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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“We are excited to welcome Ghufron, Sania and Don to the R4D community,” said Gina Lagomarsino, president and CEO at Results for Development. “They bring exceptional experience and expertise, and they are committed to helping R4D carry out our mission of working with change agents around the globe to create self-sustaining systems that support healthy, educated people. I look forward to their counsel over the coming years, especially during this period of growth and new opportunities for R4D.”

All three of R4D’s new board members are change agents themselves — having worked on health system reforms in Indonesia, Pakistan and the United States, respectively. Sania and Don also have extensive experience launching and building nonprofits.

“Since R4D was founded in 2008, it has been guided by a distinguished group of people, including former heads of state and ministers,” said David de Ferranti, R4D’s founder, board chair and senior fellow. “I’m delighted to have Ghufron, Sania and Don join this group. They are great additions, and they have already provided valuable insights.”

Dr. Mukti is recognized for his expertise in health service quality, family medicine and epidemiology. He is the former Indonesian vice minister of health and the former dean of the faculty of medicine of Gadjah Madah University. He is also an early founding member of the Joint Learning Network for Universal Health Coverage (JLN).

Dr. Nishtar is an internationally acclaimed Pakistani physician and public health expert, and the former Minister of Health in Pakistan. She currently co-chairs WHO’s High-Level Commission on Non-communicable diseases along with the presidents of Uruguay, Finland and Sri-Lanka, and the World Economic Forum’s Global Agenda Council on the Future of Healthcare. In addition, she chairs the United Nations International Institute for Global Health’s Advisory Committee. She was a candidate for Director General of the World Health Organization in 2017.

Dr. Berwick is a leading authority on health care quality and improvement. He founded and led the Institute for Healthcare Improvement (IHI), a globally recognized nonprofit, for 19 years as the CEO. He serves as a lecturer in the Department of Health Care Policy at Harvard Medical School, and he is a former Administrator of the Centers for Medicare & Medicaid Services (CMS), appointed to this position by President Barack Obama. A pediatrician by background, Dr. Berwick has also served on the faculty of the Harvard School of Public Health, and on the staffs of Boston’s Children’s Hospital Medical Center, Massachusetts General Hospital, and the Brigham and Women’s Hospital.

Drs. Nishtar and Berwick recently served together as co-chairs of the National Academies of Science, Engineering and Medicine (NASEM) Committee on Improving the Quality of Health Care Globally and the two recently co-authored a report: Crossing the Global Health Care Quality Chasm: A Key Component of Universal Health Coverage.

View a full list of R4D board members.

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About Results for Development
Results for Development (R4D) is a leading non-profit global development partner. We collaborate with change agents around the world — government officials, civil society leaders and social innovators — to create strong systems that support healthy, educated people. We help our partners move from knowing their goal to knowing how to reach it. We combine global expertise in health, education and nutrition with analytic rigor, practical support for decision-making and implementation and access to peer problem-solving networks. Together with our partners, we build self-sustaining systems that serve everyone and deliver lasting results. Then we share what we learn so others can achieve results for development, too. For more information, visit our website at: www.r4d.org.

Homepage photo © World Economic Forum / Photo by Benedikt von Loebell

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Dr. Nishtar is the CEO of Gavi, the Vaccine Alliance. She previously co-chaired WHO’s High-Level Commission on Non-Communicable Diseases along with the presidents of Uruguay, Finland and Sri-Lanka. She also co-chairs the World Economic Forum’s Global Agenda Council on the future of healthcare and the U.S National Academy of Sciences’ global study on the quality of healthcare in low- and middle-income countries. In addition, she also chairs the United Nations International Institute for Global Health’s advisory committee.

Dr. Nishtar is the founder and president of the NGO Heartfile in Pakistan and has previously served as a federal minister in the Pakistan government in 2013. She was Pakistan’s nominee for director-general of the World Health Organization in 2017 and was in the final shortlist of three. Earlier she was also founding chair of the UN Secretary General’s Independent Accountability Panel for Women’s and Children’s Health and chaired WHO’s Commission on Ending Childhood Obesity. She has received many international awards for her work and is widely published.

Dr. Nishtar graduated from Khyber Medical University and was the top graduate in 1986. She is a Fellow of the Royal College of Physicians and holds a PhD from Kings College London.

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We know that early childhood personnel — preschool teachers, home visitors, community health workers — are critical in the lives of young children, but who are these workers and how can they be best supported? The Early Childhood Workforce Initiative (ECWI), a global, multi-stakeholder effort, has been working to generate new knowledge and resources to help policymakers and program managers better address these very questions.

To understand country priorities and ongoing efforts around the early childhood workforce, a team from Results for Development and the International Step by Step Association conducted 43 key informant interviews across 15 countries — Bangladesh, Brazil, Cote d’Ivoire, Ecuador, Georgia, Ghana, Jordan, Kenya, Moldova, Peru, Philippines, Singapore, South Africa, Sri Lanka, Zambia — earlier this year. We spoke with 28 country experts from implementing NGOs, multilaterals, and research institutions, and 15 policymakers, including program managers and government officials. This series of interviews helped us identify country priorities, learn about promising approaches, and gauge interest from policymakers and officials in piloting a needs assessment tool for diagnosing gaps and workforce needs.

Countries’ priorities surrounding the early childhood workforce, as well as their main challenges in offering workforce support were unique and context-driven. Nevertheless, we were able to deduce the following four, overarching takeaways from our interviews:

To read the full blog, click here.

Photo © Assistance in Building Afghanistan by Developing Enterprises (ABADE) Program/Sohrab Samanian

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What is the best model to bring healthcare to all? Our experts offer 11 ideas for increasing access to health services around the world

1 | Accept there’s no such thing as a ‘perfect healthcare model’

All healthcare models have their challenges in terms of systems capacity, fiscal space and good governance. I think the progress of countries like Thailand and Sri Lanka towards universal health is certainly laudable, but they each have different approaches to getting there. Thailand’s journey began incrementally and over the years through consistent investment in Primary Health Care (PHC). Meanwhile, India is more focused on achieving Universal Health Care (UHC) through mixed health markets featuring both public and private sector players. Priya Balasubramaniam, senior public health scientist and director, PHFI-RNE Universal Health Initiative, Public Health Foundation of India, New Delhi, India

2 | Have the same healthcare provider for the rich and the poor

If we have dual systems with the “national service” caring for the poor and the private sector caring for the rich, quality will be an afterthought. We need the rich and poor to be cared for by the same provider – this ensures that high quality will be a political priority as those with voting influence are directly affected by the quality of services provided. Jolene Skordis, director, UCL Centre for Global Health Economics, London, UK @JSkordis

3 | Give public-private partnerships serious consideration
The PPP model needs to be taken to scale in PHC in order to achieve UHC in a planned time frame. I have worked in many parts of the developing world and in general governments have not been able to step up. Now is the time to test new models as the old system is not working. We need a blended service delivery mechanism. We have to open up the insurance space and governments must push for universal insurance cover for all citizens. This is what we’re trying to do in Kenya. Siddharth Chatterjee, resident coordinator to Kenya, United Nations, Nairobi, Kenya @sidchat1 @UNDPKenya

To read the full article, click here.

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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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