Knowledge Brief Health, Nutrition and Population Global Practice Assessing Public Financing for Nutrition in Sri Lanka (2014–2018) October 2021 Key Messages • Relative to other countries in the region, Sri Lanka has invested modestly on nutrition programs and interventions. • Current nutrition programs in Sri Lanka need to be reviewed, both in terms of design and beneficiaries, and prioritized in terms of effectiveness, cost-effectiveness, and good practices. • The resource allocation for nutrition-specific interventions deserves revisiting, considering that these investments are driven by the nutrition agenda, and are more responsive to real needs. • Mainstreaming nutrition in other sectors is also necessary, to ensure more voice in decision making, and to strengthen multisectoral engagement and coordination in nutrition. • Targeted programs can be more cost-effective than blanket coverage as long as the targets are well selected, and a prioritization exercise is conducted to consider negative side effects. • Nutrition awareness-raising programs and educational and promotive activities may deserve more allocation. Introduction increased from 52 percent in 1990 to 77 percent in 2019 (IHME 2021). More than a quarter of the disease burden Nutrition directly affects a country’s human capital for all ages can be attributed to nutrition-related risk factors, development and has a significant impact on economic and overweight—which as the second arm of the triple growth and productivity. This is a growing concern for Sri burden of nutrition—is emerging as a major threat to Lanka, as the country faces a triple burden of nutrition. health, especially for adults. Despite good maternal and child health (MCH) indicators, undernutrition remains a major health challenge for Sri The third arm of the triple burden of nutrition is Lanka. The prevalence of wasting remained largely micronutrient deficiencies. A micronutrient survey unchanged, and prevalence of stunting remained at 17.3 conducted in 2012 showed that the overall prevalence of percent between 2006 and 2016 (DCS 2009, 2017). iron deficiency anemia was 7.4 percent in children age 6– Though the high wasting rate has not resulted in high 59 months (MRI 2013). A survey conducted in 2015 mortality of children, undernutrition is the single dominant showed that one in three pregnant women is anemic (MRI risk factor of burden of disease for children under-five years 2017). of age, and childhood undernutrition increases the risk for Efforts to eliminate malnutrition require a well- noncommunicable diseases (NCDs) in later life. designed framework and coordinated implementation, The changing disease pattern and the growing burden of led by a strong nutrition policy. The first nutrition policy NCDs in the country is also a concern. The share of NCDs in Sri Lanka was developed in 1986 and was followed by in aggregate disability-adjusted life years (DALYs) several revisions. The value of the policy, however, has Page 1 HNPGP Knowledge Brief • diminished due to limited intersectoral coordination, This study assessed Sri Lanka’s public expenditure on changes in government priorities, and policies not being nutrition programs and interventions over five years updated in line with socioeconomic and demographic (2014–2018). The objective was to understand the size changes. A National Nutrition Policy (NNP) was developed and share of public investments in nutrition in relation in 2010 to address this situation, and a corresponding to the overall level of public expenditure in the country, strategic plan and action plans have also been developed. and to assess whether the country’s nutrition The NNP has five objectives: (i) to ensure optimum nutrition interventions are in line with global evidence and throughout the life cycle; (ii) to enhance the capacity to priorities set out in national policies. deliver effective and appropriate interventions; (iii) to The analytical method largely followed the three-step ensure effective management of adequate nutrition to approach proposed by the Scaling Up Nutrition (SUN) vulnerable populations; (iv) to ensure food and nutrition to movement. The first step involved identifying budget line all citizens; and (v) to strengthen research, monitoring, and items through desk reviews and stakeholder consultations evaluation. The NNP, which is in the process of revision for and determining the scope of the exercise. The second 2020–2030, reflects malnutrition in all stages of life, step involved categorizing budget line items into nutrition- including presently neglected nutrition among elders. It is specific and nutrition-sensitive interventions. The third step expected to place greater emphasis on multisectoral recommended by the SUN methodology is the weighting of coordination and partnership while increasing the coverage budget line items. In light of the subjectivity involved in the of nutrition-specific interventions at the primary health care weighting process, weighting of nutrition-sensitive level. programs was not attempted in this study. Instead, step Successive governments have taken measures to enhance three in this study involved assignment of expenditure to the nutrition situation through a multisectoral approach. different nutrition programs. A primary data collection The first Multi-Sector Action Plan for Nutrition (MSAPN), exercise was conducted at central and provincial levels. 