MASTER DI 2013 Aid to nutrition - 14052013 MDCdevinit.org/wp-content/uploads/2013/07/Development... · 2015. 2. 9. · 6! ! However,!the!distribution!of!aid!for!nutrition!amongst!the!36!countries!does!not!reflect!

The Aid Financing Landscape for Nutrition

April 2013

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Author: Mariella Di Ciommo Editor: Ian Townsend Publisher: Development Initiatives Contact: [email protected]; [email protected] This is the second published version of this report and incorporates comments from our readers. Acknowledgements The author would like to thank colleagues who contributed to producing this report with their time, professional skills and advice – in particular, Tom Berry, Harpinder Collacott, Dan Coppard, Sarah Hénon, Hilda Kalap, Laura Jump, Neil Watkins and Rhys Williams. She would also like to thank the New Venture Fund for providing funding for this project, and donor country and multilateral agency officials whose review and commentary helped develop the report further: Mags Gaynor, Alexandre Ghelew, Elizabeth Jordan-‐Bell, Elisabeth King, William McCormick, Anne Peniston, Ellen Piwoz, Kikuchi Taro and Anna Taylor.

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Table of contents

EXECUTIVE SUMMARY ................................................................................................................... 5 1. INTRODUCTION ....................................................................................................................... 7 2. THE CHALLENGE OF UNDER-‐NUTRITION ....................................................................... 8 2.1. KEY FACTS ABOUT UNDER-‐NUTRITION ............................................................................................. 8 2.2. THE DISTRIBUTION OF UNDER-‐NUTRITION ...................................................................................... 9 2.3. MEETING MDG1 – PROGRESS BY REGION ..................................................................................... 11 2.4. THE POLICY CONTEXT ........................................................................................................................ 12

3. OFFICIAL DEVELOPMENT ASSISTANCE (ODA) TO NUTRITION ............................ 14 3.1. GLOBAL TRENDS IN ODA TO BASIC NUTRITION AND FOOD AID ................................................ 14 3.2. NUTRITION COMPONENTS OF NON-‐NUTRITION PROJECTS ......................................................... 20

4. FUNDING NEEDS FOR NUTRITION .................................................................................. 23 4.1. NUTRITION BURDEN AND ITS GEOGRAPHICAL DISTRIBUTION ................................................... 23 4.2. FUNDING NEEDS FOR NUTRITION .................................................................................................... 24 4.3. ODA AND NUTRITION NEEDS ........................................................................................................... 28

5. ODA DONOR PROFILES ....................................................................................................... 33 5.1. BELGIUM .............................................................................................................................................. 33 5.2. CANADA ............................................................................................................................................... 38 5.3. DENMARK ............................................................................................................................................ 43 5.4. FRANCE ................................................................................................................................................ 48 5.5. GERMANY ............................................................................................................................................ 53 5.6. IRELAND ............................................................................................................................................... 58 5.7. ITALY .................................................................................................................................................... 63 5.8. JAPAN ................................................................................................................................................... 68 5.9. NETHERLANDS ................................................................................................................................... 72 5.10. NORWAY ........................................................................................................................................... 77 5.11. SPAIN ................................................................................................................................................. 82 5.12. SWEDEN ............................................................................................................................................ 87 5.13. SWITZERLAND .................................................................................................................................. 91 5.14. UNITED KINGDOM ........................................................................................................................... 95 5.15. UNITED STATES ............................................................................................................................. 101 5.16. EUROPEAN UNION INSTITUTIONS .............................................................................................. 106 5.17. INTERNATIONAL DEVELOPMENT ASSOCIATION ...................................................................... 110 5.18. UNICEF .......................................................................................................................................... 113 5.19. WORLD FOOD PROGRAMME ........................................................................................................ 116 5.20. THE BILL &MELINDA GATES FOUNDATION ............................................................................. 121

6. METHODOLOGY: ASSESSING ODA TO NUTRITION .................................................. 126 6.1. BASIC NUTRITION AND FOOD AID .................................................................................................. 127 6.2. NUTRITION-‐RELATED ODA ........................................................................................................... 128 6.3. IMPUTATION OF MULTILATERAL ODA TO SECTORS .................................................................. 129 6.4. DOMESTIC EXPENDITURE FOR NUTRITION .................................................................................. 130

7. ANNEXES ............................................................................................................................... 131 ANNEX 1: UNDERNOURISHED PEOPLE BY COUNTRY .............................................................................. 131 ANNEX 2: REASONS FOR WEAK COMMITMENT TO NUTRITION PROGRAMMES .................................. 133 ANNEX 3: ODA COMMITMENTS TO BASIC NUTRITION BY DONOR ....................................................... 134 ANNEX 4: ODA DISBURSEMENTS TO BASIC NUTRITION BY DONOR .................................................... 135 ANNEX 5: IMPUTED MULTILATERAL ODA COMMITMENTS .................................................................. 136

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ANNEX 6: IMPUTED MULTILATERAL ODA DISBURSEMENTS ............................................................... 137 ANNEX 7: IMPUTED MULTILATERAL ODA MATRIX ................................................................................ 138 ANNEX 8: ODA CHANNELS OF DELIVERY TO SOCIAL SECTORS, EDUCATION AND AGRICULTURE, FORESTRY AND FISHERIES ........................................................................................................................... 147 ANNEX 9: NUTRITION-‐RELATED PROJECTS BY DONOR .......................................................................... 148 ANNEX 10: SUN DONOR CONVENERS ....................................................................................................... 149 ANNEX 11: LIST OF ADDITIONAL 32 COUNTRIES WITH RATES OF STUNTING OR UNDER-‐WEIGHT HIGHER THAN 20% ...................................................................................................................................... 150 ANNEX 12: ODA TO BASIC NUTRITION AS A SHARE OF ODA TO HEALTH IN THE 36 COUNTRIES WHERE 90% OF STUNTED CHILDREN LIVE .............................................................................................. 151

8. REFERENCES ........................................................................................................................ 152

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Executive summary Under-‐nutrition is a major challenge for both low and middle income countries and significantly affects the lives of individuals and communities. Malnutrition is the underlying cause of 35% of all deaths among children under five. Under-‐nourished children are also more likely to be vulnerable to illnesses and earn about 10% less as adults if they survive. In 2006 the World Bank found that under-‐nutrition could result in a loss of about 2–3% of national GDP. Investments in nutrition are central to the eradication of poverty.

