Reaching the World Health Assembly targets for nutrition by 2025 will require substantial increases in funding from domestic governments and donor agencies over 2015 levels.

The Investment Framework for Nutrition, a collaboration between the World Bank, Results for Development and 1,000 Days, estimated that $4 billion in additional domestic contributions, and $2.6 billion in additional donor contributions would be required per year over 10 years to scale up a core package of high-impact nutrition-specific interventions. Using a detailed analysis of OECD-DAC data and program documents, we recently reported that the donor community is not only missing its target for increased spending in 2016, but has actually reduced funding for that core package of interventions below 2015 levels.

Are domestic governments picking up the slack?

Domestic spending on nutrition by low and middle-income countries has historically been difficult to track over time due to a lack of complete and reliable data on nutrition expenditures. The 2018 Global Nutrition Report reported a small uptick in budget allocations for nutrition-specific programs (and larger growth for nutrition-sensitive programs), using data collated by the SUN Movement Secretariat for 25 countries. However, as many countries routinely succeed in mobilizing and spending only a portion of what has been nominally allocated, budget allocations alone say more about aspiration than about material investments in critical nutrition programs. SUN budget data are important for civil society to advocate for governments to increase their ambition level, and provide broad information across all relevant sectors for nutrition. However, in most countries, it has not yet been possible to match these allocations against actual expenditures; and some SUN countries that represent a large share of global burden of malnutrition are not yet represented with trend data from the SUN budget exercise (e.g. Nigeria and Ethiopia).

A complementary data source for nutrition-specific program expenditure is the System of Health Accounts data gathered by governments supported by WHO and other partners. This comprehensive accounting of the health sector has been ongoing in a number of countries for many years, but only more recently have some countries routinely disaggregated expenditures to combat “nutritional deficiencies” from other priorities (see technical note below for more information on this method and its limitations). This provides a new opportunity to examine trends: 29 countries have relevant data for both 2015 and 2016, while another three (Cabo Verde, Ethiopia, Tunisia) have data for 2014 and 2016 that permit extrapolation.

The picture emerging from the data reinforces the challenges the nutrition community face in reaching the World Health Assembly targets — as well as the urgent need for renewed global commitment to financing key nutrition programs.”

Overall, across this set of countries, spending has not risen as we might have hoped. Of the 32 countries, only 12 saw any increase in spending, shown in blue in the figure below. Four countries (Sri Lanka, Samoa, Burkina Faso and Armenia) saw a drop of less than 2 percent. The remaining 16 countries saw more substantial declines, shown in red.

In absolute terms, the story is even more negative. We estimate that total domestic spending on health programs targeted at nutritional deficiencies across these 32 countries dropped from $221 million in 2015 to $183 million in 2016 — a drop of around 17 percent. This decrease was driven by very large absolute declines in Nigeria (dropping $25 million (from $46 million to $21 million) and Tanzania (dropping from $28 million to $17 million). In Nigeria, home to 2.3 million wasted children, that translates to a decline from $0.25 per capita to an even lower $0.11 per capita of domestic expenditure for nutrition within the health sector between 2015 and 2016.

When compounded with our earlier analysis demonstrating that donor financing for nutrition-specific programs may have dropped by 9 percent between 2015 and 2016, the overall financing picture for nutrition is alarming. Nonetheless, there are a few countries where the trend is more optimistic, notably Mali, which increased domestic spending on nutritional deficiencies from $2 million to $5 million between 2015 and 2016 (representing growth of $0.17 per person from an admittedly low base of $0.12 per person). Other positive stories are seen in Niger, Ethiopia and Côte d’Ivoire, all of which saw more than a $1 million increase; among smaller countries, Gabon and São Tomé and Príncipe both more than doubled their spending.

