Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security FEBRUARY 2024 Acknowledgements The Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security was prepared by the World Bank team consisting of Lubina Fatimah Qureshy (Consultant, HEAHN), Heather Grieve (Consultant, HEAHN), Kyoko Shibata Okamura (Senior Nutrition Specialist, HHNGE), Elvina Karjadi (Consultant, HEAHN), Claudia Rokx (Consultant, HEAHN), and Jose Tavares Mousaco (Senior Health Specialist, HEAHN). This report benefited from the useful comments and suggestions provided by peer reviewers including Yi-Kyoung Lee (Senior Health Specialist, HAEH2), Alief Aulia Rezza (Senior Economist, EEAM2), and Jonathan Kweku Akuoku (Nutrition Specialist, HHNGE). Overall guidance was provided by Aparnaa Somanathan (Practice Manager, HSAHN), Bernard Harborne (Resident Representative, EACDF), Somil Nagpal (Lead Health Specialist, HEAHN), and Achim Daniel Schmillen (Practice Leader, HEADR). The team is thankful for inputs provided by technical experts, including Mari Shimizu (Health Specialist, World Bank), Ilsa Meidina (Senior Social Protection Specialist, World Bank), and Faraja Chiwile (Nutrition Specialist, UNICEF). Appreciation also goes to Rideca Duarte (Program Assistant, EACDF) who provided administrative and logistical assistance, Usha Tankha for editorial services, and Indra Irnawan for graphic designing. The work was financially supported by the Government of Japan and the Bill and Melinda Gates Foundation through the Nutrition Multi-Donor Trust Fund for Scaling Up Nutrition. This report is a product of the staff of the International Bank for Reconstruction and Development/the World Bank. The findings, interpretations, and conclusions expressed in this report do not necessarily reflect the views of the Executive Directors of the World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Cover photo by Ana Teresa Sequeira, 2024 and Junia Christina Landwing, 2023. All rights reserved. Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security Lubina Fatimah Qureshy, Heather Grieve, Kyoko Shibata Okamura, Elvina Karjadi, Claudia Rokx, and Jose Tavares Mousaco Abbreviations BdM Bolsa da Mãe MUAC Mid-Upper Arm Circumference BdM-JF Bolsa da Mãe-Jerasaun Foun NHSNSP National Health Sector CF Complementary Feeding Nutrition Strategic Plan CNAP-NFS Consolidated National Action Plan ORS Oral Rehydration Salts for Nutrition and Food Security RAEOA Rejiaun Administrativu EBF Exclusive Breastfeeding Espesial Oe-cusse Ambenu (Special Administrative Region EIBF Early Initiation of Breastfeeding of Oecusse Ambeno) GDP Gross Domestic Product RUTF Ready to Use Therapeutic Food GDS General Directorate of Statistics SAM Severe Acute Malnutrition GoTL Government of Timor-Leste SBCC Social and Behavioral HCI Human Capital Index Change Counseling IFA Iron and Folic Acid SDGs Sustainable Development Goals IMAM Integrated Management SUN Scaling Up Nutrition Movement of Acute Malnutrition TLDHS The Timor-Leste Demographic LBW Low Birthweight and Health Survey LMICs Low- and Middle-Income Countries TLFNS Timor-Leste Food and MALFF Ministry of Agriculture, Livestock, Nutrition Survey Fisheries and Forestry TLFNS Timor-Leste Food and MAM Moderate Acute Malnutrition Nutrition Survey MOE Ministry of Education USDA United States Department MOH Ministry of Health of Agriculture MPW Ministry of Public Works WASH Water, Sanitation and Hygiene MSSI Ministry of Social Solidarity WFP The United Nations World and Inclusion Food Programme MTI Ministry of Trade and Industry WHO World Health Organization WRA Women of Reproductive Age Contents Abbreviations..................................................................................................................................................................................................................... 4 Executive Summary....................................................................................................................................................................................................... 6 Chapter 1. INTRODUCTION............................................................................................................................................................................................................. 9 Chapter 2. NUTRITION POLICY IN TIMOR-LESTE ........................................................................................................................................................ 12 Chapter 3. APPROACH TO COSTING ................................................................................................................................................................................... 14 Chapter 4. METHODOLOGY......................................................................................................................................................................................................... 16 Health.................................................................................................................................................................................................................... 18 Industry................................................................................................................................................................................................................ 25 Education........................................................................................................................................................................................................... 26 Public works...................................................................................................................................................................................................... 28 Agriculture......................................................................................................................................................................................................... 29 Social Inclusion............................................................................................................................................................................................... 30 Chapter 5. RESULTS AND DISCUSSION .............................................................................................................................................................................. 31 Total cost and its composition.............................................................................................................................................................. 31 High impact interventions....................................................................................................................................................................... 32 Alternative costing scenarios................................................................................................................................................................. 35 Chapter 6. CONCLUSION AND SUGGESTED NEXT STEPS................................................................................................................................... 36 References........................................................................................................................................................................................................................ 39 Annexure 1....................................................................................................................................................................................................................... 41 Annexure 2....................................................................................................................................................................................................................... 42 6 Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security Executive Summary There is compelling ethical reasoning to invest in the physical and mental nourishment of a population; that apart, investing in nutrition reaps substantial economic benefits as well. The gains are not only short-term resulting in reduced costs of childhood illness and lives saved but also long-term that extend over generations by improving a country’s human capital, the driving force of development. Timor-Leste’s 2020 human capital index (HCI) of 0.45 indicates that the productivity of its future workforce will be less than half of what it could be given the right inputs. Stunting1, an indicator of cumulative nutritional development also referred to as hidden hunger, is one of the five indicators used in the HCI precisely because childhood stunting is associated with reduced learning years and lost productivity in adulthood. The 2020 national stunting rate in Timor-Leste was 46.7 percent, one of the highest in the world. In keeping with Sustainable Development Goal 2 (SDG2) to End Hunger and Malnutrition as a national priority, Timor-Leste introduced the SDG2 Consolidated National Action Plan for Nutrition and Food Security (hereafter referred to as the CNAP-NFS) by way of consensus, which highlights the 19 key nutrition promoting priorities across seven sectors to improve nutrition outcomes and end hunger. Demonstrating a heightened understanding of the complex multisector nature of the nutrition situation and the need for greater investments to reduce the very high levels of undernutrition, the CNAP-NFS provides a holistic framework beyond the health sector and focuses on solutions to nutrition improvement, including stunting reduction. Each of the priorities and indicators where they exist are aligned with existing sector policies and plans. This costing analysis presents nutrition-specific and nutrition-sensitive cost categories, covering costing estimates for the period 2023-2030 for each of the sectors. The costing is indicative and based on estimates of scaling up nutrition interventions to a targeted increase in coverage by 2030 based on the best information available in the Timor-Leste budget books and the National Health Sector Nutrition Strategic Plan (NHSNSP) 2022-26. In addition to the core scenario, two alternative cost scenarios were also applied: (i) lower unit costs from the literature and lower target coverage relative to the core scenario, and (ii) 15 percent higher unit costs and target coverage, relative to the core scenario. The total CNAP-NFS cost estimated over eight years is expected to be US$55 million in the core scenario (in a range of US$44 million to US$61 million with the two alternative cost scenarios), distributed across education, health, industry, public works (water), and agriculture sectors2. This total cost translates into an annual increase of US$7 million in nutrition investment (ranging between US$5.5 million and US$7.6 million). The education sector (43 percent) has the largest proportion of the total cost due to a large share by school meals alone (32 percent; US$17.9 million) which costs more than the entire health sector interventions (28 percent; US$15.6 million). Health is followed by agriculture (18 percent), public works (8 percent) and industry (2.5 percent). 1 Stunting is an indicator that captures linear growth failure and is indicated when a child falls −2 SD below the length-for-age/height-for-age median stan- dards set by the World Health Organization. Stunting results from prolonged undernutrition and is associated with an increase in morbidity and mortality, reduced physical growth potential, diminished neurodevelopmental and cognitive function and also predicts increased risk of chronic disease in adult- hood, collectively leading to lost economic productivity (see for example, de Onis and Branca 2016; Shekar et al., 2017). 2 The original indicative costing included the Bolsa da Mãe Jerasaun Foun (BdM-JF) program, based on the data provided by the Ministry of Solidarity and Social Inclusion (MSSI). In view of the cancellation of the BdM-JF program in January 2024, this report presents revised estimates that exclude the estimated contribution of the BdM-JF. from the total costs presented in Executive Summary and Section 5 of the report. Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security 7 The CNAP-NFS is an ambitious plan to reach the SDG2 targets while significantly contributing to SDG3— Good Health and Wellbeing. In light of the urgency for reducing the high malnutrition burden in the country, the costing analysis was also applied to a set of high impact nutrition-specific interventions recommended by Lancet maternal and child nutrition series in 2008 and 2013 (hereafter referred to as the “Lancet Package”) that have strong evidence for reducing maternal and child undernutrition and micronutrient deficiencies. The Lancet Package that overlaps with the CNAP-NFS interventions will cost US$14 million over the eight years. Nutrition-specific investments relate to spending on the direct determinants of nutrition, dietary intake and health, and include such interventions as micronutrient supplementation, and maternal infant and young child feeding counseling. Financing of these interventions flows through the health sector, with the exception of food fortification, which falls under the Ministry of Trade and Industry. Investments in these interventions in the Lancet Package are also considered cost-effective. The inclusion of two additional nutrition-specific CNAP-NFS investments, dietary diversity counseling and iron and folic acid supplementation for all women of reproductive age, which are globally recommended by the World Health Organization (WHO) but currently have a limited evidence base, will add US$3 million. In order to ensure a sustained impact over the long term, many of the above-mentioned nutrition-specific interventions will need to be complemented with investments in nutrition-sensitive sectors. Nutrition-sensitive investments bear an indirect impact on nutrition outcomes by influencing the underlying determinants of nutrition. Interventions in these sectors (for example, water, education, and agriculture) that complement the high impact interventions in the health and trade and industry sectors to improve nutrition outcomes will need to be identified. It is also essential to identify current sources of finance and the funding gap to understand how much of the cost could be financed by the Government and how much could be contributed by development partners. Aside from presenting an indicative estimate of what it would cost to implement the CNAP-NFS in Timor-Leste, this analysis should be treated as a guide to understanding what data gaps exist to refine estimates further. This model uses the best available information from the Timor-Leste budget books and existing baselines and targets for output indicators, which form the parameters for estimates. However, in order to improve upon the costing estimates going forward, we recommend the following:  Establishing clear baselines across sectors: Baselines of output indicators were not always available for both the nutrition-specific and nutrition-sensitive sectors. For the latter, the task is more challenging as it is even less clear which activity level indicators need to be tracked to get baseline output indicators for these sectors.  