Despite rising volumes of reported nutrition official development assistance (ODA), international assistance remains below financial assessments of need. ODA to basic nutrition represents just 0.4% of total ODA (in 2011), having increased from 0.2% in 2004.

Although some countries are showing leadership in this field, resources and political will remain insufficient to eradicate under-‐nutrition worldwide. In 2010, the World Bank estimated that an increase of US$10.3 billion in annual international and national public financial resources would end under-‐nutrition. Since these estimates were made, basic nutrition ODA has increased by only US$139 million, about 1.4% of the identified need.

Interventions to address under-‐nutrition have proven to be extremely effective in reducing poverty. The 2012 Copenhagen Consensus, a panel of international development experts, found that such interventions provided a return of US$30 per child for each dollar spent. A package of interventions to reduce under-‐nutrition proposed by The Lancet in 2008 was deemed the most effective among 30 potential measures to tackle poverty.

Evidence strongly suggests that under-‐nutrition is best tackled by integrating it as an objective in programmes in other sectors, such as health, agriculture or education. The nutrition-‐specific components of such interventions are hard to identify and measure. ODA to projects that have a direct impact on nutrition is, therefore, likely to be higher than that recorded by the OECD DAC, the primary source of ODA data. For example, over 3,300 of aid projects reported to the OECD in 2011 (representing US$1.4 billion) had nutrition components but were not recorded as nutrition ODA. These were recorded under health, humanitarian aid, agriculture, government and civil society, multi-‐sector and education sectors. Assessing how much of this funding supports nutrition outcomes directly remains problematic.

Canada is currently the largest donor of basic nutrition ODA, disbursing an annual average of US$104 million between 2009 and 2011. The Bill & Melinda Gates Foundation disbursed US$64.4 million. The EU institutions, Japan and the United Kingdom were also important donors, with ODA disbursements of more than US$34 million each. When country donors are assessed for both bilateral aid and the contributions they have made through multilateral agencies, Canada remains the largest donor, allocating an average of US$108 million over 2009–2011. The UK and Japan follow, with US$47 million and US$46 million respectively.

Under-‐nutrition is geographically concentrated. South and Central Asia have the highest numbers of stunted children, amounting to 86 million, followed by sub-‐Saharan Africa (49 million). Globally, 90% of stunted children (too short for their age) live in just 36 countries.

At an aggregate level, funding for nutrition is targeted on the group of 36 countries where 90% of stunted children live. Over 2009–2011, these countries together received an annual average of US$218 million, 72% of basic nutrition ODA commitments.

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However, the distribution of aid for nutrition amongst the 36 countries does not reflect burden at either a regional or a country level. In this period, the largest increases were seen in Latin America and the Caribbean (nine times higher) and sub-‐Saharan Africa (six times higher). Sub-‐Saharan African countries among the 36 with the highest levels of stunting received about 54% of basic nutrition ODA disbursements in 2009–2011, despite representing only 26% of the estimated financial gap in funds required to tackle under-‐nutrition. South Asia received only 28% of basic nutrition ODA, although it represents 56% of the global financial gap. This is arguably concentrated in India, which accounts for most of stunted children in the region, while receiving comparably low amounts of nutrition ODA.

More positively, the share of total ODA going to nutrition interventions has been increasing, although proportions remain low. In 2011, basic nutrition ODA commitments amounted to US$418 million, having grown by 161% since 2000. Global ODA grew by only 61% over the same period. Growth has slowed in the past couple of years, with basic nutrition ODA increasing by 3% between 2010 and 2011, even though global ODA fell in real terms.

Basic nutrition ODA funding is still small when compared with emergency and development food aid. Development food aid amounted to US$1.4 billion in 2011 and the amount spent on emergency food aid was even larger at US$2.7 billion. ODA routed through these sectors can have a significant impact on nutrition, although this is not automatic and other direct nutrition interventions are vital. The increasingly recognised significance of basic nutrition interventions in relation to food aid is, therefore, yet to translate into aid funding decisions.

This report focuses on funding flows from existing donors. It shows that current volumes, while increasing, remain at odds with the scale of need. Appropriate levels of financing for basic nutrition, directed to where it is needed most, are a key component of any poverty eradication strategy that sits centrally within the post-‐2015 agenda.

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1. Introduction This report builds on Nutrition Advocacy Landscaping in Europe – An Analysis of Donor Commitments (Coppard and Zubairi, 2011), which assessed the official development assistance (ODA) contributions of major European donors and multilateral agencies addressing under-‐nutrition. Interventions to improve nutrition can be classified as nutrition-‐specific and/or nutrition-‐sensitive. The former interventions refer to actions that aim to reduce under-‐nutrition directly (e.g. micronutrient supplementation, changes in feeding practices), while nutrition-‐sensitive interventions refer to initiatives that aim to create a better environment for improvements in nutrition (e.g. cash transfers, agricultural development).The 2011 report presented ODA trends for nutrition-‐specific interventions from 2000 to 2009, putting nutrition aid in the context of development and emergency food ODA and providing profiles for key DAC donors.

The 2011 report showed that ODA for nutrition-‐specific projects was 0.3% of total ODA in 2009 and below that between 2000 and 2008. It was low in comparison with food aid. Volumes were particularly low when compared with the scale of financial resources needed to significantly expand coverage. In addition, these flows were not well targeted, as the 36 countries that collectively accounted for 90% of the world’s stunted children received only 57% of ODA to the sector over 2005–2008. However, some countries within this group were among the top recipients of these resources (Uganda, Niger, Democratic Republic of Congo, Mozambique, Vietnam, the Philippines and Tanzania).

