 percent) and Sri sensitive interventions predominantly contribute to Lanka (99.4 percent), while the funding mix in India was Page 3 HNPGP Knowledge Brief • nutritional improvement. As such, expenditure on nutrition- Hoddinott, J., H. Alderman, J. R. Behrman, L. Haddad, & S. Horton. 2013. “The Economic Rationale for Investing in Stunting Reduction. Matern specific and nutrition-sensitive interventions should be Child Nutr 9 (Suppl 2): 69–82. analyzed separately rather than as a whole. IHME (Institute for Health Metrics and Evaluation). 2018. GBD Compare. LIMITED COMPARABILITY OF STUDIES http://vizhub.healthdata.org/gbd-compare. Although the SUN methodology provides a general Kim, R., I. Mejía-Guevara, D. J. Corsi, V. M. Aguayo, S. V. Subramanian. structure, the comparability of nutrition expenditure reviews 2017. “Relative Importance of 13 Correlates of Child Stunting in South across countries is limited due to the differences in Asia: Insights from Nationally Representative Data from Afghanistan, Bangladesh, India, Nepal, and Pakistan.” Social Science & Medicine 187: methods used to conduct the assessment, differences in 144–154. the definitions and weighting process, and in the subjective McDonald, C. M., I. Olofin, S. Flaxman, W. W. Fawzi, D. Spiegelman, L. decisions made during the evaluation process. E. Caulfield, R. E. Black, et al. 2013. “The effect of Multiple Anthropometric Deficits on Child Mortality: Meta-Analysis of Individual Conclusion Data in 10 Prospective Studies from Developing Countries.” Am J Clin Nutr 97 (4): 896–901. Nutrition expenditures within countries tend to remain constant over time, with considerable differences between Nepal, MoH (Ministry of Health), NPC (National Planning Commission). 2018. Multi-Sector Nutrition Plan (2018–2022). countries in terms of per capita expenditures. Regular http://nnfsp.gov.np/PortalContent.aspx?Doctype=Resources&ID=330. review of nutrition budget allocations and expenditures can NITI Aayog. 2017. National Nutrition Strategy 2017. help governments assess whether resources are allocated http://niti.gov.in/writereaddata/files/document_publication/Nutrition_Strat in alignment with national nutrition strategies and plans. egy_Booklet.pdf. Appropriate tagging of nutrition line items, developing Rahman, M. M., S. K. Abe, M. S. Rahman, M. Kanda, S. Narita, V. Bilano, standardized systems of data collection, and assigning E. Ota, et al. 2016. “Maternal Anemia and Risk of Adverse Birth and accountability for the conduct of reviews can help ensure Health Outcomes in Low- and Middle-Income Countries: Systematic that these occur regularly. Furthermore, prioritization Review and Meta-Analysis.” Am J Clin Nutr 103 (2): 495–504. exercises led by governments, with inputs from technical Sri Lanka, MoHN (Ministry of Healthcare and Nutrition). 2010. National advisers, can help ensure that expenditures are focused on Nutrition Policy of Sri Lanka. Colombo. the right interventions, with the required balance between Sudfeld, C. R., D. C. McCoy, G. Danaei, G. Fink, M. Ezzati, K. G. nutrition-sensitive and nutrition-specific interventions, for Andrews, & W. W. Fawzi. 2015. “Linear Growth and Child Development in Low- and Middle-Income Countries: A Meta-Analysis.” Pediatrics 135 the right populations. Taken together, these actions can (5). e1266-1275. help ensure continued progress to reduce malnutrition. UNICEF, WHO (World Health Organization), & World Bank Group. 2020. References Levels and Trends in Child Malnutrition. Geneva. Bhutan, MoAF (Ministry of Agriculture and Forests). 2014. Food and WHO (World Health Organization). 2020. Global Health Observatory Data Nutrition Security Policy of the Kingdom of Bhutan 2014. Thimphu. Repository. apps.who.int/gho/data/node.main.1?lang=en/ Bhutta Z. A., T. Ahmed, R. E. Black, S. Cousens, K. Dewey, E. Giugliani, B. A. Haider, et al. 2008. “What Works? Interventions for Maternal and Child Undernutrition and Survival.” Lancet 371 (9610): 417–440. This HNP Knowledge Brief highlights key findings from a World Bank study, “Assessing Public Financing for Nutrition in Bhutan, India, Nepal Caulfield, L. E., M. de Onis, M. Blössner, & R. E. Black, 2004. and Sri Lanka” by Christopher T. Andersen, Jewelwayne Salcedo Cain, “Undernutrition as an Underlying Cause of Child Deaths Associated with Deepika Chaudhery, Hideki Higashi, and Ajay Tandon. Renu Warnasuriya Diarrhea, Pneumonia, Malaria, and Measles.” Am J Clin Nutr 80 (1): 193– provided support in summarizing this brief. Financial support was 98. provided by the Government of Japan through the Japan Scaling Up Nutrition Trust Fund and UK Aid from the UK Government and the Fracassi, P., C. Picanyol, W. Knechtel, M. D’Alimonte, A. Gary, A. European Commission (EC) through the South Asia Food and Nutrition Pomeroy-Stevens, and R. Watts. 2017. Budget Analysis for Nutrition: Security Initiative (SAFANSI). Guidance Note for Countries (update 2017). Guh, D. P., W. Zhang, N. Bansback, Z. Amarsi, C. L. Birmingham, & A. H. Anis. 2009. “The Incidence of Co-Morbidities Related to Obesity and Overweight: A Systematic Review and Mmeta-Analysis. BMC Public Health 9, 88 (March 25). Harding, K. L., V. M. Aguayo, P. Webb. 2018. “Factors Associated with Wasting among Children under Five Years Old in South Asia: Implications for Action.” PLoS ONE 13 (7). e0198749. The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, go to: www.worldbank.org/health. Page 4