Knowledge Brief Health, Nutrition and Population Global Practice Assessing Public Financing for Improving Nutrition Outcomes and Human Capital in Bhutan October 2021 Key Messages • Despite progress on population health outcomes in recent decades, malnutrition remains a policy concern in Bhutan, especially in rural areas and in the eastern region of the country. • Addressing malnutrition is high on the government agenda, with clear targets, strategies, and action plans designed to address some specific malnutrition-related challenges. • Assessing the level, distribution, and composition of public financing for nutrition is key to informing the design and implementation of corrective policies. • Considering the growing burden of disease attributable to overnutrition, it is important that Bhutan’s nutrition action plan prioritizes overnutrition in addition to undernutrition. Introduction indicate that one-fifth of all children under five are stunted. National stunting rates have declined rapidly—from 37 Bhutan’s health indicators have shown significant percent in 2008 to 35 percent in 2010 to 22 percent in 2015 improvement in recent decades, and Bhutan fares well among children age 6–59 months—but remain high in the across a range of population health indicators relative to eastern region of the country among the poor and in rural comparator countries in its income range. Life expectancy areas. Approximately 9 percent of all children under five are at birth is now over 70 years, slightly higher than that of underweight, and 44 percent are anemic. Wasting rates are neighboring India, up from 53 in 1990. 1 The under-five relatively low nationally but remain high at 7 percent among mortality rate declined by more than two-thirds between poor children. Small-scale investigations suggest a 1990 and 2015: from 128 to 33 per 1,000 live births, potentially high prevalence of micronutrient deficiencies in exceeding the Millennium Development Goal (MDG) the country. Malnutrition among population subgroups also target. 2 At 1.7 births per woman, fertility is now below remains a concern. For instance, anemia rates among replacement levels. 3 adolescent girls and women of reproductive age range Despite progress in recent decades, malnutrition remains between 27 percent and 36 percent, indicating a lingering a policy concern in Bhutan, especially in rural areas and in prominent public health problem. Underlying reasons for the eastern region of the country. Recent estimates malnutrition in Bhutan include low rates of exclusive 1 By 2019, following the publication of this report, life expectancy at birth had 3. By 2019 the fertility rate had increased to 2.1/woman, increased to 71.77 years, http://www.healthdata.org/bhutan. https://data.worldbank.org/indicator/SP.DYN.LE00.IN?locations=BT. 2. By 2019 the under-five mortality rate had reduced further to 28.5/1,000LB. UN Inter-Agency Group for Child Mortality Estimation, https://childmortality.org/data/Bhutan. Page 1 HNPGP Knowledge Brief • breastfeeding (51 percent) and poor diets: only 12 percent related strategies and action plans were reviewed to of children are provided with the recommended minimum identify relevant ministries that were formally identified as acceptable diet; only 17 percent are given iron-rich foods; having a role in delivery of nutrition interventions. Next, a just 15 percent are provided with four or more food groups; review of relevant departments within the selected and there is generally low consumption of micronutrient- ministries was conducted to better identify the locus of rich food. Delays in seeking antenatal care and low rates financing for nutrition-related activities within each ministry. of pregnant women completing the recommended Once departments were identified, a review of line-item minimum of eight antenatal care visits contribute to the budgets was conducted within those departments at both problem. The lack of adequate water and sanitation the activity and, where necessary, subactivity levels to pick facilities are additional barriers to achieving good nutrition up both allocations and expenditures that corresponded to outcomes. nutrition-related activities referenced in strategies and action plans. While the SUN methodology recommends the Bhutan’s disease pattern is rapidly shifting from optional step for weighting line-item expenditures, communicable to noncommunicable diseases (NCDs). In weighting was not done for Bhutan given the risk of 2017, almost two-thirds of the overall disease burden was subjectivity in using weights. due to NCDs, compared to less than one-third in 1990. Declining mortality and fertility rates