This new report builds on previous work to assess ODA to nutrition-‐specific interventions and compares it with development and emergency food ODA. It presents trends from 2000 to 2011, using the most recent ODA data released on the OECD Development Assistance Committee (DAC) Creditor Reporting System (CRS) database, the most comprehensive source for ODA data. The report expands on previous analysis to cover DAC donors outside the European Union and a number of multilateral agencies.1 Finally, it assesses whether ODA for addressing under-‐nutrition is allocated according to financial requirements to meet nutritional needs.

The key aim of this work is to provide sound evidence to support governments, civil society organisations (CSOs) and businesses interested in optimising and scaling up current resources for tackling under-‐nutrition. Assessing the adequacy of official donors’ ODA contributions must take into account all available resources to nutrition-‐specific activities, such as domestic government and household contributions, domestic and international private charitable transfers, and private sector investments. However, information about these flows is incomplete and not very transparent, making any assessment of whether ODA meets nutrition needs only partial. This report uses available information to more accurately assess whether DAC ODA donors are making enough resources available. It calls for more and better data on financial resources for nutrition interventions.

The report is structured as follows: section one introduces the report. Section two summarises the status of under-‐nutrition and the most recent policy developments. Section three presents data on ODA to nutrition. Section four compares ODA with assessments of financial needs in the sector. Section five presents detailed profiles of key bilateral and multilateral ODA donors to nutrition, as well as the Bill & Melinda Gates Foundation (which also reports to the DAC). Finally, section six outlines the methodology.

1See section six for a full list.

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2. The challenge of under-‐nutrition

2.1. Key facts about under-‐nutrition Under-‐nutrition refers to a deficiency of micro and macro nutrients, produced by a combination of inadequate food intake and a person’s state of health.2 Under-‐nutrition is widespread but is concentrated in a limited number of countries, mostly in South Asia and sub-‐Saharan Africa. Black et al. (2008) recently estimated that 36 countries account for 90% of the world’s stunted children.3 The World Bank (2006; see also Horton et al., 2010) have assessed that a further 32 countries have levels of stunting or underweight above 20% (see Annex 11).

Under-‐nutrition has a major affect on the lives of individuals and communities. Under-‐nourished children are more vulnerable to impaired mental and physical development and to illnesses as adults. Malnutrition is the underlying cause of 35% of all deaths among children under five globally (Food and Agriculture Organization, 2012). In adulthood, limited productivity due to a history of under-‐nutrition can mean that individuals lose 10% of their potential income. Meanwhile, national economies can lose 2–3% of their overall GDP due to the impact of under-‐nutrition on their populations (Horton et al., 2010).

Investments in nutrition are crucial to achieve the Millennium Development Goals (MDGs), as under-‐nutrition clearly hinders national achievement of MDG 1 (halve extreme poverty and hunger), MDG 2 (achieve universal primary education), MDG 3 (promote gender equality and empower women), MDG 4 (reduce child mortality), MDG 5 (improve maternal health) and MDG 6 (combat HIV/AIDS, malaria and other diseases) (World Health Organization, 2011).

Under-‐nutrition is caused by a number of factors. Limited access to nutritious food, scarce availability of water and sanitation infrastructure and health services, as well as inadequate caring and feeding practices, can affect a person’s nutrition status. The empowerment of women, pro-‐poor agricultural policies and purpose-‐designed social protection systems, along with nutrition-‐specific interventions, can contribute to improving the nutritional status of people in poverty (FAO, 2012; Hoddinott et al., 2012; Rogers, 2012).

The 2012 Copenhagen Consensus, a panel of international development experts aiming to improve the use of available resources, argues that nutrition-‐specific interventions are essential, as substantial agricultural innovations would not be sufficient to tackle this issue alone. Building on previous studies from 2004 and 2008 (Copenhagen Consensus, 2004; 2008), it argues that nutrition-‐sensitive interventions are among the most efficient measures to tackle poverty. It (Hoddinott et al., 2012) ranks a package of interventions to reduce under-‐nutrition proposed by The Lancet (Bhutta et al., 2008) as the most important of 30 measures to tackle poverty (see section four), with an expected return of US$30 per child for

2 This section uses measures of under-‐nourishment, rather than under-‐nutrition. Under-‐nourishment refers to a caloric intake lower than the minimum dietary energy requirement (MDER), which is the amount of energy necessary to undertake light activity and maintain a minimum acceptable weight-‐to-‐height ratio. Information on stunting, a measure of under-‐nutrition, is presented in section four. See Hoddinott et al., 2012. 3Stunting refers to height lower than standard for a person’s age. It is defined as height less than two standard deviations below the World Health Organization (WHO)’s child growth standard median. Stunting is irreversible after a certain age and can lead to increased exposure to illness in adult life.

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each dollar spent. De-‐worming, another measure to improve nutrition, comes fourth in the same ranking.4

2.2. The distribution of under-‐nutrition Under-‐nourishment (inadequate caloric intake) has been historically used to measure global hunger based on the data from the UN Food and Agriculture Organization (FAO). Under-‐nourishment is one of the key indicators for the achievement of MDG 1 on halving the proportion of people who suffer from hunger. This section of the report presents data on under-‐nourishment to provide a comparison with MDG indicators and to assess trends.

However, under-‐nourishment is an inexact measure of under-‐nutrition, as the latter is a medical condition with a more complex causality that is better grasped by measures of stunting and wasting, i.e. height and weight per age. Historical data for these measures are not readily available. The most recent data on stunting from Black et al. (2008) and the World Health Organization (WHO) are presented in section four and show that both rates and volumes of stunted children are still high. The analysis of aid to nutrition, the assessment of its targeting and of how well it meets financial needs are based on the burden of stunting as estimated by Black et al. (2008) in the Lancet.

