Four lessons in nutrition resource tracking based on experience in Ethiopia
[Editor’s note: The upcoming Scaling up Nutrition (SUN) Movement Global Gathering in Côte d’Ivoire is an opportunity for SUN government focal points and representatives from civil society, development partners, academia, private sector and other partner areas to come together. It is also an opportunity for those working in nutrition budget analysis and expenditure tracking to take stock of progress, share lessons learned and success stories, and discuss what 2018 and beyond have in store. Members of the R4D nutrition team will take part in these discussions during the SUN Global Gathering’s Financial Tracking Workshop. In an effort to get a head start on sharing lessons learned, we’re offering these takeaways from our nutrition resource tracking analysis in Ethiopia.]
By Mary D’Alimonte, Jack Clift and Meghan O’Connell (of R4D) and Dr. Ferew Lemma, Ministry of Health and First Lady’s Office, Ethiopia
Ethiopia made a strong commitment to end under-nutrition by 2030 through the Seqota Declaration and, in this ambitious effort, every birr and dollar counts. So, it’s important for the Government of Ethiopia to monitor funding and progress toward scaling up evidence-based, lifesaving interventions.
R4D recently collaborated with Ethiopia’s Federal Ministry of Health to answer a few key questions: How much do public sector and development partners spend on nutrition across sectors in Ethiopia? And is this spending aligned with the objectives of the Ethiopian National Nutrition Programme II?
These questions are relevant for all countries that are scaling-up their plans to improve nutrition, but are limited in their ability to track and monitor off-budget development partner support toward those plans. Countries need to understand funding flows to nutrition by source, sector and region in order to allocate domestic funding strategically.
This is where resource tracking for nutrition fits in. Building a system to routinely generate data on what’s been budgeted and spent on nutrition can inform the annual budget process and help build a coordinated, multistakeholder resource mobilization plan for nutrition. This will help ensure that funding is directed to the right interventions and the right places.
Related Resource: Tracking Funding for Nutrition in Ethiopia Across Sectors
Mapping multisectoral nutrition investments and stakeholders
Based on our Ethiopia case study, we put together four tips to improve or streamline resource tracking for nutrition. These lessons learned provide insights for partners and SUN countries interested in engaging in a multisectoral expenditure tracking effort.
1. Put the needs of decision-makers at the center of the approach and calibrate level-of-effort and data granularity accordingly
At the outset of an expenditure tracking analysis, define the primary goals and how you expect key decision makers and end-users to use of the final data. This will inform the approach used to gather and analyze data.
For example, if the goal is to monitor progress toward costs in the national nutrition plan, it is important to categorize spending data in a way that aligns with, or can be mapped back to, cost categories. This allows for an “apples to apples” comparison of expenditures and resource need.
However, this doesn’t necessarily mean you need to collect data on spending at the intervention level. For example, instead of distinguishing between spending on vitamin A supplementation and iron-folic acid, it may be as or more useful to track all micronutrients together, and likely also easier for reporting. The bottom line is that it’s important to define the minimum data needs for policy and planning at the start.
In Ethiopia, it was important to align spending data with National Nutrition Programme II strategic objectives so that funding could be mapped to these objective areas and progress could be monitored.
2. Convene stakeholders around reporting standards for nutrition to build consensus on ways to track and report nutrition commitments and disbursements
A challenge for many countries is the ability to track off-budget funding for nutrition. Without this data, planners can’t tell whether disbursements are aligned with national priority areas as identified in the national nutrition plan.
With visibility into off-budget investments by the public sector, planners and policy makers can make better allocative decisions that lead to efficiency gains in service delivery. For example — enhanced targeting of funding to the highest impact interventions in areas of most need, making use of existing implementers and networks on the ground.
In Ethiopia, the resource tracking exercise captured investments made by 55 development partners. But for this to be a sustainable flow of data — for example, aiming to feed data into the annual budget and planning cycle — development partners need to commit to annual reporting.
Ideally, countries can come together with development partners and identify ways to track nutrition funding in a way that aligns with their internal systems, which will make routine monitoring and reporting more feasible.
3. Build upon existing expenditure tracking processes in-country to maximize information available for nutrition, such as the System of Health Accounts
At the time of R4D’s nutrition resource tracking analysis, the Ethiopian Ministry of Health was already fully engaged in a System of Health Accounts (SHA) expenditure tracking exercise in the health sector, so R4D partnered with the MOH SHA team to conduct the multisectoral nutrition expenditure tracking analysis. This partnership worked well because it leveraged existing processes and resources to enhance how existing resource tracking efforts can include nutrition.
There were some technical considerations that emerged when looking at the SHA with a nutrition lens in Ethiopia — and these may be helpful to other countries that implement a SHA and also plan to do nutrition resource tracking.
We found that investments in nutrition-specific interventions where the primary objective is to improve nutrition outcomes were comprehensively captured through a nutritional deficiencies disease code in the SHA. However, investments in nutrition interventions that are integrated within wider maternal or child health or infectious disease programs do not always have a designated code in the SHA framework, and therefore may not be categorized as nutrition expenditures in the SHA data. SHA estimates of nutrition expenditures in the health sector likely exclude nutrition-sensitive activities aimed at preventing malnutrition through broader health programs. It also does not include nutrition-sensitive activities outside of health.
Building capacity in two main areas could improve the ability of the SHA to produce estimates of total nutrition spending in health:
- Nutrition expertise of the technical team: Nutrition focal points can engage with the SHA technical team to enhance the ability of the SHA process to identify nutrition activities and code them accordingly, especially those integrated within broader health programs.
- SHA coding structure: Include a SHA code to identify nutrition expenditures that are integrated within wider health programs. For example, country teams could add health care function code(s) for nutrition in the prevention and public health services category.
Nutrition focal points in countries where a SHA is being conducted should consider contacting the Health Accounts focal point in their country to discuss how the analysis currently captures spending on nutritional deficiencies, and how it could be improved to better inform planning and budgeting for nutrition programs. A list of contacts is available here.
4. For nutrition-sensitive investments, aim to identify and track discrete components within multisectoral programs that are nutrition-sensitive
Because malnutrition has underlying determinants that span many sectors (e.g., food systems and agriculture, social security, education, water and sanitation, etc.), it is critical for every sector to implement programs that are nutrition-sensitive to tackle malnutrition in a multi-pronged approach. This means programs within each sector should incorporate nutrition goals, indicators and activities in their design to make them nutrition-sensitive and maximize impact on nutrition.
Resource tracking for nutrition-sensitive activities seeks to quantify these nutrition investments across sectors. However, identifying how much of the program disbursements to count for nutrition is not always clear-cut. In Ethiopia, the analysis relied on program managers and program guidelines to quantify nutrition-sensitive disbursements across sectors because financial tracking systems often do not provide this level of detail.
By identifying disbursements toward concrete nutrition components — for example, disbursements for trainings to build capacity of Agricultural Development Agents on food-based nutrition within an agricultural extension program — as well as total program disbursements, you can track which multisectoral programs are planning for nutrition, and which are actually disbursing funds to promote good nutrition.
It is critical to have buy-in and participation from all sectors in this analysis. As noted in lesson one, above, the discussion on use-cases should include stakeholders from every sector to ensure the tracking of nutrition-sensitive disbursements makes sense for planning within each sector.
Tracking Nutrition Investments: How much do governments invest in nutrition?
Budget Analysis for Nutrition: Guidance note for countries
Pathways to Better Nutrition Country Case Studies