have resulted in Key Findings population aging and rising dependency ratios. This will EXPENDITURE ON NUTRITION INTERVENTIONS increase demand and cost pressure on the health system Based on a country-specific classification of nutrition and require a reorientation toward management and interventions, per capita public financing for nutrition in FY treatment of chronic diseases. The country is also facing a 2016/17 stands at Nu 2,003 (~US$29; 1 percent of GDP; 3 growing disease burden from overnutrition, and metabolic percent of the total government expenditures), similar to and behavioral factors linked to both overnutrition and estimates from other developing countries. These shares undernutrition are dominant risk factors in Bhutan. have remained largely stable throughout the 11th Five Year Reducing malnutrition matters critically for both economic Plan (FYP) period from 2013 to 2018. Despite the level of and human development. The World Bank’s Human spending increasing from Nu 1,744 in FY 2013/14, there Capital Project (HCP) has estimated a Human Capital does not appear to be any increase in priority to nutrition Index (HCI) to help benchmark attainment across countries during the 11th FYP period. Increases in nutrition and within countries. Bhutan remains at or around the expenditures are in line with economic growth rates, and bottom 50 percent of countries globally for under-five the share of nutrition expenditure did not increase in the survival, adult survival, and proportion of children under budget. Previous estimates of public financing for nutrition five who are not stunted—the three health-related captured only a subset of health-related expenditure. indicators of the HCI. These estimates were derived using the National Health Account (NHA) methodology, which, does not base Bhutan’s Food and Nutrition Security (FNS) policy lays out estimates on the NNTF and does not include spending the overarching nutrition strategy. The National Nutrition outside of the health sector for nutrition. Unsurprisingly, Task Force (NNTF)—comprising focal points from different NHA estimates of nutrition-related expenditures were ministries and development partners—coordinates and underestimated and were far lower than those estimated tracks nutrition-related interventions across different using the SUN methodology. For FY 2015/16, SUN sectors in Bhutan. Although the FNS policy notes the role estimates of only per capita nutrition-specific expenditures of multiple ministries in delivering on food and nutrition, two (Nu 510) were almost double NHA-based estimates (Nu ministries are formally mentioned as having the primary 306). mandate to do so: (i) the Ministry of Agriculture and Forests (MoAF) for food security policy and strategic action plans; Table 1: Expenditure on Nutrition-Related Activities (FY and (ii) the Ministry of Health (MoH) for leading and 2016/17) Share of coordinating the implementation of nutrition security Category Expenditure Per Capita Share of Government Ratio Ratio (Nu, millions) (Nu) GDP (%) MoH (%) MoAF (%) programs. The action plan developed by the NNTF aims to Total nutrition 1,561 2,003 1.0 Expenditure (%) 3.0 47.0 23.0 accelerate specific interventions targeting vulnerable Central 682 875 2.0 38.0 19.0 Subnational 879 1,127 7.0 58.0 29.0 groups—adolescent girls, under-five children, women of District 549 705 4.0 44.0 38.0 reproductive age, and pregnant/lactating women—to Block Nutrition-specific 330 439 423 563 0.3 12.0 1.0 119.0 13.0 20.0 7.0 reduce micronutrient deficiencies and improve nutrition. Central 417 535 1.0 13.0 12.0 Subnational 22 28 0.1 1.4 1.0 This study summarizes findings from the application of new District Block 19 2 25 3 0.2 0.1 1.6 0.8 1.0 0.1 multisectoral budgetary tracking methods to estimate Nutrition-sensitive 1,122 1,439 0.7 2.0 34.0 17.0 Central 265 340 1.0 15.0 7.0 public financing for nutrition in Bhutan. The study identifies Subnational 857 1,099 6.0 57.0 28.0 challenges, outlines lessons learned, and makes District Block 530 327 680 420 4.0 12.0 43.0 118.0 37.0 20.0 recommendations that could potentially facilitate future Source: Estimated from MOF expenditure data (FY2016/17) routine estimation of public financing for nutrition. The Note: MoH = Ministry of Health; MoAF = Ministry of Agriculture and Forests. methodology followed in this study is a variant of the Scaling Up Nutrition (SUN) methodology. First, nutrition- Page 2 HNPGP Knowledge Brief NUTRITION-SENSITIVE VERSUS NUTRITION nutrition expenditures were larger in the higher-burden SPECIFIC INTERVENTIONS eastern region. Per capita nutrition-related expenditures in Bhutan’s definitions