Globally, rates of under-‐nourishment have fallen from 18.5% to 15.2% since 2000–2002, but most of this fall took place before 2008 (Figures 2.2.1 and 2.2.2). The global economic crisis saw progress stall, amid rising unemployment and high food prices, which affected the most vulnerable households who spend most of their income on food. Progress made in reducing income poverty was not sufficient on their own to improve the nutritional status of people affected. Increases in income are necessary, but are not sufficient to improve nutrition because of rising food prices, food companies marketing strategies and other factors that affect decision-‐making.5 As a result, around 848 million people in developing countries are still at risk of under-‐nourishment and around 29% of children under five are stunted. Recent projections suggest that, without new investments, the number of under-‐nourished people will fall only to 766 million people by 2050 (Hoddinott et al., 2012).

Figure 2.2.1: Under-‐nourishment in the world (2000–2012). Source: FAO Food Security Indicators. Downloaded February 2013

4Subsidies for malaria treatments and child immunisation ranked second and third. 5 Nutrition practices are influenced by a variety of other factors such as culture, education, taste, intra-‐household relationships and social status.

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Figure 2.2.2: Annual change in number of under-‐nourished people in the world (2000–2012). Source: FAO Food Security Indicators. Downloaded February 2013

Regionally, under-‐nourishment is concentrated in South Asia and sub-‐Saharan Africa, with a handful of countries bearing most of the burden. South and Central Asia have the greatest number of under-‐nourished people, amounting to 314 million in 2010–2012, followed by Far East Asia with 222 million. Sub-‐Saharan Africa has the highest proportion of under-‐nourished people at 30% (Figure 2.2.3).

Figure 2.2.3: Number of under-‐nourished people by region (1990–2012). Source: FAO Food Security Indicators. Downloaded February 2013

Progress has differed across regions. Between 2007–2009 and 2010–2012, the number of under-‐nourished people in Far East Asia decreased by 5.1%, more rapidly than in all other regions. In South and Central Asia, under-‐nourishment decreased by 2.8%. Sub-‐Saharan Africa and the Middle East were the most affected by the recent economic slowdown, as the number of under-‐nourished people in these regions increased by 9.4% and 9.1% respectively over the same period (Figure 2.2.4). Far East Asia was the region where the absolute number of people at risk of under-‐nourishment decreased most (12 million people). In South and Central Asia the decrease was 9 million people. Conversely, 20 million more people were at risk in sub-‐Saharan Africa in 2010–2012 than in 2007-‐09.

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Figure 2.2.4: Trends in numbers of under-‐nourished people by selected region (2000–2012). Source: FAO Food Security Indicators. Downloaded February 2013

Almost half of those undernourished globally live in just three countries: India accounts for over a quarter of the global total, China almost a fifth and Pakistan for just over 4%. Almost two-‐thirds of all those undernourished live in just nine countries (this includes the former Sudan as one country), with 34 countries accounting for over 90% of the total (see Annex 1).

2.3. Meeting MDG1 – progress by region According to the UN Food and Agriculture Organization (FAO, 2012), the MDG target of halving the proportion of people suffering from hunger in the world is closer to being met than had been previously estimated, but additional efforts are needed to achieve this goal.6 The United Nations assesses that progress in reducing the proportion of under-‐weight children under five “was recorded in all regions where comparable data are available, but is insufficient to reach the global target by 2015” (United Nations, 2012, p.13)(Figures 2.3.1 and 2.3.2).

Sub-‐Saharan Africa and South Asia are the most off-‐track regions on both the proportion of under-‐nourished people and the under-‐weight children indicators of the MDG target. Sub-‐Saharan Africa has made only slight progress on under-‐nourishment, with the proportion of under-‐nourished people in the region standing at 31% in 1990 and 27% in 2005–2007.7 Similarly, about 29% of children were under-‐weight in 1990, falling only to 22% in 2010. Southern Asia’s under-‐nourishment rate remained high in 2005–2007, having decreased only slightly from 22% to 20% since 1990. Although proportions of under-‐weight children in this region are still high, the historic trajectory suggests more optimism, as the proportion fell from 51% to 32% between 1990 and 2010.

6 The FAO has produced new estimates based on a new methodology. For details refer to FAO, 2012. 7 Section 2.2 discusses FAO data, while section 2.3 presents UNDP data used to monitor progress on MDGs. Any discrepancy in data or time scales is attributable to the use of different sources.

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Figure 2.3.1: Progress towards MDG 1.C: halving the proportion of people who suffer from hunger. Proportion of under-‐nourished people. Source: United Nations, MDG Report 2012

Figure 2.3.2: Progress towards MDG 1.C: halving the proportion of people who suffer from hunger. Proportion of under-‐weight children among under-‐fives. Source: United Nations, MDG Report 2012

2.4. The policy context The MDGs have been successful in building consensus around the imperative of tackling hunger. However, they have not been sufficient to foster practical action to address under-‐nutrition to the scale required, and under-‐nutrition is still one of the greatest challenges faced by developing countries.

The reasons for slow progress include low capacity or commitment at developing country level as well as a lack of international leadership. The World Bank (2006) argued that most development partners have historically given low priority to nutrition-‐specific interventions, focusing more on food security and agriculture. It found that donors concentrated on responding to country requests, when a more active role as nutrition advocates would have been appropriate. The lack of a shared strategic vision and political consensus around the role of international donors and priorities, along with low levels of commitment from


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developing country governments, meant that there was no concerted action to end under-‐nutrition (see Annex 2) (World Bank, 2006).8 Similarly, Sumner et al. (2007) suggested that nutrition had a low to medium priority for the larger donors.

Responding to these challenges, the Movement for Scaling Up Nutrition (SUN), a multi-‐stakeholder global coalition to tackle under-‐nutrition, was launched in 2010 and currently involves 33 country members, along with civil society, business, international institutions and development partner supporters. SUN movement’s vision is to end malnutrition and hunger within a generation. It supports scaling up nutrition efforts within participating countries in line with national and global targets and is active in increasing the harmonisation, funding and accountability of nutrition initiatives.