2013–2016, set the platform through multisector Table 1: Ministries Having Significant Responsibilities and partnerships within the government, cutting across sectors Programs Related to Nutrition for targeted action in the nutrition agenda. The MSAPN operationalizes the framework laid out in the NNP by enhancing the synergies between the different stakeholders involved in nutrition improvement. The second MSAPN being developed aims to improve on multisectoral collaboration and coordination, and to increase the momentum toward higher nutritional status of the population in line with the Sustainable Development Goals (SDGs) related to nutrition. Sri Lanka’s Reproductive, Maternal, Newborn Child, Adolescent, and Youth Health Program is a collection of Source: World Bank. 2020. Assessing Public Financing for Nutrition in Sri Lanka evidence-based interventions implemented by the Ministry (2014–2018). of Health to improve maternal and child health and nutrition. The program provides the most widespread Key Findings community-based health care services implemented EXPENDITURE ON NUTRITION INTERVENTIONS through 354 Medical Officer of Health areas. Despite budgetary constraints, Sri Lanka has maintained a relatively stable level of investment in nutrition over the Public health services in Sri Lanka are provided free of years. Between 2014 and 2018 the country’s annual public charge at all levels, with island-wide coverage. The country investment in nutrition was around 5–6 percent of total has achieved relatively strong health indicators at low government expenditure. This is relatively low compared to health system costs. Sri Lanka’s life expectancy, recorded other countries in the region. at 77 years in 2019, was higher than the South Asian average of 70 years (World Bank 2021). Despite the strong Table 2: Public Expenditure for Nutrition Interventions as a performance in health indicators, Sri Lanka’s health Percentage of Total Public Expenditure, 2014–2018 spending has been comparatively low. Public health expenditure as a share of gross domestic product (GDP) was 1.5 percent in 2018 but has gradually increased over the years (WHO 2021). Public spending on health Source: World Bank. 2020. Assessing Public Financing for Nutrition in Sri Lanka (2014–2018). constitutes less than half of the country’s total health expenditure, and in 2018 out-of-pocket health spending In 2018, the government spent approximately LKR 140 constituted 51 percent of total health expenditure (WHO billion for nutrition-related activities, a 25 percent fall from 2021). the LKR 188 billion in 2015 in real terms. Per capita nutrition expenditure in 2018 was LKR 6,441 Page 2 HNPGP Knowledge Brief (approximately US$39.6). Nutrition expenditure as a share blister packs to improve product quality and compliance of of GDP was 1.0 percent, and the share of nutrition the maternal care program. expenditure in total public expenditure (TPE) was 5.2 Figure 3: FHB Supplements by the MCH Program percent in 2018. The nutrition share of TPE has been declining gradually since 2015, indicating less attention to nutrition in more recent years. Figure 1: Per Capita Public Expenditure on Nutrition, 2014– 2018 Source: World Bank. 2020. Assessing Public Financing for Nutrition in Sri Lanka (2014–2018). Source: World Bank. 2020. Assessing Public Financing for Nutrition in Sri Lanka (2014–2018). Sri Lanka has three kinds of school nutrition programs: EXPENDITURE ON NUTRITION-SPECIFIC School Meal Program, Food for Education Program, and INTERVENTIONS Glass of Milk Program. The government spends around Nutrition-specific programs only accounted for 5 percent of LKR 5–6 billion annually for the government School Meal TPE. On average, the government spends around LKR Program, which is implemented in around 80 percent of 5,000–8,000 per capita annually for nutrition-sensitive government schools. The Glass of Milk Program is interventions versus LKR 550–600 per capita for nutrition- implemented in around 10 percent of schools not covered specific interventions. Notably, expenditure on nutrition- by the School Meal Program. specific interventions continued to increase despite a Figure 4: Per Child Public Expenditure for School and substantial drop in nutrition-sensitive interventions in 2018. Preschool Nutritional Program, 2018 Key nutrition-specific interventions in Sri Lanka include medicines and supplements provided through the national MCH program, the Thriposha program, and the School Meal Program. These programs account for 96.7 percent of the expenditure on nutrition-specific interventions. Figure 2: Public Expenditure on Nutrition-Specific Interventions Source: World Bank. 2020. Assessing Public Financing for Nutrition in Sri Lanka (2014–2018). EXPENDITURE ON NUTRITION-SENSITIVE INTERVENTIONS In all years, nutrition-sensitive programs accounted for over 90 percent of nutrition expenditure. Government investment in nutrition-sensitive interventions is almost 10 times as high as that for nutrition-specific interventions. The government finances approximately LKR 125–170 Source: World Bank. 2020. Assessing Public Financing for Nutrition in Sri