of nutrition-specific and nutrition- the eastern region (which has an almost 30 percent sensitive interventions differ from global literature. Based stunting rate) were almost double the per capita on local classifications, in recent years, nutrition-specific subnational expenditures in the western region (where the programs have accounted for 30 percent of the total stunting rate is closer to 15 percent). However, these data nutrition-related expenditure. This share is similar to other do not include subnational allocations of central-level countries in the region. The share of nutrition-specific nutrition expenditures as this level of granularity were not expenditures increased, from 10 percent in FY 2013/14 to available; hence, this does not represent the full scope of 30 percent in FY 2016/17, largely as a result of Ministry of subnational spending for addressing malnutrition. Education (MoE) activities related to centralized ABSORPTION OF NUTRITION ALLOCATIONS procurement of the school feeding program. In FY 2016/17, At ~85 percent, the absorption rate of nutrition allocations nutrition-specific financing amounted to Nu 439 million, or was relatively high, but were slightly lower than the Nu 563 (~US$8) in per capita terms; total nutrition-sensitive absorption rates for the entire government budget (90 financing amounted to Nu 1,122 million, or Nu 1,439 percent) in FY 2016/17. Absorption capacity was lower (~US$21) in per capita terms. The 10 largest interventions (~80 percent) at the central level compared to subnational in terms of financing accounted for more than half of all levels (~90 percent). There was also a large variation nutrition-related spending. The central MoE’s school across ministries. The Ministry of Works and Human feeding program, early childhood care and development, Settlement (MoWHS), for example, absorbed just over 50 and special education needs programs were in the top 10, percent of its allocated budget for nutrition-related activities as were several WASH-related interventions in urban and whereas the MoH absorbed more than 80 percent. At the rural areas as well as at the central and subnational levels. subnational level, all relevant departments had more than Figure 1: Trends in Public Financing for Nutrition-Specific 80 percent utilization rates. and Nutrition-Sensitive Interventions Figure 2: Absorption Rates for Nutrition-Related Interventions by Ministry/Department Figure 2a. Absorption Rates for Nutrition-Related Interventions by Ministry/Department––Central Source: Estimated from Ministry of Finance expenditure data (FY 2013/14 to FY 2016/17) Note: Numbers are in 2016 constant Nu. DECENTRALIZATION OF NUTRITION EXPENDITURE Expenditures for nutrition are more decentralized than Figure 2b. Absorption Rates for Nutrition-Related Interventions by those for other sectors in Bhutan. Unlike the 70:30 Ministry/Department––Subnational 100 breakdown of total government expenditures between central and subnational governments, nutrition-related 80 expenditures were split more equally between the central and subnational levels, underscoring the importance of Absorption rate (%) 60 looking carefully at district and subdistrict level spending for tracing public financing for malnutrition, especially for 40 nutrition-sensitive interventions. Among subnational levels, district-level expenditures were much higher than those at 20 the subdistrict level. Detailed information was not available to determine whether or not there was geographic 0 convergence of nutrition expenditures toward specific high- UDE Education Livestock Health Agriculture Civil Religion Forestry Total Source: Estimated from Ministry of Finance expenditure data (FY 2016/17) priority subnational areas, although available information Note: UDE = Urban Development & Engineering; MoWHS = Ministry of Works and Human suggests this has not been the case. Geographic Settlement; CRA = Council for Religious Affairs; MoAF = Ministry of Agriculture and Forests; GNHC = Gross National Happiness Commission; MoE = Ministry of Education; convergence—whereby multisectoral coordination and MoHCA = Ministry of Home and Cultural Affairs; MoH = Ministry of Health. budgeting is conducted in targeted areas—is something that has been shown to be effective in other countries, and may be something for Bhutan to consider. Subnational Page 3 HNPGP Knowledge Brief • Limitations and Challenges also be considered but using the SUN methodology accounts for the multisectoral nature of nutrition activities, The lack of budgetary tagging in the NNTF action plan, especially as the results indicate that the locus of nutrition insufficient