A focus on nutrition has continued to grow. In 2012, the World Health Assembly (the decision-‐making body of the World Health Organisation) proposed new nutrition targets towards 2025, including reducing the number of stunted children by 40%. The 2012 G8 Accountability Report records further steps that G8 members are taking in support of nutrition interventions, although it argues that more needs to be done. G8 countries have affirmed that they are making agriculture and food security interventions more sensitive to nutrition needs and are endorsing a more cross-‐cutting approach overall. G8 members are supporting the SUN movement and have committed to the L’Aquila pledge of increasing investments in agriculture without cutting humanitarian food aid.

In August 2012, the United Kingdom and Brazil jointly hosted a hunger summit, offering international leadership and additional resources for nutrition. At this summit, the Irish Government said that it would push nutrition higher up the EU agenda during its EU Presidency in the first half of 2013 (Tran, 2012). The European Union committed to reducing the number of stunted children by 7 million by 2025 (DFID, 2012a). In 2012, the United States used its G8 presidency to launch a New Alliance for Food Security, of which nutrition is a key component (White House, 2012).9

Outlining UK priorities for its G8 presidency in 2013, the UK Prime Minister David Cameron said, “There should be, there will be, and I will back a major push on tackling global hunger, under-‐nutrition and stunting this year”, thereby potentially making it a central issue at the June 2013 G8 summit (Number 10, 2012). The UK International Development Secretary, Justine Greening, has also committed to a second major event on under-‐nutrition in 2013 (DFID, 2013).

8According to the paper the gap between operational needs for scaling up and donors’ policies regarded: (i) mainstreaming of under-‐nutrition and micronutrient programmes and integration of nutrition in HIV/AIDS programmes; (ii) addressing obesity and building evidence on the link between under-‐nutrition and non-‐communicable diseases; (iii) building commitment; (iv) promoting institutional arrangements and capacity for large-‐scale actions. 9 To improve nutrition the Alliance is committed to: (i) support the Scaling Up Nutrition movement (SUN); (ii) improve coordination of activities and tracking and disbursements of funds for nutrition; (iii) support the release, use and consumption of bio-‐fortified crops, crop diversification and new technologies to improve nutritional quality of food in Africa; (iv) support nutrition research and African research in particular.

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3. Official development assistance (ODA) to nutrition The OECD DAC Creditor Reporting System (CRS) dataset records ODA spent by donors on nutrition projects under a ‘basic nutrition’ purpose code. This core purpose code includes direct feeding programmes; micronutrient deficiency interventions; monitoring of nutritional status, nutrition and food hygiene education; and household food security. Nutritional status is also directly affected by the provision of food, which is recorded under other codes, ‘emergency food aid’ and ‘development food aid’. This report does not consider ODA that may have an indirect impact on nutrition status (see section six).

The DAC CRS dataset has certain limitations. Projects can only be recorded under a single purpose code, normally related to their main activity or objective, or under a ‘multi-‐sector’ code. While this prevents double-‐counting, it means that direct nutrition-‐relevant projects that do not have nutrition as their main component are spread among a variety of purpose codes beyond basic nutrition. This is confirmed by recent research on tracking ODA (Mutuma et al., 2012).10 An established methodology involves carrying out a word-‐matching process across the projects’ qualitative descriptions reported by donors across all sectors, and adding projects that explicitly refer to direct nutrition interventions to the assessment of food and basic nutrition aid (see section six).

To give a more comprehensive picture of ODA to nutrition, this section presents data on ODA to basic nutrition, alongside data on development and emergency food aid. It also presents more complete estimates of ODA to nutrition using the findings of the word-‐matching process, which found over 3,300 projects in 2011 with a nutrition component recorded in other sectors (the latest year for which data is available).

3.1. Global trends in ODA to basic nutrition and food aid ODA commitments11 to basic nutrition have increased substantially since 2000, reaching US$418 million in 2011.12 Between 1999–2001 and 2009–2011, basic nutrition aid more than doubled (a 161% increase in real terms). This outpaced the increase in overall ODA of 61% in the same period, although it was less than the increase in health ODA (217%).13

After a particularly large increase in 2009, ODA to basic nutrition fell in 2010, albeit to levels higher than previous years. Basic nutrition was 109% up in 2009 on 2008 levels, but then fell by 25% in 2010. Between 2010 and 2011, it increased by a further 3%. Aid commitments are

10 The codes are: ‘basic healthcare’, ‘basic nutrition’, ‘health education’, ‘water supply and sanitation’, ‘multi-‐sector aid’, ‘social mitigation of HIV’, ‘food aid/food security’, ‘material relief’ and ‘emergency food aid’. The report will be updated in the first half of 2013. 11 The analysis of ODA trends uses ODA commitments, as data on ODA disbursements before 2006 are incomplete. Shorter-‐term analysis uses disbursements, as they better reflect actual resources that DAC donors allocate to basic nutrition interventions in any given year. Acommitment occurs when a donor makes a formal pledge, expressed in writing and accompanied by the necessary funds, to provide certain support to a multilateral organisation or an ODA recipient country. Bilateral commitments are recorded in the year in which they are made. Commitments to multilateral agencies include (i) disbursements made in the year that had not previously been recorded as commitments and (ii) expected disbursements for the following year. Disbursements correspond to the actual release of funds either in cash, kind or transfer to providers in the donor country or to the recipient country. It usually takes more than one year to disburse a commitment. Source: OECD DAC glossary. 12This refers to development assistance committed by official donors. Since 2009, the Bill &Melinda Gates Foundation has been reporting to the DAC CRS. Its commitments to basic nutrition amounted to US$19.4 million in 2009, US$19.1 million in 2010 and US$60.5 million in 2011. 13 Health is here defined as ODA to the CRS purpose codes ‘health and population policies/programmes’ and ‘reproductive health’.