As we look toward Nutrition for Growth in Tokyo as a critical milestone for efforts to combat all forms of malnutrition, it is clear that global efforts must be redoubled to increase funding for critical nutrition programs. This requires strong leadership from nutrition champions in country governments and donor agencies driving enhanced resource mobilization efforts, buttressed by civil society advocacy and accountability efforts, and better leveraging of the private sector. While the overall picture on domestic financing we’ve described is disappointing, we must also grasp any opportunities to learn from successes — looking at countries who have succeeded in raising their funding for nutrition, but also reaching outside the nutrition community for examples of success in mobilizing domestic resources for other health priorities. We need to renew commitment and reinvigorate the conversation on domestic finance for nutrition, but we do not need to reinvent the wheel.

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NOTE: The SHA framework enables data to be internally consistent and comparable, while also avoiding double counting. However, there are some limitations when considering nutrition. First, the SHA framework captures expenditures within the health sector only and excludes expenditures for multisectoral nutrition programs outside of health. Second, within the health sector, the ‘nutritional deficiencies’ disease code (DIS.3) mainly captures direct nutrition-specific interventions, and it is likely to miss nutrition expenditures delivered through wider maternal and child health programs or infectious disease programs to avoid double counting. For example, a reproductive health program that includes expenditures on micronutrient supplementation would likely be coded as ‘reproductive health’ rather than ‘nutritional deficiencies,’ and it is not standard to split expenditures across both disease codes. Therefore, the data shown here may be an underestimate of total domestic expenditure on nutrition within health that would account for all types of nutrition investment, whether through direct programming or integrated within a wider program.

Photo © Morgana Wingard, USAID

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As many countries pursue universal health coverage in the context of rising incomes and plateauing or declining donor assistance, maintaining and expanding effective coverage of essential immunization services will require careful planning for sustainability within macro-fiscal constraints. The Learning Network for Countries in Transition (LNCT) will bring together practitioners from transitioning countries and development partners to learn from each other around specific Gavi transition-related challenges that exist within broader health system and UHC reform processes.

“Peer learning is an effective and efficient approach for supporting implementation across multiple countries. It responds to the immediate needs of countries and produces practical tools that are likely to be utilized,” said Gina Lagomarsino, president and CEO at Results for Development. “We’ve seen success with this approach through our work on other peer-to-peer learning network models, and hope to build a similarly active and engaged community of experts through this new platform.”

In the coming years, significant increases in domestic financing for immunization programs will be needed to expand and sustain immunization programs in low- and lower-middle-income countries. As a country’s economy grows, it crosses Gavi’s eligibility threshold and begins to transition out of support. Transitioning countries often face challenges in achieving high and equitable immunization coverage, and in planning, budgeting and securing adequate financing of their immunization program after Gavi support ends. Insufficient planning can lead to gaps in vaccine coverage, which in turn result in a rise of vaccine-preventable deaths and debilitating illnesses.

For Gavi-transitioning countries, LNCT offers the opportunity to share transition planning and implementation experience, work together to solve common problems, and add to a global knowledge base of tools and approaches that contribute to successful transition. For development partners, this platform offers the chance to engage across countries on transition-related issues. LNCT will consist of both in-person and virtual engagements. The initial cohort of platform members will draw from 13 invited countries in various stages of Gavi transition, with potential membership expansion in 2018 and 2019.

“The ultimate goal of this platform is to improve sustainability of national immunization programs,” said Meghan O’Connell, program officer and LNCT project lead at Results for Development. “More immediately, though, participation can help countries tackle specific technical challenges related to Gavi transition. This will reduce the chance that vaccines will be dropped after a country transitions away from Gavi support, increase the chance that coverage will be maintained or increased and ensure that countries have the skills and ability to introduce new vaccines in the future.”

The platform, which is funded by the Bill & Melinda Gates Foundation, will host its inaugural meeting in May to identify technical topics that can then be taken forward by the relevant countries for more focused engagement. The countries that will be represented at the launch meeting include Armenia, Congo, Georgia, Ghana, Indonesia, Lao People’s Democratic Republic, Moldova, Sudan, Sri Lanka, Timor Leste, Uzbekistan and Vietnam.