Lanka billion annually for nutrition-sensitive interventions, which (2014–2018). accounts for around 5–6 percent of the general Note: MCH = Maternal and child health; IYCF = Infant and young child feeding; government expenditure. Around 92 percent of the IEC = Information, education, and communication investment in nutrition-sensitive programs is allocated to Public expenditure under the Family Health Bureau (FHB) the Samurdhi Welfare Program, water, sanitation and medicines/supplements in the MCH program increased hygiene (WASH), and the agriculture sector. sharply in 2018, chiefly due to the change in the micronutrient supplementation, with the introduction of Page 3 HNPGP Knowledge Brief • Figure 5: Public Interventions Expenditure on Nutrition Sensitive- Conclusion In Sri Lanka, a significant share of resources has been used by a small number of programs, which may or may not be the most effective interventions in reducing malnutrition. A rigorous prioritization exercise would be warranted by investigating the effectiveness, cost- effectiveness, and good practices of nutrition interventions, both nutrition-specific and nutrition-sensitive programs. The evidence of nutrition-specific interventions is generally more robust, and these interventions address the immediate determinants of malnutrition. As such, more investment in nutrition-specific programs would be Source: World Bank. 2020. Assessing Public Financing for Nutrition in Sri Lanka warranted given their current lower share compared to (2014–2018). nutrition-sensitive programs. However, the effects could be undermined if underlying causes are not properly Limitations and Challenges addressed; therefore, it is important to mainstream nutrition THE MULTISECTORAL NATURE OF NUTRITION in all sectors for more voice in decision making. The primary challenge noted during this study was the multisectoral nature of nutrition, and the resulting References difficulties in collecting information from relevant sectors DCS (Department of Census and Statistics). 2009. Sri Lanka Demographic and Health Survey 2006. Battaramulla: Department of and consolidating it into a single platform. This situation Census and Statistics and Ministry of Health, Nutrition, and Indigenous was exacerbated by the challenge of communicating a Medicine. clear definition for all sectors. Data collection was affected ———. 2017. Sri Lanka Demographic and Health Survey 2016. by the lack of consensus on what constitutes nutrition- Battaramulla: Department of Census and Statistics and Ministry of Health, specific and nutrition-sensitive programs, and in some Nutrition, and Indigenous Medicine. cases, particularly with the nonhealth sectors, IHME (Institute for Health Metrics and Evaluation). 2021. GBD Compare. miscommunication complicated the process. https://vizhub.healthdata.org/gbd-compare/. MRI (Medical Research Institute). 2013. National Nutrition and LIMITED AVAILABILITY OF DATA Micronutrient Survey 2012. Colombo: Ministry of Health, Nutrition, and The lack of a consolidated database and the fact that Indigenous Medicine. paper-based recording was widely practiced, especially for ———. 2017. National Nutrition Survey of Lactating Women in Sri Lanka 2015. Colombo: Ministry of Health, Nutrition, and Indigenous Medicine. older data, resulted in difficulties in finding comprehensive data sets for over 10 years. WHO (World Health Organization). 2018. Guideline: Implementing Effective Actions for Improving Adolescent Nutrition. Geneva: WHO. Recommendations ———. 2021. Global Health Expenditure Database. https://apps.who.int/nha/database/Home/Index/en. INTRODUCE STANDARD CODING World Bank. 2021. World Development Indicator. The study notes that a budget tagging mechanism, https://databank.worldbank.org/source/world-development-indicators. whereby line items are tagged for nutrition, would improve resource tracking. Budget and expenditure of programs This HNP Knowledge Brief highlights key findings from a joint study by the and funding sources can be reasonably traced if institutions World Bank and the United Nations Children’s Fund (UNICEF), “Assessing Public Financing for Nutrition in Sri Lanka (2014–2018)” by at all levels use a standard coding system with program Priyanka Jayawardena, Louise Moreira Daniels, Suganya Yogeswaran, names. Such a system would also prevent potential double Upula Vishwamithra, Safina Abdulloeva, Deepika Attygalle, and Hideki counting when reporting to the central level. Higashi, with technical support from Renuka Jayatissa, Yi-Kyoung Lee, and Ajay Tandon. Renu Warnasuriya provided support in summarizing UPGRADING DATABASES FOR ANALYSIS this brief. Financial support was provided by the UK Aid from the UK The monitoring and evaluation functions of institutions Government and the European Commission (EC) through the South Asia could improve significantly if existing databases are Food and Nutrition Security Initiative (SAFANSI) and the Government of Japan through the Japan Scaling Up Nutrition (SUN) Trust Fund. upgraded to provide more flexibility in performing analysis. Following common formats and standardized good practices could enhance consistency and enable comparison of data. The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, go to: www.worldbank.org/health. Page 4