Establishing clear targets across sectors: Setting clear targets in all concerned sectors is one of the first steps to strengthen impacts of nutrition investments. While the NHSNSP 2022-26 for 2026 served as a basis to set the target coverage to be achieved in the health sector by 2030, targets were either not available or were unclear for many of the nutrition-sensitive interventions included in the analysis. Establishing feasible targets will also rest on having information on baseline indicators.  Obtaining sub-activity level details: The delineation of budget line items needed for the costing was based on activity level information (where available) from the Timor-Leste budget books. However, many of the activity lines did not reflect nutrition budget alone. Therefore, greater granularity at the subactivity level will enable more precision in identifying budget and expenditure for the nutrition-relevant sectors. 8 Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security  The analysis has certain limitations: it does not cost the contribution of the different ministries to nutrition- enabling or governance activities as these costs could not be demarcated in the budget line items, and it excludes the nutrition-enabling contribution of State Administration and the Ministry of Finance for the same reason; the study focuses instead on the nutrition-specific and nutrition-sensitive contribution of the other sectors. To address fiscal constraints we suggest:  Explore alternative strategies for nutrition-sensitive social protection: As global evidence suggests, nutrition-sensitive social assistance is one of the best-buy investments in reducing stunting and malnutrition, hence minimizing economic productivity loss of Timor-Leste’s future human capital. The government should consider maintaining investment in children and women by ensuring that social assistance supports are provided during the critical first 1000-day window (from conception until the child’s second birthday) and by guaranteeing the inclusion of the poor and vulnerable. Such evidence-driven approaches could allow for allocative efficiency of limited resources while maximizing the investment returns.  Consider an optimization exercise to allocate the budget across interventions: The government could consider using Optima Nutrition, a quantitative tool that helps to optimize the allocation of current or projected budgets across nutrition programs. The model also contains a geospatial component that can determine funding allocations that minimize stunting, wasting, anemia or under-five mortality at both the national and regional levels. Given fiscal constraints, such an exercise can help to identify the interventions and the allocations for those investments that would use the available funds in a cost-effective way (Optima Consortium for Decision Science 2021). Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security 9 1. Introduction There is compelling ethical reasoning to invest in the physical and mental nourishment of a population; that apart, investing in nutrition reaps substantial economic benefits as well. A healthy population is more productive and has a direct bearing on the Gross Domestic Product (GDP). The returns on health investments are not immediate and within health; the productivity benefits of investing in child nutrition, for example, emerge over a longer time frame mainly when the children enter the workforce. Budget constraints can overshadow these benefits, with other investments that have quicker paybacks out competing child nutrition. Such an approach, however, is short-sighted. It overlooks the fact that not only does addressing malnutrition result in short-term gains in terms of reduced costs of childhood illness and lives saved but its long-term gains extend over generations by improving a country’s human capital, the driving force of development. Timor-Leste’s 2020 Human Capital Index (HCI) of 0.45 indicates that the productivity of its future workforce will be less than half of what it could be given the right inputs. Human capital is quantified using the HCI to assess how much current investment in health and education contributes to the productivity potential of the next generation of workers. It includes the proportion of children under 5 years who are not stunted as one of its five indicators since stunting3 is widely considered a good proxy for chronic undernutrition or cumulative nutritional deprivation that begins in the womb, often referred to as hidden hunger. The 2020 stunting rate in Timor-Leste was 46.7 percent.4 The other four indicators of the HCI are probability of child survival till age 5, expected years of school, quality of learning, and adult survival rate. The Copenhagen Consensus 2004 marked the turning point in bringing hunger and malnutrition to the forefront of Refer to Footnote 1. 3 https://data.worldbank.org/indicator/SH.STA.STNT.ZS?locations=TL 4 10 Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security Box 1. Nutrition categories Nutrition categories Programs and interventions Nutrition-Specific: Adolescent health and preconception nutrition These are high impact direct nutrition Maternal dietary supplementation interventions. Micronutrient supplementation or fortification Breastfeeding and complementary feeding Dietary supplementation for children Dietary diversification Feeding behaviors and stimulation Treatment of severe acute malnutrition Nutrition-Sensitive: Agriculture and food security These are indirect nutrition actions having Social safety nets nutrition-relevant objective, outcome and/or Early child development action. Water and sanitation Health and family planning services Enabling: Rigorous evaluations These are system-enhancing interventions that Advocacy strategies improve governance and increase effectiveness Horizontal and vertical coordination of nutrition interventions. Accountability, incentives regulation, legislation Capacity investments Domestic resource mobilization Source: Adapted from Black et al. 2013, see also Annexure 1, which provides the 2013 Lancet frameowork for actions to achieve optimum nutrition and how the different types of nturition interventions are linked. development policy discourse and urged the world to invest in interventions to improve nutrition. Attention thereby turned to understanding what constitutes adequate investments in nutrition. The 2008 and 2013 Lancet Series on maternal and child nutrition (hereafter referred to as “Lancet Series”) recommended a set of core interventions that would have a high impact on nutrition outcomes, in particular, stunting. The evidence base for these and other interventions has been updated recently in a Lancet systematic review and meta-analysis (Keats et al. 2021). The 2013 Lancet Series5 categorized nutrition actions into direct or “nutrition-specific” interventions primarily implemented under the health sector which are considered high impact interventions, and indirect or “nutrition- sensitive” interventions, falling under a number of other sectors, which complement nutrition-specific interventions and improve their effectiveness. To elaborate, “nutrition-specific” investments relate to spending on the direct determinants of nutrition, dietary intake and health and include such interventions as micronutrient supplementation and maternal, infant and young child feeding counseling. Financing of these interventions flows through the health This 2013 Series also costed a list of 10 interventions, shorter than the list of 13 proposed in the 2008 Series. 5 Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security 11 sector, with the exception of food fortification, which falls under the Trade and Industry sector in Timor-Leste. “Nutrition-sensitive” investments bear an indirect impact on nutrition outcomes by influencing the underlying determinants of nutrition (see Box 1). Examples include water, sanitation and hygiene (WASH) interventions, food security through agricultural investments, and providing social safety nets. Expenditures on these interventions are undertaken by multiple ministries overseeing these different sectors. There is a third category of nutrition enhancing investments that refer to interventions and programs that provide the enabling environment to support nutrition programs and include such activities as evaluations, coordination, policy environment, system strengthening, and capacity building. While the high impact nutrition interventions focus primarily on nutrition-specific interventions, it is well recognized that complementing these with nutrition-sensitive interventions is crucial to the sustained success of improving nutrition outcomes. To achieve this, different sectors need to work synchronously for optimal nutrition results. However, the need for multisectoral engagement or a ‘whole-of government’ approach also poses the potential risk for underfunding nutrition. This is owed in great part to the difficulty in delineating the proportion of activities and investments that directly or indirectly impact nutrition outcomes in sectoral budgets. Launched in 2010 the Scaling Up Nutrition (SUN) Movement constitutes a global movement to catalyze multisectoral approaches for supporting and financing a scale- up of nutrition programs (Wang et al. 2022; IFPRI 2016; Ruel and Alderman 2013; Fracassi et al. 2017). A landmark report published by the World Bank in 2010, Scaling Up Nutrition: What Will It Cost? made the first estimates of the cost of scaling up 13 proven nutrition interventions (modified from Lancet’s 2008 list) in 36 high burden countries (Horton et al. 2010). The 2017 World Bank report, An Investment Framework for Nutrition: Reaching the Global Targets for Stunting, Anemia, Breastfeeding and Wasting, went beyond such a package to estimate the cost of global nutrition targets, including the sustainable development goals (SDGs) targets, and estimated the nutrition financing gap (Shekar et al. 2017). This report found that every dollar invested in a core package of interventions would yield more than US$10 in economic returns. Estimates from Horton et al. (2010) ranged from a return of US$3.8 in the Democratic Republic of Congo to US$34.1 in India for each dollar invested in the set of nutrition interventions identified. Alderman, Behrman, and Puett (2017) estimated even higher returns if the investment is raised to reach more ambitious stunting reduction targets. These global estimates provide the rationale and encouragement for investing in nutrition. However, countries have only recently begun to identify activities that qualify as nutrition-relevant. This is a challenging task since nutrition line items in country budgets are often embedded in other budget line items, including those that fall in the health sector. The identification is even harder in other sectors. Therefore, there is not yet enough data to provide country level evidence of an impact of specific nutritional investments. Nevertheless, the importance of costing nutrition is an accepted prerequisite for investing in nutrition. The objective of this report is to provide such an estimate of these costs for Timor-Leste. As a parallel exercise, the authors identified nutrition line items in the 2019 budget and estimated a nutrition budget at US$44 million or 2 percent of the total 2019 budget. The intended audience of this report is not confined only to the government, development partners, civil society and other stakeholders in Timor-Leste. The report is also expected to serve as a reference document for other countries undertaking nutrition cost estimates. 