budgetary granularity for some relevant financing lies outside the MoH. From a global perspective, activities and subactivities, bundling of nutrition there needs to be greater standardization for the interventions with other interventions, unclear subnational interventions that are classified as nutrition-specific and allocations of national expenditures, and agglomeration of those that are classified as nutrition-sensitive. Even if salaries and operating costs in reported budgetary data countries classify such interventions differently, some were some of the significant challenges faced while semblance of comparability across countries could be estimating public financing for nutrition in Bhutan. achieved if global standardization were conducted. Recommendations References INSTITUTIONALIZE FINANCING ASSESSMENTS Bhutan, MoAF (Ministry of Agriculture and Forests). 2014. Food and Institutionalizing nutrition financing assessments and Nutrition Security Policy of the Kingdom of Bhutan 2014. Thimphu. conducting them regularly in conjunction with costing Bhutan, National Nutrition Task Force. 2018. Accelerating Actions for exercises could ensure that the lack of financing is not a Reducing Undernutrition and Micronutrient Deficiencies among Women bottleneck for improving nutrition outcomes in Bhutan. and Children. Thimphu. Additionally, it is recommended that the NNTF action plan Levinson, J., Y. Balarajan, and A. Marini. 2013. Addressing Malnutrition annually tags and tracks relevant budgetary line items that Multi-Sectorally: What Have We Learned from Recent International represent allocations and expenditures for these Experience? New York: UNICEF and MDG Achievement Fund. interventions–—both at the national and subnational levels. Marini, A., C. Rokx, and P. Gallagher. 2017. Standing Tall: Peru’s This would make it easier to monitor financing flows and to Success in Overcoming Its Stunting Crisis. Washington, DC: World make corrective allocations as needed, to assess where Bank. there may be absorption problems, and to identify areas Prendergast, A., and J. Humphrey. 2000. “The Stunting Syndrome in where greater and more effective financing may be Developing Countries.” Pediatrics and International Health 34: 250–65. needed. Rokx, C. 2000. Who Should Implement Nutrition Interventions? The Application of Institutional Economics to Nutrition and the Significance of RAISE AWARENESS ABOUT MALNUTRITION Various Constraints to the Implementation of Nutrition Interventions.” ACROSS MINISTRIES Washington, DC: World Bank. Given the multisectoral nature of malnutrition, it is key that SUN Movement. 2019. Tracking Nutrition Investments. Geneva. awareness be raised to give nutrition a more prominent https://scalingupnutrition.org/share-learn/planning-and- profile as a cross-cutting development challenge facing the implementation/tracking-nutrition-investments/. country and that this message be made explicit in the WHO (World Health Organization), and Bhutan, MoH (Ministry of strategies and action plans of the different ministries and Health). 2016. Report on Bhutan Global School-based Student Health local governments so that accountability can be shared. Survey (GSHS) 2016. New Delhi: WHO. PRIORITIZE FINANCING FOR NUTRITION-SPECIFIC This HNP Knowledge Brief highlights key findings from a World Bank INTERVENTIONS IN THE EARLY YEARS study “Assessing Public Financing for Improving Nutrition Outcomes and Given low coverage rates of early initiation and exclusive Human Capital in Bhutan” by Shakil Ahmed, Manav Bhattarai, Dorji breastfeeding and inadequate complementary feeding Drakpa, Laigden Dzed, Mamata Ghimire, Pema Lhazom, Ajay Tandon, practices, priority in addressing these problems should be and Valerie Ulep. Renu Warnasuriya provided support in summarizing this brief. Financial support was provided by the UK Aid from the UK considered, both nationally and subnationally. Government and the European Commission (EC) through the South Asia PRIORITIZE OVERNUTRITION IN ADDITION TO Food and Nutrition Security Initiative (SAFANSI) and the Government of Japan through the Japan Scaling Up Nutrition (SUN) Trust Fund. UNDERNUTRITION Although problems related to undernutrition rightfully receive prominent policy attention in Bhutan, it would be prudent to also address the growing burden of disease attributable to overnutrition. Conclusion How much and how public financing flows for malnutrition is an important piece of information in the design and implementation of evidence-based policies. Including such an estimation as part of regular updates of the NHA may 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