Assessing Public Financing for Nutrition in Sri Lanka (2014–2018)

Nutrition directly affects a country’s human capital development and has a significant impact on economic growth and productivity. This is a growing concern for Sri Lanka, as the country faces a triple burden of nutrition. Despite good maternal and child health (MCH) indicators, undernutrition remains a major health challenge for Sri Lanka. The prevalence of wasting remained largely unchanged, and prevalence of stunting remained at 17.3 percent between 2006 and 2016 (DCS 2009, 2017). Though the high wasting rate has not resulted in high mortality of children, undernutrition is the single dominant risk factor of burden of disease for children under-five years of age, and childhood undernutrition increases the risk for noncommunicable diseases (NCDs) in later life.


Introduction
Nutrition directly affects a country's human capital development and has a significant impact on economic growth and productivity. This is a growing concern for Sri Lanka, as the country faces a triple burden of nutrition. Despite good maternal and child health (MCH) indicators, undernutrition remains a major health challenge for Sri Lanka. The prevalence of wasting remained largely unchanged, and prevalence of stunting remained at 17.3 percent between 2006and 2016(DCS 2009. Though the high wasting rate has not resulted in high mortality of children, undernutrition is the single dominant risk factor of burden of disease for children under-five years of age, and childhood undernutrition increases the risk for noncommunicable diseases (NCDs) in later life.
The changing disease pattern and the growing burden of NCDs in the country is also a concern. The share of NCDs in aggregate disability-adjusted life years (DALYs) increased from 52 percent in 1990 to 77 percent in 2019 (IHME 2021). More than a quarter of the disease burden for all ages can be attributed to nutrition-related risk factors, and overweight-which as the second arm of the triple burden of nutrition-is emerging as a major threat to health, especially for adults.
The third arm of the triple burden of nutrition is micronutrient deficiencies. A micronutrient survey conducted in 2012 showed that the overall prevalence of iron deficiency anemia was 7.4 percent in children age 6-59 months (MRI 2013). A survey conducted in 2015 showed that one in three pregnant women is anemic (MRI 2017).
Efforts to eliminate malnutrition require a welldesigned framework and coordinated implementation, led by a strong nutrition policy. The first nutrition policy in Sri Lanka was developed in 1986 and was followed by several revisions. The value of the policy, however, has • 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.
• diminished due to limited intersectoral coordination, changes in government priorities, and policies not being updated in line with socioeconomic and demographic changes. A National Nutrition Policy (NNP) was developed in 2010 to address this situation, and a corresponding strategic plan and action plans have also been developed. The NNP has five objectives: (i) to ensure optimum nutrition throughout the life cycle; (ii) to enhance the capacity to deliver effective and appropriate interventions; (iii) to ensure effective management of adequate nutrition to vulnerable populations; (iv) to ensure food and nutrition to all citizens; and (v) to strengthen research, monitoring, and evaluation. The NNP, which is in the process of revision for 2020-2030, reflects malnutrition in all stages of life, including presently neglected nutrition among elders. It is expected to place greater emphasis on multisectoral coordination and partnership while increasing the coverage of nutrition-specific interventions at the primary health care level.
Successive governments have taken measures to enhance the nutrition situation through a multisectoral approach. The first Multi-Sector Action Plan for Nutrition (MSAPN), 2013-2016, set the platform through multisector partnerships within the government, cutting across sectors 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 evidence-based interventions implemented by the Ministry of Health to improve maternal and child health and nutrition. The program provides the most widespread community-based health care services implemented through 354 Medical Officer of Health areas.
Public health services in Sri Lanka are provided free of charge at all levels, with island-wide coverage. The country has achieved relatively strong health indicators at low health system costs. Sri Lanka's life expectancy, recorded at 77 years in 2019, was higher than the South Asian average of 70 years (World Bank 2021). Despite the strong performance in health indicators, Sri Lanka's health 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 constitutes less than half of the country's total health expenditure, and in 2018 out-of-pocket health spending constituted 51 percent of total health expenditure (WHO 2021).
This study assessed Sri Lanka's public expenditure on nutrition programs and interventions over five years (2014-2018). The objective was to understand the size and share of public investments in nutrition in relation to the overall level of public expenditure in the country, and to assess whether the country's nutrition interventions are in line with global evidence and priorities set out in national policies.
The analytical method largely followed the three-step approach proposed by the Scaling Up Nutrition (SUN) movement. The first step involved identifying budget line items through desk reviews and stakeholder consultations and determining the scope of the exercise. The second step involved categorizing budget line items into nutritionspecific and nutrition-sensitive interventions. The third step recommended by the SUN methodology is the weighting of budget line items. In light of the subjectivity involved in the weighting process, weighting of nutrition-sensitive programs was not attempted in this study. Instead, step three in this study involved assignment of expenditure to different nutrition programs. A primary data collection exercise was conducted at central and provincial levels.

Key Findings EXPENDITURE ON NUTRITION INTERVENTIONS
Despite budgetary constraints, Sri Lanka has maintained a relatively stable level of investment in nutrition over the years. Between 2014 and 2018 the country's annual public investment in nutrition was around 5-6 percent of total government expenditure. This is relatively low compared to other countries in the region.

EXPENDITURE ON NUTRITION-SPECIFIC INTERVENTIONS
Nutrition-specific programs only accounted for 5 percent of TPE. On average, the government spends around LKR 5,000-8,000 per capita annually for nutrition-sensitive interventions versus LKR 550-600 per capita for nutritionspecific interventions. Notably, expenditure on nutritionspecific interventions continued to increase despite a substantial drop in nutrition-sensitive interventions in 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.

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 billion annually for nutrition-sensitive interventions, which accounts for around 5-6 percent of the general government expenditure. Around 92 percent of the investment in nutrition-sensitive programs is allocated to the Samurdhi Welfare Program, water, sanitation and hygiene (WASH), and the agriculture sector.

Limitations and Challenges THE MULTISECTORAL NATURE OF NUTRITION
The primary challenge noted during this study was the multisectoral nature of nutrition, and the resulting difficulties in collecting information from relevant sectors and consolidating it into a single platform. This situation was exacerbated by the challenge of communicating a clear definition for all sectors. Data collection was affected by the lack of consensus on what constitutes nutritionspecific and nutrition-sensitive programs, and in some cases, particularly with the nonhealth sectors, miscommunication complicated the process.

LIMITED AVAILABILITY OF DATA
The lack of a consolidated database and the fact that paper-based recording was widely practiced, especially for older data, resulted in difficulties in finding comprehensive data sets for over 10 years.

INTRODUCE STANDARD CODING
The study notes that a budget tagging mechanism, whereby line items are tagged for nutrition, would improve resource tracking. Budget and expenditure of programs and funding sources can be reasonably traced if institutions at all levels use a standard coding system with program names. Such a system would also prevent potential double counting when reporting to the central level.

UPGRADING DATABASES FOR ANALYSIS
The monitoring and evaluation functions of institutions could improve significantly if existing databases are upgraded to provide more flexibility in performing analysis. Following common formats and standardized good practices could enhance consistency and enable comparison of data.

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, costeffectiveness, 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 warranted given their current lower share compared to nutrition-sensitive programs. However, the effects could be undermined if underlying causes are not properly addressed; therefore, it is important to mainstream nutrition in all sectors for more voice in decision making.