12 Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security 2. Nutrition Policy in Timor-Leste In keeping with the SDG2 goal of ending hunger and malnutrition as a national priority, the SDG2 Consolidated National Action Plan for Nutrition and Food Security (CNAP-NFS) was developed in Timor-Leste by way of consensus and highlights the key nutrition promoting priorities (19 in total) of seven sectors to improve nutrition outcomes and end hunger and goes beyond a focus on stunting reduction alone. Figure 1 presents the CNAP-NFS priorities and the interventions covered under each sector. Each of the priorities and indicators where they exist are aligned with existing sector policies and plans. The seven sectors include ‘Health’ (under the Ministry of Health (MOH), hereafter referred to as the health sector); ‘Tourism, Trade and Industry’ (under the Ministry of Trade and Industry (MTI), referred to as the industry sector); ‘Education, Youth and Sports’ (under the Ministry of Education (MOE), referred to as the education sector); ‘Social Solidarity and Inclusion’ (under the Ministry of Social Solidarity and Inclusion (MSSI), referred to as the social inclusion sector); ‘Agriculture and Fisheries’ (under the Ministry of Agriculture, Livestock, Fisheries and Forestry (MALFF), referred to as the agriculture sector); and ‘Public Works’ (under the Ministry of Public Works (MPW), referred to as the public works or water sector), and ‘Equality and Inclusion’ which addresses gender disparities in a nutrition context across relevant sectoral interventions. The Ministry of State Administration and the Ministry of Finance play a coordinating and enabling role in the implementation of the sector priorities. The priorities included under each sector are outlined in Figure 1. Demonstrating a heightened understanding of the complex multisector nature of the nutrition situation and the need for greater investments to reduce the very high levels of undernutrition, Timor-Leste also joined the SUN Movement in September 2020. Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security 13 This costing analysis covers costing estimates for the period 2023-2030 for each of the sectors and also presents nutrition-specific and nutrition-sensitive cost categories. Most of the health sector priorities fall under the former category. While it is more straightforward to cost nutrition-specific interventions, costing nutrition-sensitive interventions, particularly food security, is challenging. UNICEF plans to undertake a detailed costing of the National Health Sector Nutrition Strategic Plan (NHSNSP) 2022-26, which outlines the baseline coverage and targets of nutrition indicators beyond the CNAP-NFS health priorities until 2026. CNAP-NFS also includes health priorities that are outside the remit of the Directorate of Nutrition, which is responsible for the delivery of the NHSNSP 2022-26. For those priorities that overlap, the cost estimates will be aligned. Figure 1. Priorities under SDG2 Consolidated National Action Plan for Nutrition and Food Security HEALTH TOURISM, TRADE AND EDUCATION, YOUTH SOCIAL SOLIDARITY INDUSTRY AND SPORTS AND INCLUSION Improve • Breastfeeding (early • Legislate food fortification • Keep girls and boys in • Strengthen the Bolsa da initiation, exclusively for 6 (e.g., rice and salt) school Mae program months and continued up • Support a nutrition-sensitive • Improve the school feeding • Provide nutrition-sensitive to 2 years or beyond) food marketing environment program (SFP) as a social support to poor households • Complementary feeding (e.g., International Code safety net and a nutrition with pregnant and lactating and promotion of healthy of Marketing of Breat milk education program women and children (age diets Substitutes) • Provide food-based 0-59 months) • Micronutrient nutrition education supplementation for students, teachers, • Integrated management of administrators, and school acute malnutrition feeding programs • Access to improved sanitation and hygiene • Access to contraception AGRICULTURE AND EQUALITY AND FISHERIES INCLUSION • Increase diversification and • Reduce gender-based sustainable intensification PUBLIC WORKS violence of homestead food • Ensure gender-sensitive production (including small • Improve access to safe nutrition promoting livestock) drinking water activities across all sectors • Increase fish production and consumption STATE ADMINISTRATION FINANCE • Support effective multisector coordination at subnational levels • Prioritize appropriate budget allocation toward activities to • Ensure SDG2 CNAP-NFS priorities are reflected in the budget achieve the SDG2 CNAP-NFS priorities and activities at subnational levels • Collect, analyze, and share data on progress against each priority on a regular basis 14 Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security 3. Approach to Costing This modeling exercise offers an indicative costing based on estimates of scaling up interventions to a targeted increase in coverage by 2030. It is based on the best (albeit limited) information available in the Timor-Leste budget books and the NHSNSP 2022-26. We do not cost the contribution of the different ministries to nutrition-enabling or governance activities as these costs could not be demarcated in the budget line items. We also do not cost the contributions of the Ministry of State Administration and the Ministry of Finance for the same reason and focus instead on the nutrition-sensitive and nutrition-specific contribution of the other sectors. Aside from presenting an indicative estimate of what it would cost to implement the CNAP-NFS in Timor-Leste, this analysis should be treated as a guide to understanding what data gaps exist to further refine estimates. Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security 15 There are two approaches to costing nutrition promoting interventions—the ingredients approach and the program experience approach. The former approach outlines all possible nutrition relevant interventions to be costed with details on the inputs necessary to roll out that activity, for example, the number of community health workers needed to deliver the intervention or the number of beneficiary visits to a health facility. The unit cost to supply the various inputs are applied and aggregated across the different components of the intervention to get the total cost of each intervention. The program experience approach uses median estimates of unit costs from programs operating in other countries. This is the approach followed in the Horton et al. (2010) report on the cost of scaling up nutrition as well as in Scott et al. (2020). We use unit costs estimated per beneficiary available in both Horton et al. for East Asia and Pacific and Scott et al. and apply a cumulative inflation factor to the costs, as applicable. We use Timor-Leste costs where available (for example, multiple micronutrient supplementation). This approach was used for all ‘nutrition-specific’ interventions aimed at providing a direct impact on nutrition. These are mainly health sector interventions. For the other sectors which provide indirect interventions that can impact nutrition and are classified as ‘nutrition-sensitive’, such as school meals, we use budget estimates to predict the future incremental cost. This is estimated as an indicative proportional increase in the nutrition-relevant budget based on available data and assumptions on baseline indicators of achievements and estimated target achievements of those indicators. For the unit cost approach, we estimated the number of beneficiaries for 2023 (the baseline year), from population estimates available from World Population Prospects 2019 projections (United Nations 2019). The costs are calculated based on the number of beneficiaries that are not receiving the intervention and require coverage. Data on current or baseline coverage and target coverage was obtained from the Timor-Leste Food and Nutrition Survey 2020 (TLFNS 2020), the National Health Sector Nutrition Strategic Plan (NHSNSP 2022-26), and the Timor- Leste Demographic and Health Survey (TLDHS) 2016, General Directorate of Statistics (GDS, MOH and ICF 2018). Assumptions were made where data was not available. We assumed that all costs calculated are incremental on the basis that programs have already begun implementation and require no additional startup costs. Costs are inflated to 2020 using the GDP deflator series for inflation in Timor-Leste available from 2000 and the Indonesia series prior to that year (World Bank 2022a). We used the higher end of unit cost estimates from the literature in our core indicative scenario to be conservative in our estimates. All costs are adjusted for a 1 percent inflation rate and population growth over the period 2023-2030 using the Timor- Leste World Population Prospects estimates (United Nations 2019). 16 Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security 4. Methodology This section presents the methods used to calculate costs by sector. The sectors included in CNAP-NFS as noted above are health, industry, education, agriculture, social inclusion and public works (water). Table 1 presents a summary of the unit costs, baseline and target coverage for output indicators used to calculate the costs. The methodology is limited by the data available from the literature, the government budget data, and the prevailing forecasts from the MSSI. Further refinement of the methodology would be possible with greater granularity in the budget data, providing subactivity level information. Likewise, once there is greater clarity in the amounts spent by the government in implementing nutrition programs, the unit costs could be revised to reflect the actual costs incurred in Timor-Leste rather than using the costs available in the literature. Figure 2 summarizes the interventions covered under the different CNAP-NFS priorities and the costing method used. Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security 17 Figure 2. Summary of costing methods by sectoral interventions Costed as: Costed as: “Unit cost per beneficiary” x “Number of beneficiaries” Proportional Increase in Activities Budget Needed to Reach 2030 Target HEALTH PUBLIC WORKS Behavioral change counseling • Safe drinking water access • Early initiation of breastfeeding, exclusive breastfeeding 0-5 mths • Complementary feeding, growth promotion, 6mth-2 yr • Minimum dietary diversity, women of AGRICULTURE AND reproductive age FISHERIES • Water sanitation and hygiene behavior change, 0-2 yr • Food security through increase • Teen pregnancies, birth intervals in homestead production and (nutrition sensitive) livestock and fish production Micronutrients and supplements • Iron and folic acid in pregnancy • Iron and folic acid for adolescent girls EDUCATION, YOUTH • Vitamin A supplements, 6 mth-2 yr AND SPORTS • Zinc and oral rehydration salts during diarrhea, 0-5 yr • Nutrition education • Deworming, 1 yr-5yr • Micronutrient supplement, 6mth-2 yr • RUTF severe wasting, 6mth-5yr • RUTF moderate wasting, 6mth-5yr Not Included Due to Policy Change TOURISM, TRADE AND INDUSTRY Micronutrient fortification SOCIAL SOLIDARITY • Salt iodization AND INCLUSION • Iron fortification of rice • Bolsa da Mae EDUCATION, YOUTH AND SPORTS Not Costed as Data Not Available • Minimum dietary diversity through school meals, elementary schools EQUALITY AND INCLUSION NUTRITION-SENSITIVE STATE ADMINISTRATION; FINANCE NUTRITION-SPECIFIC 18 Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security Health There are three broad categories of nutrition interventions administered under the health sector: social and behavior change counseling (SBCC), micronutrient supplementation, and the provision of ready-to-use therapeutic food (RUTF) for the treatment of acute malnutrition. The first category of interventions selected for costing (see Table 1) refers to providing counseling for social and behavior change. It includes: counseling for early initiation of breastfeeding (EIBF) aimed at pregnant mothers; exclusive breastfeeding (EBF) for the first six months (and continued breastfeeding); complementary feeding (CF) for children six months to two years old, promoting dietary diversity for women of reproductive age; improving water, sanitation and hygiene (WASH) behaviors focused on children aged under five years and prevention of teenage pregnancies; and promoting appropriate birth spacing. Although we have calculated the costs separately following Horton et al. (2010), these interventions are interrelated and synergistic and the target beneficiaries overlap in many cases. The delivery modalities, that is whether they are rolled out through community programs, health centers or individual counseling, may also overlap. As the finer details on the modalities become available, the costs can be revised for precision. In this report, we present an indicative costing and err on the side of being conservative in our estimates. The second category of interventions relate to micronutrient supplementation: two doses of vitamin A per year for children between 6 and 59 months of age; deworming twice a year for children one year to five years old; multiple micronutrient supplementation for children aged six months to two years; iron and folic acid (IFA) supplementation during pregnancy; and intermittent IFA for menstruating adolescent girls (aged 10 years to 19 years). The third category of interventions relate to the provision of RUTF to treat severe and moderate acute malnutrition. Table 1 indicates the target population, baseline coverage and unit cost used for each intervention. The annual cost is calculated as the unit cost times the number of additional beneficiaries from the target population reached each year for that intervention. The number of beneficiaries reached each year is in turn calculated as: percentage point increase in beneficiaries needed to reach the target coverage times the number of beneficiaries. We present cost estimates for a core conservative scenario where we employ higher unit costs or higher target coverage levels, as applicable. Given the uncertainty in the parameters used in the model—unit costs, baseline coverage rates, and target coverage rates—we also consider two alternative scenarios. One alternative scenario uses lower unit costs or lower target coverage in the case of sensitive sectors that use the proportional increase in program budget approach. The second alternative scenario considers a 15 percent higher unit cost or target coverage relative to the core scenario. Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security 19 Table 1. CNAP-NFS interventions: target beneficiaries, coverage, and unit costsa Unit cost Unit cost core alternative Target Target scenario scenario coverage coverage (per (per Target Number of Baseline core alternative beneficiary beneficiary Sector Intervention beneficiaries beneficiaries coverage scenario scenario per year) per year) NUTRITION-SPECIFIC Social and behavioral change counseling (SBCC): Early initiation of breastfeeding Pregnant mothers 41,078 10% 80% - $15 $11.30 Exclusive breastfeeding Pregnant mothers, for first 6 months and mothers of 19,301 10% 80% - $15 $11.30 continued breastfeeding infants <6m Caregivers of 6-23m Complementary feeding 18,288 10% 80% - $15 $11.30 old children Water, sanitation and Caregivers of 0-5y 217,694 10% 80% - $15 $11.30 hygiene (WASH) old children Dietary diversity 15-49y old women 337,324 10% 80% - $15 $11.30 Family planning to reduce teenage pregnancies and 15-49y old women 337,324 10% 80% - $15 $11.30 lengthen birth spacing Micronutrient supplementation Health IFAb supplementation Pregnant mothers 41,078 32% 70% - $13.80 $6.90 in pregnancy IFA supplementation for 10-19y old girls 151,123 1% 90% - $13.80 $6.90 menstruating girls Vitamin A (2 rounds per year) 6m-5y old children 198,394 78% 90% - $1.60 $1.36 ORSb + Zinc in diarrhea (cost adjusted for number of 0-5y old children 221,718 50% 70% - $3.08 $2.06 episodes per child in a year) Deworming (2 rounds per year) 1-5y old children 182,403 50% 90% - $0.70 $0.47 Multiple micronutrient 6-23m old children 18,288 19% 80% - $7 $5 supplementation Management of Acute Malnutrition Ready to use therapeutic 6m-5y old children 7,880 12% 80% - $266 $247 food for SAMb with SAM Ready to use therapeutic 6m-5y old children 14,346 10% 80% - $133 $123.50 food for MAMc with MAM Fortification Industry Salt iodization Population level 1.1 million 85% 90% - $0.19 $0.06 Multiple micronutrient Population level 1.1 million 5% 80% - $1.41 $0.98 fortification of ricec NUTRITION-SENSITIVE School lunch program 3-15y old 319,583 76% 85% 80% Education (Merenda Eskola) Other interventions in education 15% 80% 70% Public works Safe water access 65% 80% 70% Agriculture Food security 20% 80% 70% a See Annexure 2 for details on cost components and delivery platforms. Two alternative scenarios are also presented in the report given the uncertainty of the parameters used to estimate costs. The first alternative (shown in this table) uses lower unit costs or lower targets depending on the intervention and the second alternative considers 15 percent higher costs or coverage relative to the core scenario. b IFA: Iron and Folic Acid; ORS: Oral Rehydration Salts; SAM (severe acute malnutrition) and MAM (moderate acute malnutrition). More generally referred to as wasting (low height-for-weight), MAM is indicated when weight-for-height falls between -2 and -3 z-scores of the median WHO growth standards or a mid-upper arm circumference (MUAC) between 115 and 125 mm; and SAM refers to weight-for-height less than -3 z-scores, clinical signs of bilateral oedema of nutritional origin, or a MUAC of less than 115mm (WHO 2012). c Rice fortification plans to include iron and folic acid, B12 and zinc. 20 Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security Social and behavioral change counseling (SBCC) We cost counseling separately for sessions delivering a different message such as promotion of breastfeeding versus awareness on family planning. We use this approach because the preparation of the material for counseling and training of trainers will be different across these groups. This also provides conservative or higher cost estimates. The five categories of counseling sessions we consider are: (i) pregnant mothers and mothers of children up to six months of age for EIBF and EBF6; (ii) caregivers of children six months to two years old for CF; (iii) WASH behavioral change targeting households with children up to five years old; (iv) promoting dietary diversity among women of reproductive age (WRA), 15-49 years old; and (v) promoting awareness on family planning to reduce teenage pregnancies and increase birth intervals, also targeting all WRA. Target population and coverage The target population for counseling for promotion of EIBF is pregnant mothers, and for EBF until six months of age is aimed at pregnant mothers and mothers of babies under six months of age. For 2023, we estimate the total beneficiaries in the former group at 41,078 and the latter at 19,301 (half the number of one-year olds), bringing the total beneficiaries for these counseling sessions to 60,378. Counseling for CF sessions extends to mothers of 6-23 month old infants, estimated at 18,288 beneficiaries. Social and behavior change counseling promoting appropriate WASH practices is aimed at mothers of children 0-5 years of age or 217,694 beneficiaries. Counseling sessions for promotion of improved dietary habits among WRA and promotion of awareness of family planning to reduce teenage pregnanies and increase birth intervals is estimated to have 337,324 potential beneficiaries. The counseling sessions addressing pregnant mothers and mothers of children up to the age of two years are more often provided through mother support groups where these operate. Currently, limited counseling on nutrition is provided at antenatal care visits although there is evidence to support that delivering the messages and support simultaneously through a variety of platforms is most effective in improving results. A study in low- and middle- income countries (LMICs) found that early initiation of and exclusive and continued breastfeeding rates showed a significant and positive change when counseling was provided at home, in a community setting or through the health system. However, the impact was stronger when delivered in a combination of settings (Sinha et al. 2017). We did not find any reliable statistics on the current coverage of the different counseling services. However, discussions with development partners and civil society indicated that a number of organizations are providing nutrition information and counseling to the different groups listed above and in particular for EIBF, EBF and CF. Therefore, we made the assumption that the current level of coverage was 10 percent of the target population for these counselling services. We assume that Timor-Leste will attain 80 percent coverage of the target population group by 2030. Thus, over the eight years from 2023 to 2030, this would need a 10 percentage point incremental increase in coverage each year. As mentioned above, counseling for continued breastfeeding is also included in these sessions; we do not cost this separately. 6 Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security 21 Unit cost Using the East Asia and Pacific cost estimates reported by Mason et al. (1999) cited in Horton et al. (2010), community counseling sessions are estimated to cost US$7.50 per beneficiary. With an allowance made for inflation using the GDP deflator series for Timor-Leste available till 2020 (World Bank 2022a), the cost is estimated at US$15. An alternative lower cost scenario assumes a cost of US$11.2 per beneficiary annually using the Alive and Thrive estimates from Vietnam (Shekar et al. 2017).7 Iron and folic acid (IFA) supplementation Supplementation with iron and folic acid (IFA) during pregnancy prevents anemia and neural tube defects and has been found to reduce maternal mortality from postpartum hemorrhage (Allen 2000) and reduce the risk of low birthweight (LBW) by as much as 19 percent (Peña-Rosas et al. 2015). IFA in pregnancy is delivered through the primary health care system. Intermittent IFA supplementation is also recommended for menstruating adolescent girls to improve iron status and reduce susceptibility to anemia as recommended by the World Health Organization (WHO) (2016). Timor-Leste have commenced programs to administer IFA for adolescent girls in schools. Target population and coverage The number of pregnant mothers in 2023 is estimated at 41,078. According to NHSNSP 2022-20268, 32 percent of pregnant women currently receive 90 plus IFA tablets during pregnancy. The TLDHS 2016 estimate of actual intake is lower, at 13 percent. We model the costing based on number of IFA tablets received rather than consumed, and assume a target coverage set out in the NHSNSP 2022-26 of greater than 50 percent by 2026. We assume a target of 70 percent by 2030. Spread over eight years, this implies an increase in coverage of 9 percentage points each year from 2023 to 2030 or increasing the number of pregnant women who are covered by 1,966 each year. We use the target population for IFA supplementation in adolescent girls starting with the age of 10 years until 19 years. The supplements are given to girls who have commenced menarche. Since this program is in its infancy we assume one percent current coverage. The NHSNSP 2022-2026 sets a target of 80 percent coverage by 2026. Therefore, we assume that the coverage by the end of the 2023-2030 period will reach 90 percent. This is an optimistic target, but achievable since schools will be used as the platform of delivery. Unit cost Scott et al. (2020) report the unit cost for IFA supplementation in pregnancy at US$13.8 per pregnancy. The estimate reported in Horton et al. (2010) is US$2.0. Applying the cumulative inflation rate, the approximate estimate is US$6.9 per pregnancy. We use estimates from Scott et al. (2020) in our core scenario and use the lower cost as an alternative scenario. 7 We don’t use a cumulative inflation factor here as over this period there was deflation in Timor-Leste, which would not reflect the current prices post the COVID-19 pandemic. The GDP deflator series was not available beyond 2020 at the time of writing this report. 8 NHSNSP reports this percentage from monthly records of the Health Management Information System of the Ministry of Health. 22 Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security Vitamin A Vitamin A supplementation is known to reduce child morbidity and mortality and improve immune function. It should be delivered through the public health system biannually (Bhutta et al. 2013). Target population and coverage The target population for vitamin A supplementation consists of children six months to five years old. In 2023, the total number of potential beneficiaries in this group were 198,394. Vitamin A coverage reported in TLDHS 2016 is 64 percent. We use the current coverage estimated by the TLFNS 2020 at 78 percent for our modelling. The NHSNSP 2022-26 assumes a coverage of greater than 80 percent by 2026. For 2030, we assume a coverage of 90 percent. This indicates a deficiency of 12 percent in the target population coverage. Spread over eight years, this is a 1.5 percentage point increase in beneficiaries each year. With the total potential estimated beneficiaries of 198,394, this translates to reaching an additional 13,228 children annually. Unit cost The unit cost of vitamin A supplementation, including administrative costs is etimated at US$1.2 per child per year (Horton et al. 2010). Applying the cumulative inflation rate, the cost inflates to US$1.6 per child per year. Scott et al. (2020) estimates a unit cost of US$1.36. We use the higher unit cost of US$1.6 in the core scenario and the lower cost in an alternative scenario. Zinc supplementation in diarrhea Oral rehydration salts (ORS) and zinc supplements are regarded as cost-effective treatments for diarrhea in children and are administered during an episode of diarrhea. This regime reduces the severity and duration of an episode as well as the frequency of recurrence (Bhutta et al. 2013). Target population and coverage The target population for zinc supplementation during diarrhea are the number of children who report diarrhea in the 0-5 year age group, which was an estimated 217,694 children based on TLDHS 2016 and TLFNS 2020. Both reported diarrhea incidence of 15.2 percent over the last two weeks prior to the surveys in this age group. This translates to 0.15 episodes per child over two weeks or 3.95 episodes per child per year. Zinc and ORS consumption during diarrhea reported in TLDHS 2016 is 50 percent whereas NHSNSP 2022-26 reports 29.9 percent. We use the TLDHS 2016 baseline of 50 percent in the core scenario. The NHSNSP 2022-26 indicates a target coverage of 50 percent for 2026. We assume a 70 percent target by 2030. Given eight years to achieve the target, there will need to be a 3 percentage point increase in number of children with diarrhea treated with this recommended regime annually or 217,694 children in the 0-5 age group each year. Unit cost The cost of zinc supplementation with ORS for the course of each diarrhea episode is estimated at US$0.47 per course (Robberstad, et al. 2004 in Horton et al. 2010). Since there are 3.95 episodes per child per year, the annual cost for Zinc and ORS therapy would be US$1.86 per child per year. Applying cumulative inflation, the current unit cost would be US$3.08 per child per year. Scott et al. (2020) report a lower unit cost of US$2.06, used as an alternative scenario. Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security 23 Deworming Mass deworming protects against soil-transmitted helminth infections. Elimination of helminth infections is essential to allow optimal absorbtion of nutrients, to protect against anemia, and to promote growth and physical development of children. Target population and coverage The target population for this intervention is 1-5 years or 182,403 children. TLDHS 2016 reported a coverage of 50 percent and the TLFNS 2020 reported 71 percent. The target coverage reported in the NHSNSP 2022- 26 is greater than 80 percent by 2026. We assume a 90 percent target coverage. While previous evidence from other countries has shown low deworming coverage (Horton et al. 2010), Timor-Leste is optimistic in reaching the targets set since deworming is normally administered along with vitamin A supplementation and this program has been institutionalized for many years. Assuming a lower coverage rate of 50 percent reported in TLDHS 2016 to be conservative in our costing, the deficit in deworming coverage is 40 percent. This indicates increasing the beneficiaries by 5 percentage points or 5,442 children per year. Unit cost The annual cost suggested by Hall, Horton and de Silva (2009) in Horton et al. (2010) for two rounds of deworming per child is US$0.50 per year. Using cumulative inflation the current cost is estimated at US$0.70 per child per year. The average unit cost reported by Givewell (2021) for Vietnam is lower at US$0.47 with variations across countries. For example, in India the cost is US$0.05; in Kenya US$0.43; and in Nigeria US$0.65 per child. Thus, the costs we use are closer to those for Nigeria. We use US$0.47 in an alternative scenario. Micronutrient supplementation Multiple micronutrient powders provide supplementation with vitamins and minerals for infants and young children as well as pregnant women. In Timor-Leste, the micronutrient mix is called Mikronutrient Rahun, which is administered only to infants and young children under the age of 23 months. Target population and coverage In Timor-Leste, the target group for multiple micronutrient powder supplementation is 6 months to 23 months with an estimated 18,288 children. According to TLFNS 2020, the baseline coverage for this intervention is at 19 percent. The NHSNSP 2022-26 assumes a target coverage of 80 percent for 2026. We continue to assume an 80 percent target for 2030 given that the current baseline is relatively low. Thus, the coverage deficit based on this target is 61 percent. Over eight years, Timor-Leste would need to increase the coverage by 7.7 percentage points annually to reach the 80 percent target. This translates to extending micronutrient powder supplementation to an additional 1,399 children aged 6-23 months per year. Unit cost Horton et al. (2010) report a unit cost of US$1.8 per child per year, which inflates to US$2.39 when applying cumulative inflation. The unit cost reported in Shekar et al. (2017) is US$4.64 whereas Scott et al. (2020) also report a cost as high as US$53.24. Our personal communication with UNICEF and GoTL indicates a unit cost of US$7 per child per year for Timor-Leste, which we use in the core scneario. We use the figure given by Shekar et al. of US$4.64 for the alternative scenario. 24 Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security Ready-to-use therapeutic food (RUTF) for wasting RUTF is recommended to treat uncomplicated severe acute malnutrition (SAM) through home-based administration and is also used to treat moderate acute malnutrition (MAM) in Timor-Leste in a move toward using one product for both forms (WFP 2020). The RUTF used in Timor-Leste is called Plumpy’Nut. Both SAM and MAM are generally referred to as wasting (low height-for-weight). MAM is indicated when weight for height falls between -2 and -3 z-scores of the median WHO growth standards or a mid-upper arm circumference (MUAC) between 115 and 125 mm. SAM refers to a weight for height measurement of less than -3 z scores, clinical signs of bilateral oedema of nutritional origin, or a MUAC of less than 115mm (WHO 2012). Target population and coverage RUTF is given to chidren with SAM in the age group 6 months to 5 years (estimated at a total of 198,294 in 2023). In 2020, the prevalance of total wasting (SAM and MAM combined) was estimated at 8.6 percent (TLFNS 2020). The prevalence of SAM is reported at 1.5 percent and MAM 7.1 percent (TLFNS 2020). Shekar et al. (2017) apply a factor of 1.6 on the prevalence to account for annual SAM incidence. Applying the same incidence factor, the total annual SAM burden in Timor-Leste is estimated at 7,737 children aged 6 months to 5 years. Isanaka et al. (2021) suggest an incidence factor of 2.6 for settings with nonspecific data. Since this is not the case in Timor-Leste, we do not apply the higher incidence factor. MAM prevalence is estimated at 7.1 percent. Following Shekar et al. (2017) we do not consider an incidence adjustment for MAM. Current treatment coverage for SAM using “Plumpy’Nut” is estimated at 12 percent according to the review of the integrated management of acute malnutrition (IMAM) in 2018 (cited in NHSNSP 2022-26). The estimate presented in TLDHS 2016 is a little higher at 13 percent. We consider the 12 percent coverage in our core scenario. We assume 80 percent coverage by 2030. Thus, the discrepancy to meet that target is 68 percent, which indicates an incremental increase in coverage of 8.4 percentage points per year over eight years from 2023 to 2030 or increasing the number of children with SAM treated each year by 658. The baseline coverage for “Plumpy’Nut” consumption among those with MAM is estimated at 10 percent (TLDHS 2016), indicating a 70 percent deficit in reaching a target coverage of 80 percent. This implies an increase of 8.8 percentage points annually in coverage or treating an additional 1,197 children with MAM under the program. Unit cost Horton et al. (2010) use a unit cost of US$200 per child per year for the treatment of SAM. Adjusting for cumulative inflation, the current cost is estimated at US$266 per child treated for SAM, which is close to the unit cost reported in Scott et al. (2020) at US$247. We consider the US$266 cost in the core scenario and the global average estimate by Scott et al. (2020) as an alternative scenario. These costs include operational costs in addition to the market price of the therapeutic food. For MAM, we assume that the therapuetic food is adminsitered for half the period that it is given to those with SAM, which indicates a unit cost of US$133 per MAM child treated per year under the core scenario and US$123.5 under an alternative scenario. Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security 25 Industry The nutrition-relevant interventions that fall under the Ministry of Trade and Industry are universal salt iodization and fortification of rice. Food fortification through these channels is considered a cost-effective strategy to improve the micronutrient status of a population (see, for example, Keats et al. 2019) . Both the national salt iodization law and the food fortification standards in Timor-Leste are still in draft form. Salt iodization While much of the common salt is imported from Indonesia and is iodized, iodization of locally produced salt is not standard and the legislation is still in draft form (since 2014). Similar to the health sector interventions, the approach we use to calculate the cost of salt iodization is to apply a unit cost. Target population and coverage Currently, 85 percent of households in Timor-Leste have access to iodized salt (TLDHS 2016). The government plans to extend access to all households. We assume that the maximum coverage reached will be 90 percent, leaving a deficit of 5 percent between the baseline and target. This will require a 0.6 percentage point increment in the number of households reached annually over the eight-year period from 2023 to 2030. Applying this to the total population estimated in 2023, an additonal 54,891 people would need to be reached each year. Unit cost Salt iodization is estimated to cost US$0.06 per beneficiary per year adjusting for cumulative inflation over the period 2011 to 2020 following Horton, Wesley and Mannar (2011). At this cost, it is possible to reach 80-90 percent of the population. The cost of reaching the remaining population would be higher. The unit cost in Bangladesh is reported to be US$0.19 per beneficiary per year. We use the latter in our core scenario and the lower cost in an alternative scenario. Rice fortification Currently, Timor-Leste does not have standards for food fortification including micronutrient fortified rice. While fortified rice is being trialed in schools receiving imported USDA commodities, plans are in place to introduce legislation and policies to mandate this as one of the strategies to tackle micronutrient deficiencies. Target population and coverage We assume that coverage of fortified rice will reach 80 percent by 2030 if fortification is initiated in 2023, indicating a 10 percentage point annual increase in coverage to reach that target. Applying the annual increment to the population, 109,782 people would need to be reached each year. Unit cost Cost of rice fortification reported in Shekar et al. (2017) for Indonesia is US$1.41 per beneficiary per year, following Alavi et al. (2008). As an alternative scenario, we use a unit cost of US$0.98 per beneficiary per year estimated in a recent study for India (Qureshy, Alderman and Manchanda 2023). Rice fortification costs are higher than wheat flour fortification ($0.15 per beneficiary per year) because it needs to employ the extruder rice technology where a small proportion of rice kernels are pulversized and mixed with an iron compound, usually Ferric Pyrophosphate (FePP), and extruded to make fortified rice kernels that are then mixed with unfortifed rice kernels. 26 Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security Education We divide the costing for the education sector into the school lunch program that is costed using the unit cost approach and other nutrition education initiatives at schools, costed by estimating a proportional increase in the nutrition budget. School lunch program Target population and coverage There are four levels of education: pre-school (3–5 years), primary from Grade 1 to 6 (ages 6–11 years), lower secondary from Grade 7 to 9 (ages 12–14 years), and higher secondary from Grade 10 to 12 (ages 15–17 years) (GDS, UNICEF and UNFPA 2017; EPDC 2018). Our personal communication with GoTL confirms that the current school lunch program serves children in pre-school until Grade 9 (approximately ages 5–15 years). The current coverage (see Andrews et al. 2023) is 329,403 students of which 9,820 are pre-school beneficiaries and the remaining 319,583 belong to the category of basic education. Although the official age to start schooling is six years and the age for Grade 9 is 14 years, we accommodate for delayed commencement of schooling and include the 15 year old category in our calculations for school meals in order to be conservative. The total number of children aged 3–15 years is estimated at 428,093 in 2023 (using World Population Prospects 2019 projections for Timor-Leste, adjusted for population growth). When we discount this estimate by weighting the total number of children at each level with the 2018 enrolment rate for the primary level at 95 percent (World Bank 2022b), secondary level rate of 63 percent and enrolment ratio for those in pre-school at 25 percent in 2019 (World Bank 2022c), we get a lower estimate of children enrolled than those receiving school meals: 287,140 versus 319,583. This includes both private and public schools. We calculate the remaining coverage from the latter data on the number of children receiving meals. The percentage of children receiving a meal, relative to the total 3–15 year olds estimated, would be 319,583/428,093 or 75 percent. We assume that by 2030, 85 percent of the children will be covered. Thus, the remaining coverage is 10 percent. Assuming an eight year period from 2023 to 2030, this would result in a one percentage point increase in meals provided per year or an increment of 4,134 students per year. For those students who are already receiving a meal, we assume a target coverage increase in meal quality of 85 percent, amounting to an 11 percentage point increase over an 8 year period or 33,956 students per year. Unit cost The cost of meal per child, using the 2019 budget, was US$0.25 or US$48 per child per school year of 192 days. We calculate the cost of the program for those currently not covered at the rate of US$96 per child per year and for those already covered at US$48 per child per year to account for the additional cost of improved quality of meals. We assume a cost of US$0.50 per meal. For school lunch, we build scenarios using the target coverage reached. In our core scenario, we use a target coverage rate of 85 percent; in an alternative scenario we consider 80 percent and in the third scenario with a 15 percent higher coverage relative to core, we assume the coverage reaches 98 percent. Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security 27 Nutrition education and other behavioral change initiatives Aside from the school lunch program, there are a number of other initiatives, which contribute indirectly to improving nutrition outcomes. These activities identified among the education budget line items are: developing a program on reproductive and sexual rights in all levels of education; monitoring the implementation of the school lunch program in basic education; school health plan; and pedagogical garden project. The budget in 20199 for these activities was US$214,752 and was reduced to US$108,209 in 2022. Therefore, we assume an average budget for the two years at US$161,481 for our calculations. Given the limited information we currently have on baseline and target indicators, we assume that the current baseline is collectively on average 15 percent for the indicators addressed through the education sector nutrition- relevant activities. We base this tentatively on the information we have on the performance indicator baseline and 2022 annual target for the activity, ‘school health plan’, since the information we have from the annual plan is the clearest for this line item.10 The performance indicator listed for this activity is to estabish a health committee in every municipality. The annual target for 2022 indicates setting up the health committee in two municipalities of Manatuto and RAEOA. Out of 14 municipalities, this indicates a 2022 coverage of 15 percent. Assuming a target of 80 percent, this indicates a coverage deficit of 65 percent. While for the school health plan the unit to monitor progress is municipality, for the pedagogical garden activity, the performance indicator is measured in terms of the number of schools within a municipality that implement the pedagogical garden project. The target for 2022 is to have 29 schools in the municipalities of Baucau and Viqueque implementing the pedagogical garden plan. For a more detailed costing, we would need to have data on the total number of schools in these municipalities and how many are planned to be covered. Given that we do not have that granularity in the data at this stage, we assume that the plan has not been implemented in the remaining 11 muncipalities out of 14, and assuming we want to reach a target coverage of 80 percent of the municipalities (and schools) by 2030, it indicates a deficit of 65 percent. Since the nutrition relevant budget in education is estimated at US$161,481, scaling up this budget in proportion to the coverage deficit of 65 percent indicates a budget increase of US$699,749 over eight years from 2023 to 2030 or US$87,469 annually. We use 2019 and not 2021 budget data since this was the pre-Covid year and was not influenced by the particularity of the pandemic years. 9 The performance indicator listed in the 2022 budget for the activity, ‘developing a program on reproductive and sexual rights in secondary education’, is 10 the integration of the program in the new secondary education curriculum. The baseline reported for this indicator in the annual plan is 40 percent and the target set for 2022 is 60 percent. For monitoring the school lunch program, the indicator listed is ‘monitoring of classes’. The baseline indicated is 100 and the target is 130. However, it is not clear what the unit of measurement is. 28 Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security Public works Under the CNAP-NFS, the priority listed under MPW is access to safe drinking water. The percentage of households with safe drinking water in Timor-Leste is estimated at 89 percent in urban and 54 percent in rural areas. Using a weighted average with percentage of rural and urban population as weights, the national access to safe drinking water is estimated at 69 percent. For the core scenario, we assume that 80 percent of households will have access by 2030, indicating a remaining coverage of 15 percent. For one of the alternative scenarios we assume a lower target of 70 percent and for the other scenario we assume a 15 percent higher coverage relative to our core scenario or a 92 percent coverage. Under the budget for MPW, we filtered out activities under the program referring to the management of water resources and providing clean drinking water to reflect the sector’s contribution to nutrition. The activities selected are: developing and maintaining water supply systems in rural and urban areas; managing water resources; improving access to basic sanitation for households in rural areas; planning, developing, operating and maintaining sanitation systems in municipal centers and administrative posts; and planning, developing, operating and maintaining sanitation systems in Dili. In the absence of more detailed data, we assume that each line item listed above makes a 100 percent contribution to nutrition. With more information, it may be possible to break up, for example, an item like ‘planning, developing, operating and maintaining sanitation systems’ into a planning versus an operation and maintenance component where the latter would qualify as nutrition-sensitive but not the former. It would also be important to break up the costs into capital and recurrent expenditures by line item to understand how much of the expeniture would be made upfront in the initial years of investment and how much would be recurring. The current 2022 nutrition relevant contribution of MPW is US$17 million. This contribution corresponds to 69 percent of the population having access to safe drinking water. Scaling up the budget proportionally to reach the remaining 15 percent of the population by 2030 would cost another US$3.9 million or an investment of US$496,000 per year over 2023-2030. This would cover an additional 2 percent of the population each year. The current CNAP-NFS priorities enlist the provision of safe drinking water but not the planning, development and maintenance of sanitation systems. However, we include the latter in the nutrition estimate for this sector since the presence of and the functioning of sanitation infrastructure is a necessary prerequisite for WASH social behavior change interventions, costed under the health sector. Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security 29 Agriculture The Ministry of Agriculture, Livestock, Fisheries and Forestry (MALFF) identifies the attainment of a sustainable increase in production and productivity in specific subsectors of agriculture, horticulture, livestock, fisheries, and forestry in order to achieve food security and improved nutrition to fulfill the SDG2 of zero hunger. The sector, therefore, addresses an underlying determinant of nutrition outcomes, food security, to be accomplished through a sustainable increase in production of food crops and animal products, and providing access to consumers to increase consumption. A program has been assigned within the agriculture sector to address these objectives. The 2022 budget assigned for the program to address SDG2 was US$10.5 million, almost half of the total 2022 MALFF budget of US$23.5 million.11 Under this program, we examined each activity line item that would classify as being nutrition-relevant. We excluded salaries and wages for MALFF staff as well as items that referred to conservation of forests and biodiversity, and investment in agroforestry and commercial forestry (such as teak plantations), as well as investment in agricultural technical education. In line with MALFF priorities in CNAP-NFS, the relevant activity line items identified can be grouped under four categories: producing and supporting livestock for food security; production of food crops (line items referring to coffee production were not included); fish production; and promoting diverse consumption for improving dietary diversity. The budget associated with these activities alone is US$3,035,843, about 30 percent of the budget assigned to address SDG2 under the agriculture sector. The following activities fall under each of the following categories: Livestock for food Production of food crops security • Establishing integrated agriculture in potential irrigated areas • Establishing communal pastures • Developing and improving community horticulture and improving pasture lands • Providing subsidies to farmers for growing rice and maize and investing in and other activities that support horticulture livestock rearing • Supporting the cultivation of other food crops and promoting good • Supporting the acquisition of agricultural practices for rice and corn improved breeds of cows • Mobilizing groups or associations of farmers to increasingly use certified and • Investing in the general commercial seeds for food crops (rice, corn, vegetables, legumes, and tubers) treatment of farm animals • Supporting the initiatives of youth groups (women and men) in sustainably (buffalos, cows, pigs, goats, increasing crop production chickens, and others) • Rehabilitating, expanding, diversifying, and intensifying the planting of annual crops Fish production Promoting diverse consumption for improving dietary Developing the production of diversity Tilapia, breeding freshwater fish, • Promoting fish consumption for the improvement of the Timorese diet and the production of brackish • Developing agricultural associations to diversify local foods and supporting and marine water fish the nutrition program The baselines and targets indicated in the budget are not easily translatable. It is also not clear what the specific targets for 2030 are. The activity list above is varied and the measurement unit for the different indicators associated The remaining MALFF budget is assigned to good governance and institutional management. 11 30 Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security with the activities is different. For the core scenario, we assume on average an 80 percent target achievement by 2030 for all of these indicators. Further, we assume that the 2022 budget will allow achievement of 20 percent of the target set. The cost estimates can be revised if more detailed information is available to identify and precisely measure the current achievements in relation to targets. Thus, the 2022 nutrition relevant MALFF budget of US$3,035,843 is assumed to meet 20 percent of the 80 percent target set for 2030. To reach the remaining 60 percent, the budget would need to be increased proportionally or by US$9.1 million over the next eight years from 2023 to 2030 in our core scenario. This would imply an annual MALFF budget increase of US$1,138,441. In one alternative scenario, we assume a lower target coverage of 70 percent. In the other alternative, we assume a 15 percent higher coverage relative to our core case, reaching a coverage of 92 percent. Social Inclusion Cash transfers are regarded as nutrition-sensitive interventions aimed at alleviating poverty, improving household food security, and nutrition-promoting behaviors. In Timor-Leste the cash transfer program, Bolsa da Mãe (BdM ), was introduced in 2008 to enable poor women-headed households to address hardships by providing cash benefits on the condition that the identified child attends and successfully completes each level of schooling. BdM was extended as a universal and unconditional cash transfer program, named Bolsa da Mãe-Jerasaun Foun (BdM-JF ), with an explicit aim to improve nutrition among its beneficiaries; in particular, pregnant mothers and children under three years, thus covering the first 1,000 days of one’s life from conception to the second birthday, which is critical for preventing irreversible consequences of malnutrition. The BdM-JF program was originally planned to be rolled out in stages to cover the complete cohort of beneficiaries till they complete six years in every municipality by 2030, with a cash transfer allowance of US$15 per month for pregnant mothers and US$20 per month for children, and an additional allowance of US$10 per month for children identified with a disability; GoTL has announced a cancellation of the program in January 2024, followed by the increase in benefit level of the original BdM program. We therefore excluded the estimated costs for the entire Social Inclusion sector from the overall costing analysis presented in the Executive Summary and Section 5. The estimates shown below are only for illustrative purposes. A recent systematic review and meta-analysis found a significant i mpact of c ash t ransfer p rograms on reducing stunting, increasing the consumption of animal-source proteins, improving dietary diversity, as well as reducing diarrhea incidence (Manley, et al. 2020). Horton et al. (2010) refer to conditional cash transfers as a supportive program for encouraging improved nutrition at the household level. The supply cost of the conditional cash transfers in their study is estimated at US$294 per child per year (Horton et al. 2010). Using cumulative inflation for Timor-Leste this is approximately US$430 at current prices. Scott et al. (2020) estimate the annual cost per child at US$351. However, we use MSSI data to estimate the costs of expanding the existing BdM to cover the first 1000 days of life, as shown below, instead of applying the method found in the international literature. Including an operational cost of 10 percent, the average annual costs of expanding coverage of BdM to pregnant mothers and children under 2 years old for three years starting January 2025 is estimated to range between US$ 2.4 million (20 percent coverage) and US$ 4.8 million (40 percent coverage). This calculation used the MSSI data of projected beneficiaries of the BdM-JF and assumed a benefit level of US$8 per month which is the minimum one can receive under the recently-adjusted BdM program. This translates to a benefit level of US$96 per beneficiary per year. It is important to note that this costing excludes additional benefit for children with disability. Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security 31 5. Results and Discussion We discuss the total estimated cost of the CNAP-NFS over 2023-2030, the nutrition-specific and nutrition-sensitive split in cost, and the sectoral split of costs under the core scenario in Section 5.1. The costs for alternative scenarios are presented in Section 5.2. Total cost and its composition As seen in Figure 3, full implementation of the CNAP-NFS from 2023 to 2030 is estimated to cost US$55 million over the eight years, distributed across sectors including education, health, industry, public works (water) and agriculture. Interestingly, the education sector (43 percent) has the largest proportion of the total cost due to a large share by school meals alone (32 percent; US$17.9 million) which costs more than the entire health sector interventions (28 percent; US$15.6 million). Health is followed by agriculture (18 percent), public works (8 percent) and industry (2.5 percent). 