Public Financing for Improving Nutrition Outcomes and Human Capital in Bhutan Key Messages • Recognition of importance of budget tagging against nutrition specific and sensitive interventions of the nutrition action plan • Per capita nutrition-related expenditures in Fiscal Year 2016-17: Nu. 2,003 (~US$29); 1% share of GDP and 3% share of total government expenditures • Increases in the levels of expenditure for nutrition have resulted from growth of the economy and not because of a higher share of the budget to addressing nutrition • Largest expenditures were those related to the national school feeding program and water, sanitation and hygiene -related interventions. • Need to prioritize financing for nutrition-specific interventions in the early years. • Nutrition action plan should consider prioritizing overnutrition in addition to undernutrition. Background feeding for children 6-59 months, provision of mid-day meals in schools, food fortification, ensuring availability of Despite progress in recent years, malnutrition – a key subsidized seeds and tools to improve kitchen and risk factor for human capital accumulation -- remains a community gardens, as well as investments in water and policy concern in Bhutan, especially in rural areas and in sanitation, among others. the eastern region of the country. Improvements in stunting in Bhutan will require increases in optimal infant Tracking and implementation of the nutrition action and young child feeding practices including early plan breastfeeding and exclusive breastfeeding for the first six months of life, attention to appropriate complementary One missing piece of information in the tracking and feeding during the 6-24 months period when child growth implementation of the nutrition action plan is that the falters, and treatment of childhood illnesses. Lack of dietary level and distribution of public financing for addressing diversity and low levels of nutrient-rich food intake have malnutrition is unknown. The availability of robust and contributed to the high rates of anemia and other regular financing data is essential for informing policy- micronutrient deficiencies among children under-five, making for addressing malnutrition, not only to increase children of school age, adolescent girls, and women. Lack of accountability but also, to enable adjustments so that funds adequate sanitation facilities in rural areas as well as poor can be prioritized and allocated efficiently and equitably. water and sanitation in health facilities are additional barriers Information on nutrition expenditures can also be an to achieving good nutrition outcomes in the country. important complement to enable an assessment of adequacy of financing by comparing expenditures with the estimated Bhutan’s expanded focus on malnutrition i n the 2018- costs of implementation so that any financing gaps can be 2023 12th five-year year plan is notable, and the country identified and filled. Bhutan is not unique in this regard: is currently tracking the implementation of a multi- estimating public financing specifically for malnutrition is a sectoral action plan that includes several activities that challenge given the multisectoral nature of interventions contribute directly (nutrition-specific) and indirectly aimed at addressing it. This brief summarizes estimates and (nutrition-sensitive) to improving nutrition outcomes. lessons learnt from application of the Scaling Up Nutrition These activities include revitalizing of the baby-friendly (SUN) methodology to assessing public financing for hospital initiative for early initiation of breastfeeding and nutrition in Bhutan. monitoring exclusive breastfeeding, micronutrient supplementation, strengthening of infant and young child Using Bhutan’s classification of nutrition interventions, feeding (IYCF) counseling, promotion of locally available in FY 2016-17, per capita public financing for addressing foods and recipes, improving quality of complementary malnutrition is estimated to be Nu. 2,003 (~US$29; 1% of 1 GDP; 3% of total government expenditures), 30% of which The ten largest interventions in terms of financing were for nutrition-specific activities, and about one-third the accounted for more than half of all nutrition-related level of public spending on health. The level of public spending. Central Ministry of Education (MoE)’s school spending for nutrition in Bhutan is similar in magnitude -- feeding program, early childhood care and development, and and in the shares across nutrition-specific and nutrition- special education needs programs were in the top ten, as sensitive interventions – when compared with other were several WASH-related interventions in urban and rural developing countries; recent estimates from Asia indicated areas as well as at the central and sub-national levels. Central an average of 2% of aggregate government expenditures Ministry of Health (MoH)’s vaccine-preventable disease went towards addressing nutrition, with a 20% share for program was the only nutrition-related health intervention nutrition-specific interventions. Despite the level of among the top ten; the remainder were either education- spending increasing from Nu. 1,744 in FY 2013-14, there related, WASH-related, or agriculture-related interventions. does not appear to be any increase in priority to nutrition The school feeding program is designed to reduce anemia over the course of the 11th five-year national plan: increases and improve nutrition among school-age children (6-18 in the levels of expenditure for nutrition have resulted from years). growth of the economy and not because of a higher share of the budget to addressing nutrition. Trends in public financing for top ten nutrition-related interventions Expenditure on nutrition-related activities (FY 2016-17) 100 Expenditure Per capita Share Share government Ratio Ratio Category (millions Nu.) (Nu.) GDP expenditure MoH MoAF Total nutrition 1,561 2,003 1.0% 3% 47% 23% Central 682 875 2% 38% 19% 80 Sub-national 879 1,127 7% 58% 29% District 549 705 4% 44% 38% Block 330 423 12% 119% 20% Share (%) Nutrition-specific 439 563 0.3% 1% 13% 7% 60 Central 417 535 1% 13% 12% Sub-national 22 28 0.1% 1.4% 1% District 19 25 0.2% 1.6% 1% Block 2 3 0.1% 0.8% 0.1% 40 Nutrition-sensitive 1,122 1,439 0.7% 2% 34% 17% Central 265 340 1% 15% 7% Sub-national 857 1,099 6% 57% 28% 20 District 530 680 4% 43% 37% Block 327 420 12% 118% 20% 0 Expenditures for nutrition are more decentralized than FY 2013-14 FY 2014-15 FY 2015-16 FY 2016-17 those for other sectors. Unlike the 70:30 breakdown of the