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The network — known simply as Linked — is co-led by Results for Development (R4D), the Tbilisi, Georgia-based Curatio International Foundation and the Sri Lanka-based Institute for Health Policy.

The network is a foundational part of the Gavi 5.0 strategy, which focuses on reaching “zero-dose” children and missed communities. Estimates suggest that by 2030, 70% of the world’s under-immunized populations will live in middle-income countries. Linked is one of the core mechanisms through which Gavi connects with, supports and influences key immunization change agents across 24 middle-income countries who have graduated from or never received Gavi’s financial assistance.

Since 2019, Linked has convened immunization practitioners, policymakers and partners from middle-income countries for a facilitated process designed to allow them to share experiences, identify common challenges to immunization programs and tap into one another’s implementation knowledge. Linked supports countries as they translate those learnings into locally driven solutions that are equitable, resilient and sustainable.

“We are so pleased that Gavi recognizes the benefits of this relatively low-cost approach to engaging immunization program leaders across many countries and supporting them to drive their own progress. We are delighted to continue our collaboration with Gavi,” R4D CEO Gina Lagomarsino said.

Linked’s two-year extension will build upon the network’s initial successes, which were catalogued in an impact brief. This brief offers evidence of meaningful policy and program impact through the Linked network.

“At R4D, we have been honing our collaborative learning approaches over the past 15 years. We’re thrilled that Linked has provided solid evidence that collaborative learning contributes to critical health outcomes,” said Program Director Elizabeth Ohadi.

Linked Impact Brief

Discover how Linked's collaborative learning approach is accelerating countries' progress toward improving access to lifesaving vaccines.

Read more

Eleven Linked member countries have developed plans to translate learnings from Linked engagements to actions which strengthen their immunization programs — and nearly 90% of network countries with an action plan say they have made progress in implementation.

The learnings from Linked engagements have supported countries to strengthen the implementation of immunization program activities to improve coverage and equity, including the development of a cost-effectiveness study for the introduction of the HPV vaccine in Tunisia; strengthening the interpersonal communication skills of immunization providers in Uzbekistan; the development and operationalization of a strategy for caregiver education in Vietnam; and the integration of a zero-dose reporting mechanism in the national immunization registry in Armenia.

In a 2023 member survey, 100% of Linked member countries reported being highly satisfied with the technical quality of learning activities and resources, and more than two-thirds (71%) agreed that Linked has contributed to their progress toward sustainable and equitable immunization coverage and the sustainable introduction of new vaccines.

“Facilitating knowledge transfer and peer-to-peer exchange of good practices and lessons learned is a proven way to drive better immunization performance, as demonstrated by Linked,” said Ivdity Chikovani, research unit director at the Curatio International Foundation. Chikovani is also Linked’s country outreach lead for health policy and systems expertise.

“During the next two years, Linked will continue to provide a learning space between countries from different regions, embracing diversity and innovation,” Chikovani added.

Linked will pilot a new subnational peer learning platform in Indonesia in its next phase. It will also transition its focus from regional engagements to cross-regional and global learning engagements.

Learn more about Linked here.

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About Results for Development
Results for Development (R4D) is a leading nonprofit global development partner. We collaborate with change agents — government officials, civil society leaders and social innovators — supporting them as they navigate complex change processes to achieve large-scale, equitable outcomes in health, education and nutrition. We work with country leaders to diagnose challenges, co-create, innovate and implement solutions built on evidence and diverse stakeholder input, and engage in learning to adapt, iterate and improve. We also strengthen global, regional and country ecosystems to support country leaders with expertise, evidence, and innovations. R4D helps country leaders solve their immediate challenges today, while also strengthening systems and institutions to address tomorrow’s challenges. And we share what we learn so others around the world can achieve results for development too. www.R4D.org

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