32 Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security Figure 3. Distribution of CNAP-NFS costs across different sectors under the core scenario INDUSTRY EDUCATION, $1.4m OTHER (2.5%) US$6.2m (11%) WATER EDUCATION, US$4.4m SCHOOL MEALS (8%) US$17.9m (32%) AGRICULTURE US$10m (18%) HEALTH US$15.6m (28%) Figure 4. Nutrition-specific and nutrition-sensitive split of nutrition cost under the core scenario Total nutrition: US$55m Nutrition-sensitive: US$42m (77%) Nutrition-specific: US$13m (23%) High impact interventions The 2008 and 2013 Lancet Series and the recent Lancet systematic review and meta-analysis by Keats et al. (2021) recommend a set of interventions that have a strong or moderate evidence base of being effective in improving nutrition outcomes and are also cost-effective (see also Horton et al. 2010 and Shekar et al. 2017). These interventions fall under the health and industry (fortification) sectors. In Table 2 we list the 16 CNAP-NFS interventions for these two sectors. All but three of these interventions (counseling for dietary diversity among WRA, Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security 33 IFA supplementation for nonpregnant WRA, and treatment of MAM)12 overlap with those recommended by Lancet based on a strong or moderate evidence of being effective. Family planning and birth spacing is the most recent addition to these interventions and is considered a nutrition-sensitive intervention whereas all other interventions fall under the nutrition-specific category. Fourteen of the interventions are included under the health sector and only two fall under industry (salt iodization and rice fortification). Figure 4 provides a split of the total nutrition spending of US$55 million aggregated into the two broad categories of nutrition-specific and nutrition-sensitive. The former forms about a fifth of the total nutrition spending at US$13 million. Nutrition-sensitive interventions take up the remaining share at US$42 million). Table 2. CNAP-NFS interventions compared with the recommended Lancet interventions Whether in the list of recommended interventions in Lancet 2008, 2013, or 2021 with evidence of strong Intervention Target beneficiaries or moderate evidence Social behavioral change counseling (SBCC) for: 1. Early initiation of breastfeeding Pregnant mothers Yes, in all three 2. Exclusive breastfeeding for first 6 months Pregnant mothers, mothers Yes, in all three and continued breastfeeding of infants <6m 3. Complementary feeding Caregivers of 6-23m old children Yes, in all three 4. Water, sanitation and hygiene (WASH) Caregivers of 0-5y old children Yes, in all three 5. Dietary diversity 15-49y old women Not included 6. Family planning to reduce teenage 15-49y old women Included only in Keats et al. (2021) pregnancies and lengthen birth spacing Yes, in all three either as IFA or multiple 7. IFA supplementation in pregnancy Pregnant mothers micronutrient supplementation 8. IFA supplementation for menstruating girls 10-19y old girls Not included 9. Vitamin A (2 rounds per year) 6m-5y old children Yes, in all three 10. ORS + Zinc in diarrhea (cost adjusted for 0-5y old children Yes, in all three number of episodes per child in a year) 11. Deworming (2 rounds per year) 1-5y old children Not included in Lancet 2021 12. Multiple micronutrient powder supplementation 6-23m old children Yes, in all three 13. Ready to use therapeutic food for SAM 6m-5y old children with SAM Yes, in all three 14. Ready to use therapeutic food for MAM 6m-5y old children with MAM Not included Yes, in all three, as large 15. Salt iodization Population scale fortification for micronutrient deficiencies Yes, in all three, as large 16. Multiple micronutrient fortification of rice Population scale fortification for micronutrient deficiencies Horton et al. (2010) include treatment of MAM in their estimates. Dietary counseling and IFA supplementation for WRA are not included because the 12 evidence base is currently not as strong due to a smaller number of studies. 34 Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security As Figure 5 illustrates, the largest contribution to the cost among the CNAP-NFS interventions comes from family planning and birth spacing counseling and dietary diversity for WRA, taking up half of the total cost of US$17 million. This is primarily because of the large number of beneficiaries in these programs. WASH counseling follows next at 15 percent, which also covers a large group of beneficiaries from the age of 0-5 years. Treatment of SAM and MAM together make up 17 percent of the total nutrition-specific cost. Food fortification contributes a tenth of the total cost. Counseling for EIBF, EBF and CBF constitutes 4 percent of the costs and a 3 percent share is constituted by IFA supplements to WRA who are not pregnant. The remaining interventions, IFA supplements in pregnancy, vitamin A supplementation, zinc and ORS treatment during diarrhea, micronutrient supplementation, salt iodization, and deworming each form 1 percent less of the total nutrition-specific costs. Figure 5. Relative contribution of CNAP-NFS health and fortification interventionsa Teen pregnancies, birth intervals counseling. US$3,970,433 Dietary diversity counseling, WRA. US$3,970,433 WASH counseling. US$2,562,347 Therapeutic food, SAM. US$1,571,837 Therapeutic food, MAM. US$1,430,774 Rice fortification. US$1,280,185 EIBF, EBF, and CBF counseling. US$710,673 IFA supplementation for WRA. US$456,444 IFA supplementation in pregnancy. US$243,484 Complementary feeding counseling. US$215,252 Vitamin A supplementation. US$189,682 Zn + ORS suplementation. US$150,487 Nutrition-sensitive Nutrition-specific, additional in CNAP-NFS Micronutrient supplementation. US$87,988 Nutrition-specific recommended in Lancet Salt iodization. US$82,803 Deworming. US$57,914 a All interventions shown are high-impact and recommended in Lancet 2008, 2013 and/or 2021. Counseling for dietary diversity and IFA supplementation in WRA are currently not recommended because of fewer studies and weaker evidence. WRA: Women of reproductive age; WASH: Water, Sanitation, and Hygiene; SAM: Severe acute malnutrition; MAM: Moderate acute malnutrition; EIBF: Early initiation of breastfeeding; EBF: Exclusive breastfeeding; CBF: Continued breastfeeding; IFA: Iron and folic acid; Zn + ORS: Zinc and Oral Rehydration Salts. Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security 35 Alternative costing scenarios We consider two alternative scenarios, relative to the core scenario as noted above, given the uncertainty in the parameters used for costing the CNAP-NFS. These refer to the unit costs and target coverage: (i) lower unit costs for nutrition-specific interventions and correspondingly lower targets for the costing for the nutrition-sensitive sectors, based on budget projections, and (ii) 15 percent higher unit costs or target coverage, relative to the core scenario. The eight-year total cost for the component ranges between US$44 million and US$61 million under the three cost scenarios. Our core indicative scenario is estimated to cost US$55 million. The lower alternative cost scenario using a lower range of unit costs (relative to the core scenario) for nutrition-specific interventions and lower targets for nutrition-sensitive interventions is estimated to cost US$44 million. The higher alternative cost scenario is estimated at $61 million where we assume that all unit costs for nutrition-specific interventions and targets for nutrition- sensitive ones are 15 percent higher than the core scenario (Figure 6). Figure 6. Estimated CNAP-NFS costs under alternative cost scenarios Alternative scenario 1: Lower unit costs/target coverage US$44m Core scenario US$55m Alternative scenario 2: 15% higher costs/target coverage US$61m 36 Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security 6. Conclusion and Suggested Next Steps The CNAP-NFS is an ambitious plan to reach the SDG2 targets. We have provided an indicative costing estimate of the SDG2 CNAP-NFS for Timor-Leste. The total cost over eight years is expected to be US$55 million, approximately US$7 million per year and equivalent to US$5 per capita annually. This investment will be in addition to the 2019 nutrition budget estimate of US$44 million or US$34 per capita and amounts to a 15 percent increase in the 2019 nutrition budget.13 The incremental nutritional investment of US$5 per capita accounts for a 0.3 percent of the total GDP and a 0.4 percent of the non-oil GDP in 2019 and is a 15 percent increase from the 2019 nutrition budget. The total nutrition investment—existing (US$34) and projected incremental (US$5)—is a half of the current health sector per capita expenditure of US$80 (World Bank 2023). 13 This estimate was calculated by the authors from line budget items at the activity level for illustrative purposes. However, given the lack of granularity in the budget, nutrition budget items were not easily identifiable and this exercise needs to be revisited and strengthened. Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security 37 The high-impact interventions covered under Lancet (2008, 2013, and/or 2021) that overlap with the CNAP-NFS interventions will cost US$14 million over the eight years. Including two additional CNAP-NFS investments will add US$3 million. These investments relate to the health sector and food fortification under the industry sector and are also considered cost-effective. In order to ensure a sustained impact over the long term, many of these interventions will need to be complemented with investments in nutrition-sensitive sectors. Other interventions will need to be identified in the sectors (water, education, agriculture) that complement the high-impact interventions of the health and industry sectors to improve nutrition outcomes. Further, a growing body of evidence suggests that high-impact interventions, such as breastfeeding promotion, dietary counseling, dietary diversification, and prevention of severe malnutrition, can be rapidly scaled up and effectively reach the most vulnerable segments of the population through adaptive safety net programs (Gentili 2022). It is also essential to identify the current sources of finance and the funding gap to understand how much of the cost could be financed by the Government and how much could be contributed by development partners. Our work found that it was challenging to obtain unit costs for the different sectors. While some of these are available from a global evidence base for health interventions and fortification, we did not find unit costs for interventions in the other sectors that we have included in this costing (agriculture, water and education sectors, except for the school lunch program). Instead, we assumed a proportional increase in the current budget in order to expand current activities. While this model uses the best available information from the Timor-Leste budget books and existing baselines and targets for output indicators, which form the parameters on which the estimates are based, in order to improve upon the costing estimates going forward, we recommend the following:  Establish clear baselines across sectors: Baselines of output indicators (see Box 2) are not always available for both the nutrition-specific and nutrition-sensitive sectors. For the latter, the task is more challenging as it is even less clear which activity level indicators need to be tracked to get baseline output indicators for these sectors. Box 2. Data needs for costing Data needs for quantifying nutrition are better understood in terms of the components of a monitoring and evaluation system for nutrition: inputs, outputs, intermediate outcomes, and impacts or final outcomes (Levinson et al. 1999). Inputs and outputs refer to indicators collected routinely during project operations and feed into monitoring whereas outcome and impact indicators inform project evaluation. Inputs are the goods and services purchased with project funds and include such indicators as the number of iron and folic acid supplements procured or training of project staff in exclusive breastfeeding counseling. Outputs denote goods and services used by beneficiaries of the project and track coverage relative to baseline (prior to initiation of the project), for example, number of pregnant mothers receiving iron and folic acid supplements. Intermediate outcomes are an immediate result of the outputs of the project and may be in the form of a behavioral change measured, for example, as the percentage of women who adopted exclusive breastfeeding (relative to baseline) as a result of the project output. A number of such outcome variables collectively contribute to the final outcomes or impacts, corresponding to the objectives of the nutrition strategy and relate to how the intervention has impacted the nutrition status of the recipient population. An example is the anthropometric measure of height-for-age to identify stunting. 38 Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security  Establish clear targets across sectors: We assumed the target coverage for 2030 for most interventions. For the health sector, we assumed these were based on the targets set in the NHSNSP 2022-26, where these were available. However, for nutrition-sensitive interventions, many of the targets are not available or are unclear. Establishing feasible targets will also rest on having information on baseline indicators.  