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often volatile as they are reported in the year they are made, rather than when they are disbursed (which is often over a longer timeframe). Figure 3.1.1 presents a three-‐year rolling average that smoothes the ODA trend, and shows a constant increase.14 The share of total ODA going to basic nutrition is consistently low over time, but it doubled from 0.2% of total ODA to 0.4% between 2004 and 2011.

Figure 3.1.1: ODA commitments to basic nutrition (2000–2011). Source: DAC CRS database online. Accessed February 2013

ODA for basic nutrition is small compared with emergency and development food aid, but proportions have risen (Figure 3.1.2). Basic nutrition ODA as a share of food and nutrition aid combined rose from 3.1% in 2000 to 9.3% in 2011. Development food aid almost halved, from US$2.6 billion in 2000 to US$1.4 billion in 2011. Conversely, support to emergency food interventions rose more than threefold, from US$609 million to US$2.7 billion, over the same period.

Figure 3.1.2: ODA commitments to basic nutrition, emergency and development food aid (2000–2011). Source: DAC CRS database online. Accessed February 2013

14A three-‐year rolling average was not calculated for 2011, as 2012 data are still unavailable.

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3.1.1. Bilateral and multilateral ODA trends DAC countries’ bilateral basic nutrition commitments have been larger than those from multilateral organisations in most years. In 2011, bilateral basic nutrition commitments amounted to US$352million, while multilateral ODA totalled US$67 million. Over 2000–2011 bilateral ODA increased threefold, conversely, ODA committed by multilateral agencies fell by 24%, from US$88 million to US$67 million. Using smoothed three-‐year rolling averages, ODA commitments from both bilateral and multilateral donors increased by three times over the same period (Figure 3.1.3). Average ODA commitments by multilateral organisations represented 41% of ODA to basic nutrition in 2000, down to 16% in 2011, while the share of bilateral commitments increased from 59% to 84%. However, the role of multilateral agencies remains significant as country donors choose to channel significant proportions of their nutrition bilateral ODA through such institutions (see section 3.1.3 below and Annexes 3 and 4).

Figure 3.1.3: Bilateral and multilateral ODA commitments to basic nutrition (2000–2011). Source: DAC CRS database online. Accessed February 2013

3.1.2. Major ODA donors to basic nutrition: ODA disbursements Over 2009–2011, Canada was the largest donor to basic nutrition, disbursing US$104 million annually on average. The Gates Foundation followed with US$64 million.15EU institutions, Japan and the UK followed with ODA disbursements of more than US$30 million each. In relative terms, this corresponds to 2.7% of all ODA for Canada, 2.8% for the Gates Foundation, 0.3% for the EU institutions, 0.2% for Japan and 0.4% for the UK. Contributions from these five donors accounted for more than half (60%) of global ODA to basic nutrition. Other top 15 donors include bilateral country donors, a number of UN agencies, the International Development Association (IDA) and the Asian Development Bank (Figure 3.1.4).

15 The Bill & Melinda Gates Foundation reports to the DAC, with data presented in the ‘private grants’ line of the CRS dataset. This line includes grants for development assistance or relief from private bodies based in the donor countries, made to or for developing countries, multilateral bodies, international appeals or international NGOs. These Foundation’s data are included in the ranking for comparison purposes, but are not included in the total volumes of ODA for basic nutrition presented in section 3.1, i.e. total volume in that section refers to ODA from official donors only and excludes private grants.

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Figure 3.1.4:Top ODA donors to basic nutrition (2009–2011 average disbursements). Source: DAC CRS database online. Accessed February 2013

Donor strategies vary considerably, and ODA to basic nutrition by country donors can also be assessed in terms of the sum of their bilateral and imputed multilateral ODA disbursements – i.e. the share of their core contributions to multilateral agencies that is then spent on basic nutrition.16In fact, some donors explicitly choose to deliver nutrition through core contributions to key agencies, rather than bilaterally. Imputed multilateral ODA to address under-‐nutrition from countries such as Germany, France, Sweden, the Netherlands, Italy and Norway is greater than bilateral ODA disbursed for the same aim. When imputed multilateral ODA is considered, Canada is by far the largest donor, allocating US$108 million on an annual basis over 2009–2011. The UK and Japan follow with US$47 million and US$46 million respectively (Figure 3.1.5).17

16 Excluding ODA to the World Health Organization. The WHO only reports to the DAC as a donor, while information on it as a recipient is not present in the DAC database. 17 Between 2009 and 2011, the Bill &Melinda Gates Foundation reported an annual average of US$142 million in multilateral aid to multilateral bodies recorded under the ‘other multilateral’ category. Organisations grouped under this label did not commit any ODA to basic nutrition, so the Foundation’s figures include only aid defined as bilateral within the DAC CRS dataset (see section 6).If the Foundation were included in the ranking, it would be the second largest donor, disbursing US$64 million annually on average between 2009 and 2011.

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Figure 3.1.5: Top DAC country donors to basic nutrition (2009–2011 average, bilateral and imputed multilateral disbursements). Source: DAC CRS database online. Accessed February 2013

Changes in large donors’ disbursements affect trends in overall nutrition ODA. In 2009 total basic nutrition disbursements jumped to US$402 million, US$171 million more than in 2008, due to increased bilateral disbursements from Japan, the EU institutions and the IDA. Japan disbursed US$58 million in 2009, having made no contribution in the previous year. The EU institutions and the IDA disbursed US$54 million and US$40 million, increases of US$50 million and US$18 million respectively (see Annexes 5 and 6).

Conversely, in 2011 increases on the previous year in disbursements by the United States (US$28 million more), Canada (US$15 million more) and the EU institutions (US$26 million more) were partially offset by a fall in ODA disbursements by Japan (US$42 million less) and the World Food Programme (WFP) (US$18 million less).

3.1.3. Channels of delivery In 2009–2011 total ODA to basic nutrition was delivered primarily through multilateral organisations (67%). ODA channelled through multilateral organisations includes both core contributions to multilateral agencies (multilateral ODA discussed above) and country donor ODA to multilateral agencies that is earmarked specifically for nutrition purposes (see methodology in section six).

