The third episode of our Deeply Talks series came on the first anniversary of the release of the World Bank’s Investment Framework for Nutrition. The document was the first to set a price tag – $7 billion – on reaching the global malnutrition targets by their 2025 deadline. Meera Shekar, the report’s lead author, joined us to discuss how the framework has shifted the global discussion around nutrition financing.
Shekar, the global lead for nutrition with the bank’s health, nutrition and population global practice, said the framework has encouraged new funding from donors and new thinking about nutrition programming among government officials. But one year on, the nutrition community is far from realizing the full funding goal Shekar and her team set.
“We know in the world of development, you ask for $7 billion, you’re not going to get $7 billion tomorrow,” she said. “But if you aim for $7 billion over the next several years, perhaps gradually you can build that up.”
Even $7 billion might not be enough. Malnutrition Deeply talked with Save the Children about its report released last week calling for as much as $23 billion in financing, which would include nutrition-sensitive interventions. Talking to Andrew Green in this Deeply Talks episode, Shekar explains why the bank focused its framework on nutrition-specific interventions, while acknowledging the role multisectoral efforts can play.
You can listen to the episode here or read an edited and condensed transcript below, featuring highlights from the discussion with Shekar.
Malnutrition Deeply: It has been one year since the launch of the Investment Framework for Nutrition, which was really a landmark in quantifying nutrition financing. I’m hoping we might start just by talking about what led you to create the framework and the impact it has had in the past year.
Meera Shekar: About a decade ago, we released a report called “Repositioning Nutrition as Central to Development.” And soon after that there was a Lancet series on nutrition. And all of this has led to the argument that nutrition’s not just a welfare issue, it’s an investment issue.
The challenge was, when people came back to us and said, “OK. It’s an investment issue. How much do we need to invest and what will we pay for it?”
The investment framework really focuses on the evidence. What impact can we buy and what will it cost to get there? And the big picture message from that is really that we need about $7 billion a year, globally, from donor financing, domestic resources, which are absolutely critical, as well as innovative financing from groups such as the Power of Nutrition.
Now that seems like a lot of money: $7 billion a year. But if we think about the fact that the world is actually investing about $1.5 billion a day on agricultural subsidies, many of them that are not very productive subsidies, I think there are ways to achieve that $7 billion a year.
Malnutrition Deeply: When you’re talking about global donors and the international community, what was their response and have they risen to the challenge that was laid out in the framework?
Shekar: Yes. Nothing in development happens automatically. So it’s been a process. I think your listeners must be aware of the Nutrition for Growth events that have been organized since 2013. The idea of the N4G event was to get donors, as well as innovative financing sources and new financiers, as well as countries to pledge investments for nutrition. And this is where the framework has been extremely useful. Not only have new financiers come forth, but we’ve also seen domestic governments rising to the challenge to say, “Yes. This is an important issue, and we need to invest in this.”
Malnutrition Deeply: I know it’s still early days, but do you think the framework has helped to increase interest in the issue of nutrition and to reframe the way that people are thinking about it?
Shekar: Absolutely. And again, the reframing has been happening not just because of the investment framework, but because of the discussion, the dialogue around nutrition has changed dramatically.
Reframing this as something that is not just a welfare issue, but an investment issue, reframing it as not just a health benefit, but an issue of investing in economic benefit and investing in people to build human capital in countries that will drive the economies. That, I think, has really changed the dialogue around nutrition and investment in the early years.
Malnutrition Deeply: One of the other really unique aspects of the framework was the way that your team laid out how a certain level of investment would achieve a certain number of reductions in the different areas. What was the thinking behind that?
Shekar: There were at least two things that we considered when laying out those different packages. First was readiness for scale-up. There are some investments, some interventions that are ready to be scaled up now. And in most cases, countries are able to do this right away. So the only thing that is limiting there is having the resources in order to be able to scale those up.
Some of the other interventions need either a little bit more research or there is a need to build more capacity at the country level, so that they can scale these up.
Then of course, thirdly, we know in the world of development, you ask for $7 billion, you’re not going to get $7 billion tomorrow. But if you aim for $7 billion over the next several years, perhaps gradually you can build that up. That being the case, we developed three different scenarios. One, of course, if you had all the $7 billion that you needed right away, then this is what you would achieve. If you didn’t have the $7 billion, then perhaps, with $3.7 billion, which is almost half of that, you could still achieve a lot. And we really put a lot of focus on what you could buy with each of those. And then the third scenario was around $2.3 billion, which is really the core, basic minimum.
I do want to emphasize one other thing that I haven’t mentioned, which is that all of these estimates are estimates of financing that is needed over and above what is already being spent in these countries. So it’s not starting from zero.
Malnutrition Deeply: Turning to the country level, which countries are starting to do well in terms of stunting? And if you can give us some insight into why they’ve been successful?
Shekar: It’s been interesting to watch which countries are doing well. And I think many people on this forum have heard about how well Peru has done.
First and foremost, Peru has really focused on the evidence, which was the big push in the investment framework. It’s not just how much you invest, but how you invest, what you invest it in. If you invest in evidence-based actions, you can get impacts. And Peru has been a classic example of that. Senegal, similarly.
Interestingly, at the time the bank team started having a conversation with the government of Peru, they were spending between $200–300 million a year on “nutrition.” But many of those were not evidence-based investments. So over time the bank team worked very closely with the government and the leadership in Peru to reprioritize those existing investments and much of the impact that we’re seeing is not additional financing, but really reprioritizing toward the evidence. So that’s one thing. Focus on the evidence. That has really made a difference.
The second thing is around focusing on institutional arrangements and delivery mechanisms. In the case of Peru, we want to make sure that the interventions that are scaled up are scaled up (a) rapidly and (b) [with] high quality. And that’s only possible if you have strong institutions that are managing this and if we have strong mechanisms to deliver these investments.
In the case of Peru, there was a strong focus on what we refer to as results-based financing. And that really helped to push this along. In the case of Senegal, there was a strong focus on community-based delivery of services. So every country has a slightly different solution, but the important thing is to pay attention to delivery mechanisms and institutional arrangements.
And last, almost every country that has done well has focused on learning, adjusting program design as they go along, and linking that to some rigorous evaluation so that not just that country can learn, but other countries can learn from that experience as well.
Malnutrition Deeply: Circling back to the initial conversation we were having about the investment framework, now that it’s a year out what have been some of the key lessons learned from your perspective? And is that going to shift anything moving forward, in terms of looking to encourage new partners, to bring new people on board or to work with domestic government to increase their own investments in these areas?
Shekar: In terms of going forward, as you know, there is a huge movement on universal health coverage (UHC). And we’re trying to make sure that the investments that are highlighted, the nutrition-specific ones at least, that are highlighted in the investment framework are included under the UHC umbrella. That’s one.
Second, as we all know, the next N4G event will be in 2020 in Tokyo. So we need to make sure that we keep the focus on getting more domestic governments to invest. Donors need to come in, and as we highlighted in the investment framework, they need to kickstart this investment, and they seem to be doing so.
But in terms of sustainable financing, the solution lies with the domestic governments, and we see more and more governments coming forward to do that. But I think it will remain a work in progress.