Obtain subactivity level details: The delineation of budget line items needed for the costing was based on activity level information available from the Timor-Leste Budget Books. However, many of the activity lines did not reflect nutrition budget alone. Greater granularity at the subactivity level will enable more precision in identifying budget and expenditure for the nutrition relevant sectors. In addition to the specifics on improving costing estimates, we suggest the following:  Revise estimates of nutrition budget: The estimate of the nutrition budget of US$44 million in 2019 was calculated by the authors from nutrition line budget items at the activity level. However, given the lack of granularity in budget, nutrition budget items were not easily identifiable and this exercise needs to be revisited and strengthened when subactivity level details are available in the budget data. Applying the recently developed nutrition-responsive budgeting guide (Piatti et al. 2023) would help strengthen such analyses. To address fiscal constraints we suggest:  Explore alternative strategies for nutrition-sensitive social protection: As global evidence suggests, nutrition-sensitive social assistance is one of the best-buy investments in reducing stunting and malnutrition, hence minimizing economic productivity loss of Timor-Leste’s future human capital. The government should consider maintaining investment in children and women by ensuring that social assistance supports are provided during the critical first 1000-day window (from conception until the child’s second birthday) and by guaranteeing the inclusion of the poor and vulnerable. Such evidence-driven approaches could allow for allocative efficiency of limited resources while maximizing the investment returns.  Consider an optimization exercise to allocate the budget across interventions: The government could consider using Optima Nutrition, a quantitative tool that helps to optimize the allocation of current or projected budgets across nutrition programs. The model also contains a geospatial component that can determine funding allocations that minimize stunting, wasting, anemia or under-five mortality at both the national and regional levels. Given fiscal constraints, such an exercise can help to identify the interventions and the allocations for those investments that would use the available funds in a cost-effective way (Optima Consortium for Decision Science 2021). 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Interlinkages among different nutrition categories to achieve optimal nutrition Framework for actions to achieve optimum fetal and child nutrition and development Benefits during the life course Morbidity and Cognitive, motor, School performance Adult stature Work capacity mortality in childhood socioemotional and learning capacity and productivity development Obesity and NCDs Nutrition-specific Optimum fetal and child nutrition and development Nutrition-sensitive interventions and programs and approaches programs • Agriculture and food • Adolescent health and security preconception nutrition • Social safety nets Breastfeeding, Feeding and • Maternal dietary Low burden of • Early child development nutrientrich foods, and caregiving practices, supplementation infectious diseases • Maternal mental health eating routine parenting, stimulation • Micronutrient • Women’s empowerment supplementation or • Child protection fortification • Classroom education • Breastfeeding and • Water and sanitation complementary feeding Feeding and caregiving Access to and use of • Health and family planning Food security, including • Dietary supplementation resources (maternal, health services, a safe services availability, economic for children household, and and access, and use of food • Dietary diversification community levels) hygienic environment • Feeding behaviors and stimulation • Treatment of severe acute malnutrition Building an enabling • Disease prevention and Knowledge and evidence environment management Politics and governance • Nutrition interventions in • Rigorous evaluations Leadership, capacity, and financial resources • Advocacy strategies emergencies Social, economic, political, and environmental context (national and global) • Horizontal and vertical coordination • Accountability, incentives regulation, legislation • Leadership programmes • Capacity investments • Domestic resource mobilization Source: Lancet 2013 (Available from: https://www.thelancet.com/pb/assets/raw/Lancet/stories/series/nutrition-eng.pdf. Accessed 07/29/2023) 42 Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security Annexure 2. Components of unit costs and delivery platforms for interventions sources from the literature Unit cost used in this Unit cost study = cost in original in original source per source, Assumptions and platform for beneficiary adjusted for Sector Intervention Scenario Source delivery used in original source (US$) inflation (US$) Delivery platform: Community health programs. Community nutrition programs are costed Social and at per child under 5 years of age assuming behavioral two children under 5 years of age per change participating mother. The program engages counseling community health workers who are linked (SBCC): Mason et al. Core to the primary health care system. Their 1999 in Horton 7.50 15 Counseling on scenario role is to help with community organization et al. 2010 breastfeeding, and provide counseling to households Health complementary and refer cases to the health centers as feeding, water, needed. They may also measure child sanitation growth but this is not their main role. and hygiene Majority of the costs comprise (handwashing), spending on nutrition education. dietary diversity and family Includes cost of individual or group- planning Alternative Shekar et based counseling sessions to promote 11.30 11.30 scenario al. 2017 exclusive breastfeeding delivered in the community and/or health facility. Micronutrient supplementation Delivery platform: Community health facilities. Core Includes commodity costs for 1 tablet per day Scott et al. 2020 for 6 months + 8 minutes of specific health 13.80 13.80 scenario provider time per pregnancy assumed to be supplied through community health facilities. Delivery platform: Health facilities Health Iron and and community programs. folic acid Unit costs are approximated on the basis supplementation of the unit cost of delivering iron and folic in pregnancy acid supplementation in antenatal visits Horton 1992 Alternative and captures the median cost of coverage in Horton et 2.00 6.90 scenario in 25 countries. The delivery costs are al. 2010 estimated to be 90 percent of the total cost of US$2 per pregnant woman. Community programs also support delivery. 90 percent of the cost is assumed to be for delivery. Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security 43 Unit cost used in this Unit cost study = cost in original in original source per source, Assumptions and platform for beneficiary adjusted for Sector Intervention Scenario Source delivery used in original source (US$) inflation (US$) We assume the same cost as for IFA supplementation in pregnancy. Note, however, that the modality for delivery in Timor-Leste will be through schools. The Core Scott et al. 2021 costs may be lower than those assumed here 13.80 13.80 scenario per beneficiary and should be considered a conservative high-end estimate until we IFA receive more detailed information on how the supplementation program will be rolled out in Timor-Leste. for menstruating girls We assume the same cost as for IFA supplementation in pregnancy as an alternative scenario. Note, however, that Horton 1992 Alternative the modality for delivery in Timor-Leste in Horton et 6.90 6.90 scenario will be through schools. We use this cost al. 2010 as an alternative lower unit cost scenario. Program data for estimates for delivery in Timor-Leste are currently not available. Delivery platform: Child health days. Study assumes supplement distribution on child health days shared with such interventions as deworming or through the primary health care system and also use a mixed approach with outreach (mini campaigns) Core Horton et Health to children 18–59 months of age who have 1.20 1.60 scenario al. 2010 completed routine vaccinations and will not Vitamin A (two be referring to the health care system. rounds per year) Cost of delivery is US$1.2 per child per year for two doses of Vitamin A. Cost of a capsule is US$0.02. Remaining costs are for delivery, accounting for 96 percent of the costs. Delivery platform: Health system Alternative Includes commodity costs (US$0.10 + 18 Scott et al. 2020 1.36 1.36 scenario minutes of specific health provider time per annum from the One Health tool. Delivery platform: Health centers. Cost of zinc supplements is US$1 per Oral rehydration Robberstad et al. child per year. Cost of each tablet is Core salts (ORS) + zinc (2004) in Horton US$0.02. Authors assume two to three 1 3.08 scenario supplements et al. 2010. episodes of diarrhea per year. in diarrhea (cost adjusted Delivery cost and tablet cost each for number of contribute 50 percent to total cost. episodes per Delivery platform: Health system. child in a year) Alternative Scott et al. 2021 Includes commodity costs (US$0.77 + 2.06 2.06 scenario 10 minutes of specific health provider time per case of diarrhea. 44 Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security Unit cost used in this Unit cost study = cost in original in original source per source, Assumptions and platform for beneficiary adjusted for Sector Intervention Scenario Source delivery used in original source (US$) inflation (US$) Delivery platform: Child health days. US$0.25 per child 24–59 months of age per round per year; number of rounds Hall et al. 2009 Core depends on prevalence of soil-transmitted in Horton et 0.50 0.70 scenario helminths in the soil. Assume two rounds. al. 2010 Delivery costs vary from 30 percent to 50 percent of the total cost of US$0.50 for two Deworming (two rounds depending on the age of the child. rounds per year) Delivery platform: Schools. Costs include teachers’ and principals’ allowances for deworming-specific trainings, Alternative cost of drugs, cost of prevalence surveys, cost Givewell 2018 of technical implementation assistance, costs 0.47 0.47 scenario of community education and sensitization campaigns: all costs of trainings to government personnel and others involved, and the cost of monitoring and evaluation. Timor-Leste Delivery platform: Community health systems. Core cost provided 7 scenario Includes cost of the micronutrients and delivery. by UNICEF Multiple Cost reported for micronutrient powders micronutrient (Sprinkles) supplementation for children from powder the Democratic Republic of Congo. A box of Health supplementation Alternative Shekar et 30 sachets of micronutrient Sprinkles costs US$0.86; each child receives 120 sachets per 5 scenario al. 2017 year; additional 25 percent for transportation costs US$0.31 per child for distribution of kits, identification of beneficiaries, establishment of community health structures, and supervision. Delivery platform: Community nutrition program for referrals and formal health system. Cost includes identification of children through primary health care; referral through community nutrition programs or child health days. Service delivery assumed through community-based management of acute malnutrition, and Core Horton et referrals are sent to primary health centers. 200 266 scenario al. 2010 Ready to use Food cost approximated between US$50- therapeutic 70 per episode sourced from local produce. food for SAMb Total cost of US$200 includes the cost of hospitalization for the small number of cases that may need it. For example, for one country in their sample this was about US$30-40 averaged over all cases. Delivery platform: Health systems. Alternative Costs include commodity costs (US$44.60 Scott et al. 2020 for material costs) and inpatient care costs 247 247 scenario + 200 minutes of specific health provider time per case of SAM on average. Ready to use Core Horton et Assumed half of SAM costs for 133 133 therapeutic scenario al. 2010 half the treatment time. Health food for MAMc Alternative Assumed half of SAM costs for Scott et al. 2020 123.50 123.5 scenario half the treatment time. Indicative Costing of Timor-Leste’s Consolidated National Action Plan for Nutrition and Food Security 45 Unit cost used in this Unit cost study = cost in original in original source per source, Assumptions and platform for beneficiary adjusted for Sector Intervention Scenario Source delivery used in original source (US$) inflation (US$) Fortification Delivery platform: Market-based. Core Costs include capital and operating cost Givewell 2018 for a continuous spray mixing plant and 0.19 0.19 scenario packing material. Costs of monitoring and evaluation are not included. Salt iodization Delivery platform: Market-based. Alternative Horton, Wesley, 20 percent of cost of US$0.05 per person 0.05 0.06 scenario and Mannar 2011 per year includes cost of ingredients and the rest is the cost of amortizing the capital equipment and processing costs. Alavi et al. 2008 in Shekar Delivery platform: Market-based. et al. 2017 Cost includes preparing the premix where (cost taken fortificants are added to a portion of from Shekar et the rice usually in a 1:100 ratio for the Core al. adjusts for Industry extrusion method. A third of the cost 1.41 1.41 scenario inflation on the is for premixing. The remaining cost cost presented covers blending with regular rice kernels, in Alavi et al. equipment, including capital and interest Details of costing costs. From our reading, monitoring and were obtained program evaluation costs are not included. Multiple from the original micronutrient source) fortification Delivery platform: Public of rice distribution system of India. Costs include technological costs of fortification, cost of the fortificants used, and cost of production of Fortified Rice Kernels Alternative Qureshy et (FRK) in a 1:100 ratio and its blending with regular rice, and depreciation as well as the 0.98 0.98 scenario al. 2022 annual interest on cost incurred by rice millers toward their investments for fortifying rice such as for facility upgradation, for example, for installing blending machines, and working capital. The estimate does not include the cost of program monitoring and evaluation.