Notably, although multilateral ODA to basic nutrition is lower than bilateral ODA (see section 3.1.1), a large proportion of bilateral ODA is disbursed through multilateral agencies (49%). On average, between 2009 and 2011, multilateral institutions channelled US$132 million as

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core multilateral ODA and US$116 million as earmarked ODA to basic nutrition interventions, making a total of US$248 million.18

Around 34% of bilateral ODA to basic nutrition was channelled through NGOs and CSOs, amounting to US$82 million. The public sector19 was the third largest channel of delivery, administering about 11% of the total (Figure 3.1.6).

This lesser role for the public sector is peculiar to basic nutrition, as this sector is the largest channel of delivery for bilateral ODA to both education (53%) and health (40%).20 Its share was 46% of bilateral ODA to all social sectors21 and 38% of ODA for agriculture, forestry and fisheries (see Figure 3.1.7 and Annex 8).

Figure3.1.6: Bilateral ODA disbursements to basic nutrition (2009–2011 average disbursements – US$ million, constant 2010 prices). Source: DAC CRS database online. Accessed February 2013

18 For a discussion of the role of multilateral agencies in the system of delivery of aid, see Coppard et al., 2013. 19 The CRS records only the first recipient of ODA from country donors or multilateral agencies. ODA disbursed to the first intermediary can then be transferred to other actors within the system of delivery to implement projects or for other activities. In addition, the CRS ‘public sector’ channel of delivery does not make a distinction between ODA allocated to donor country agencies that then use ODA funds for international development purposes, or to recipient country governments that use these funds for national development. This label includes both, undermining the ability to assess how much ODA has been transferred directly to recipient country governments. 20 Health is here defined as ODA to the CRS purpose codes ‘health and population policies/programmes’ and ‘reproductive health’. The ‘basic nutrition’ code falls under the ‘health and population policies/programmes’ sector CRS code. 21 This includes purpose codes under social infrastructure and services, including activities in the areas of education, health, population policies/programmes and reproductive health, water supply and sanitation, government and civil society, other social infrastructure and services.

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Figure 3.1.7: Bilateral ODA to health, excluding basic nutrition (2009–2011 average disbursements – US$ million, constant 2010 prices). Source: DAC CRS database online. Accessed February 2013

3.1.4. Grants and loans Grants are the largest component of ODA to basic nutrition (Figure 3.1.8), accounting for more than 70% of the total spend in every year but one since 2000. In 2005, large concessional loan commitments of US$67 million by the International Development Association (IDA) meant that grants accounted for around 56% of total basic nutrition ODA. In 2007, the Asian Development Bank Special Fund made loan commitments of US$53 million. However, the IDA is the only agency that regularly uses loans for nutrition interventions.22

Figure 3.1.8: ODA commitments to basic nutrition (2000–2011). Source: DAC CRS database online. Accessed February 2013

3.2. Nutrition components of non-‐nutrition projects Two forms of project can contribute to reducing under-‐nutrition. Nutrition-‐specific interventions act directly on the nutritional status of mothers and children, from conception to 24 months of age. These actions are best supported by nutrition-‐sensitive policies in other sectors, for example the integration of nutrition as an objective in multi-‐sector programming in areas that have an impact on nutrition, such as; agriculture, education, water and sanitation, social security, health care, governance and gender.

22 For a discussion of aid composition, see Coppard et al., 2013.

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According to SUN’s Framework for Action (undated), multi-‐sector approaches can help to tackle under-‐nutrition in three ways: 1. Actions in other areas can affect the determinants of under-‐nutrition (e.g. agricultural

production, empowerment of women); 2. Nutrition can be integrated into other sector programmes (e.g. school meals); 3. Policy coherence should take into account the effects of broader policies on nutrition

outcomes (e.g. fuel prices, biofuels production).

Tracking ODA to projects with a nutrition component that do not have nutrition as their main goal is not straightforward. As noted above, DAC CRS projects are recorded exclusively under a single purpose code based on their main area of activity (see section 3.1). Reporting practices can vary, with different donors reporting similar projects under different codes. In some cases, project descriptions can be incomplete or missing, preventing more detailed analysis of these activities.

Therefore ODA to projects that have an impact on nutrition can be greater than the volumes recorded under the basic nutrition code. In this report, a word-‐matching exercise using project descriptions under other codes was undertaken to assess how much ODA for nutrition-‐related projects was reported under other codes in 2011.23 A total of 3,309 projects were found, mostly under the health, humanitarian aid, agriculture, government and civil society, multi-‐sector aid and education-‐related purpose codes (this compares with a total of 1,413 projects recorded under the ‘basic nutrition’ purpose code). Their total value was US$1.4 billion, more than three times the US$418million in basic nutrition ODA in that year.24 The five largest projects by value of commitments were financed by the US, Sweden and Canada (see table 3.2.1 and Annex 9).

Donor Recipient Commitments (US$ milion)

Purpose (code) Project description

United States

Mozambique 109.9 Sexually transmitted diseases control including HIV/AIDS (13040)

Prevent mother-‐to-‐child HIV transmission through nutrition and HIV counselling and testing and ARV prophylaxis

Sweden Bangladesh 57.1 Basic health care (12220)

Improve access to and utilisation of essential health, population and nutrition services by the poor

United States

Afghanistan 28.4 Reproductive health care (13020)

Increase the availability and use of proven life-‐saving interventions that address the major killers of mothers and children and improve their health and nutrition status

Canada Mali 28.3 Basic health care (12220)

Improve maternal, newborn and child health supporting better national response to diarrhoea, respiratory and infectious diseases and under-‐nutrition

United States

Haiti 25.2 Reproductive health care (13020)

Increase the availability and use of proven life-‐saving interventions that address the major killers of mothers and children and improve their health and nutrition status

Table 3.2.1: Largest nutrition-‐related projects (2011 commitments). Source: DAC CRS dataset. Accessed February 2013

23The assessment of whether these activities were nutrition-‐specific or nutrition-‐sensitive would require a project-‐by-‐project analysis that goes beyond the purpose of this current work. The key words used were: ‘nutrition’, ‘feeding’, ‘vitamin’, ‘micronutrient’, ‘stunting’ and ‘fortification’. 24 A similar exercise found estimated values of US$925 million in 2008 and US$833 million in 2009. See Coppard and Zubairi, 2011. The keywords used for the word-‐matching process were ‘nutrition’ and ‘stunting’.