Agriculture ECCD Other Reproductive health Rural WASH School WASH total government expenditures between central and sub- School health/nutrition Urban WASH Vaccines national governments, nutrition-related expenditures were split more equally between the central and sub-national levels, underscoring the importance of looking carefully at In terms of ministries/departments, MoE and the sub- district and subdistrict level spending for tracing public national departments of Urban Development & financing for malnutrition, especially for nutrition-sensitive Engineering and Health account for the largest shares of interventions. Among sub-national levels, district-level nutrition-related expenditures. Each accounted for about expenditures were much higher than those at the subdistrict one-fifth of all nutrition-related expenditures in the country. level. Detailed information was not available to determine Interventions that received financing via central MoH whether there was geographic convergence of nutrition accounted for roughly 7% all nutrition-related outlays. expenditures towards specific high-priority sub-national Ministry of Agriculture and Forestry accounted for 5% of all areas, although available information suggests this has not nutrition-related spending. These shares have remained been the case. stable over the course of the 11th five-year plan. Trends in public financing for nutrition-specific and Nutrition-related expenditures by ministry/department, nutrition-sensitive interventions FY2016-17 Per capita financing for nutrition 2,000 1,500 Nu. 1,000 500 0 FY 2013-14 FY 2014-15 FY 2015-16 FY 2016-17 Year Specific Sensitive Note: numbers are in 2016 constant Nu. 2 At ~85%, the absorption rate – i.e., the share of allocations as needed, assess where there may be absorption nutrition-related allocations that were expended – was problems, and identify areas where greater and more relatively high. Absorption rates for nutrition-related line- effective financing may be needed. It is better to items were slightly lower than the absorptions rates for the institutionalize such a budgetary line-item identification and entire government budget (90%) in FY2016-2017. tagging process rather than have this done as a separate one- Absorption capacity was lower (~80%) at the central level off activity. compared to sub-national levels (~90%). Prioritize Financing for Nutrition-Specific Interventions Absorption rates for nutrition-related interventions by in the Early Years. This includes prioritizing financing for ministry/department interventions including promotion of appropriate infant and young child feeding and maternal nutrition practices and increasing the coverage and quality of antenatal care. Given Central low coverage rates of early initiation and exclusive 100 breastfeeding and inadequate appropriate complementary feeding practices, more priority towards financing for 80 addressing these problems should be considered, both nationally and sub-nationally. Investments would be Absorption rate (%) 60 required to build capacity of health and other workers on behavior-change communication interventions and monitoring, and on the incidence of expenditures by 40 geographic region and target population. Currently, the largest financing for nutrition is for school-feeding programs 20 and for WASH-related interventions, neither of which are effective or cost-effective for addressing stunting among 0 MoWHS CRA MoAF GNHC MoE MoHCA MoH Total those under five. While feeding children in school is good to increase attendance and provide basic nutrition among other Sub-national reasons, it does not do much (if anything) to prevent or reverse stunting. It also misses the critical years when 100 anemia sets in at about 6 months of age, impacting cognitive development. 80 Absorption rate (%) Prioritize Overnutrition in Addition to Undernutrition. 60 Although problems related to undernutrition rightfully receive prominent policy attention in Bhutan, it would be 40 prudent to also address the growing burden of disease attributable to overnutrition. The ‘mal’ in malnutrition refers to both ‘over’ and ‘under’ nutrition, and the importance of 20 diet and exercise for addressing overnutrition will increasingly need to be prioritized in coming years. For 0 UDE Education Livestock Health Agriculture Civil Religion Forestry Total example, many countries such as Sri Lanka are beginning to implement fiscal and other modalities to reduce intake of sugar-sweetened beverages and of other forms of unhealthy Key policy messages consumption of food items as part of a broader program of activities aimed at addressing malnutrition-related health Assessing Public Financing for Nutrition Should be challenges. Institutionalized. Having action plans and strategies are not very meaningful if financing for them is not monitored and Raise Awareness about Malnutrition across Ministries. assessed. Hence, it is recommended that this activity be Finally, given the multi-sectoral nature of malnutrition, both institutionalized and conducted regularly in conjunction in terms of interventions designed to address it but also in with work on costing of interventions in order to ensure that terms of malnutrition’s impact on outputs of other sectors lack of financing is not a bottleneck for improving nutrition such as education and labor, it is key that awareness of this outcomes in Bhutan. Bhutan’s National Nutrition Task be raised to give nutrition a more prominent profile as a Force (NNTF) action plan is clear in terms of which cross-cutting development challenge facing the country and interventions are prioritized as well as which ministries and that this be made explicit in the strategies and action plans departments have the primary responsibility for the range of of the different ministries and local governments so that nutrition-specific and nutrition-sensitive interventions that accountability can be shared. are being implemented. It would be useful if, in future iterations, the NNTF action plan also tags and tracks This policy brief has been prepared by Shakil Ahmed, Manav annually relevant budgetary line-items that represent Bhattarai, Dorji Drakpa, Laigden Dzed, Mamata Ghimire, Pema allocations and expenditures for these interventions – both at Lhazom, Ajay Tandon, and Valerie Ulep, Health, Nutrition and the national and sub-national levels. This would make it Population Global Practice, World Bank, with kind support from the easier to monitor financing flows and make corrective South Asia Food and Nutrition Security Initiative (SAFANSI), 3