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Table 3.2.2 summarises the potential scale of these activities (see also methodology in section six). It is not possible to determine how much impact on nutrition these projects have using the DAC CRS alone. By assuming that the nutrition component of such projects accounts for 10%, 25% or 50% of their value, the potential ODA that can be added to basic nutrition volumes varies significantly. These estimates should obviously be considered with caution and best serve to illustrate how large volumes of nutrition ODA lie outside the basic nutrition category. A common reporting standard allowing the coding of projects under multiple sectors and by activity would allow a more accurate analysis of both humanitarian and development aid.25

Low estimate (10%) Medium estimate (25%)

High estimate (50%)

Basic nutrition US$418.3m US$418.3m US$418.3m

Emergency food aid US$270.2m US$675.6m US$1,351.2m

Development food aid US$139.0m US$347.5m US$695.0m

Nutrition-‐related projects US$141.9m US$354.6m US$709.3m

Total US$969.4m US$1,796.0m US$3,173.7m

Table 3.2.2: Estimates of ODA to nutrition (2011 commitments). Source: DAC CRS dataset. Accessed February 2013

If 50% of ODA identified outside of basic nutrition was financing basic nutrition interventions, the total would be over US$3.1 billion – well over seven times the US$418 million to basic nutrition ODA alone. A medium estimate, based on 25% of identified non-‐basic nutrition ODA, would give a total of US$1.8 billion (over four times the ODA for basic nutrition), while a more conservative 10% estimate would give US$969 million, still more than double the ODA reported as basic nutrition.

Although these figures are significant, aid for nutrition as estimated above is still insufficient when compared with financial needs; this is discussed in more detail in section four.

25The International Aid Transparency Initiative (IATI) aims to make information about aid more accessible, easy to use and understand. The initiative intends to track aid from donors to final recipients, including making information available by activity and using a multi-‐coding system. This kind of reporting would allow a more detailed analysis of aid flows. Development Initiatives is exploring how the expanding pool of data reported to IATI standards can deepen the analysis of ODA flows. For more information, see: http://www.aidtransparency.net/.

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4. Funding needs for nutrition

4.1. Nutrition burden and its geographical distribution In research published in The Lancet, Black et al. (2008) found that 36 countries account for 90% of all stunted children worldwide. This study will be updated in 2013, providing new information on the geography of under-‐nutrition.26 According to the 2008 study, the region with the largest number of stunted children is South and Central Asia (85.7 million), followed by sub-‐Saharan Africa (48.3 million). India is home to over a third of the global population that suffers from stunting, although a number of other countries have higher rates of stunting as a proportion of their populations, such as Burundi (63%), Guatemala (60%) and Ethiopia (57%) among others. Indonesia, Nigeria, Bangladesh, Pakistan and Ethiopia each represent more than 4% of the global total. Updated figures from the WHO suggest that stunting rates in these countries remain high (Table 4.1.1).27

Black et al. (2008) WHO (latest available year)

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of stunted children would require additional resources, estimating an annual scaling up cost of US$11.8 billion beyond that already available. The scaling up of the package in a further 32 countries where stunting or under-‐weight rates exceed 20% would increase this cost by a further 6%. The cost of nutrition interventions changes due to a number of factors such as technological innovation, transport costs and the number of people who need support. These changes have arguably affected the funding needs for scaling up nutrition in recent years. However, the Horton et al. study is still the most accurate estimate available.

Complementary and therapeutic feeding would account for more than 50% of required investments in the package. The second largest expenditure would be for behaviour change (24%), followed by micronutrients and de-‐worming activities (13%).32

South Asia (approximately 50%) and sub-‐Saharan Africa (24%) together account for almost three quarters of the total additional investments required. Complementary and therapeutic feeding would absorb most of the funding going to South Asia, sub-‐Saharan Africa, East Asia and the Pacific (Figure 4.2.1).

Figure 4.2.1: Cost of scaling up nutrition interventions in the modified Lancet package by region. Source: adapted from Horton et al., 2010. Accessed February 2013

According to Horton et al. (2010), roughly US$1.5 billion of the financial need could be covered by out-‐of-‐pocket expenditures by better-‐off families, whose children may also suffer from under-‐nutrition. International donors and governments of developing countries should cover most of the remaining US$10.3 billion. Private corporations could absorb some costs for commercially viable products, iodisation and behaviour change.

Another recent report (Pratt, 2012) highlights that the split of funding responsibilities between international donors and recipient country governments in line with historical practice may have considerable consequences for distribution of costs.33 Countries where

due to insufficient information available on WHO protocols, compliance, delivery mechanisms, costs or due to lack of capacity for scaling up them. See Horton et al. (2010) for further details. 32 Other costs that are not allocated to any region would cover expenditures in capacity development and monitoring and evaluation (M&E). 33 According to these practices, external donors pay for the cost of materials and country governments pay for in-‐country labour and implementation. Horton et al. (2010) proposes a two-‐step implementation process that prioritises labour-‐intensive activities (behaviour change, micronutrients,

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under-‐nutrition is more prevalent would face higher costs than richer, less under-‐nutrition-‐prone regions.34

This burden would fall mostly on domestic governments, as contributions from private sources (companies and households) would be insufficient to cover the cost of interventions. A World Bank study (2006) argues that under-‐nutrition is not evident without clinical checks, so households may not react effectively or in a timely manner if more market-‐based solutions are in place. Good nutrition has broad and long-‐lasting effects on the health and productivity of the population which qualify it as a public good,

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