India is currently not on track to meet Millennium Development Goals 1 and 4 and presents an exceptionally high burden of global undernutrition. One of the main challenges of implementation and monitoring of nutrition-specific interventions lies in adequate financing. New research by POSHAN (Partnerships and Opportunities to Strengthen and Harmonize Actions for Nutrition in India) sheds light in this regard by estimating the costs of implementing the specified nutrition actions in budgetary terms to fully cover target populations in the 35 states and union territories of India.
This research uses the methodology from a 2010 World Bank study “Scaling Up Nutrition: What Will It Cost?” that estimates the total cost of scaling up a package of direct nutrition interventions from current coverage levels to full coverage. It also uses local costing data and information on delivery platforms and target populations to calculate and compare the cost of delivering two sets of interventions at scale. The first set consists of 10 Scaling up Nutrition (SUN) interventions that covers several globally-recommended interventions and the second is a set of 14 nutrition interventions that are included in India’s policy framework (that authors call India Plus interventions).
To calculate the cost of providing interventions at full coverage per year (100 percent of the target population or 80 percent for sever acute malnutrition), authors used the following steps: I) they described each intervention to be costed; II) defined the target population of each intervention; II) estimated the size of the target population in 2014 for each intervention; IV) specified the platform through which each intervention will be delivered; V) obtained local unit cost data for both sets of interventions ; VI) they multiplied the size of the target population by the unit cost to arrive at a total cost of implementing each intervention at full coverage; VII) they adjusted for inflation.
The costing exercise for the SUN and India Plus interventions shows that implementing the ten core SUN interventions at full coverage nationwide is US$4.22 billion. Of this total, 21 percent is allocated to community nutrition programs for behavior change communication, 14 percent is dedicated to micronutrient and deworming interventions, and 65 percent to supplementary and therapeutic feeding interventions.
On the other hand, the cost of implementing the entirety of India Plus interventions at full coverage would be US$5.93 billion comprised of 49 percent to support breast feeding, 39 percent to supplementary food rations, 4 percent for health interventions, 5 percent for counseling action and 3 percent for micronutrient supplements and deworming. When calculating the India plus costs to cover one child (0-24 months) authors find that it would take a total of US$140 distributed as US$54.2 for food supplements, US$68.4 for maternity benefits, US$6.8 for counseling US$4.7 for micronutrient supplementation and deworming and US$5.9 for health interventions (per year).
Authors found considerable variability in the costs for delivering both the SUN and India Plus interventions at scale in the different states across India, driven mainly by differences in target populations. The Indo-Gangetic plains (including states like Uttar Pradesh, Bihar, West Bengal and Jharkhand) are the most expensive. Other regions that require a considerable investment are the central states (Madhya Pradesh, Maharashtra, Chhattisgarh, and Odisha) as well as a few other individual states like Rajasthan, Gujarat, Andhra Pradesh, Tamil Nadu and Karnataka.
For example, the state of Uttar Pradesh alone comprises 20 percent of the estimated cost of implementing all India plus interventions, around US$1.2 billion per year. This is due to the existing population level, high fertility rates and the state’s poor performance on nutrition. Other regions that present high wasting rates and large populations like Bihar, Madhya Pradesh, Rajasthan, and Maharashtra also have large costs in terms of interventions.
Furthermore, authors performed an expenditure analysis to compare the SUN and India Plus cost estimates with actual government expenditures on the Integrated Child Development Services Program (ICDS). Authors find that that current expenditure levels are lower than would be needed to assure full coverage. The cost and expenditure comparisons for 2014 show that the ICDS spends less on each beneficiary it covers than it would cost if the reported cost norms were applied to the reported number of beneficiaries, and as expected, this difference varies across states.
Lastly, authors provide policy recommendations based on the findings of their research. They consider that since financial requirements for delivering nutrition interventions vary within India, financing for nutrition across India will need to consider the gaps between projected costs for each state, current expenditures, and the availability of national and state level finances to deliver fully for nutrition. Further research is required to re-estimate some of the costs shown in the study based on updated unit costs for supplementary feeding as well as updated target population estimates for severe acute malnutrition and other updates to other unit costs. Finally authors note that government departments need to align reporting of expenditures and coverage data to target specific age categories and nutrition interventions in order to facilitate a better analysis of adequacy of spending on nutrition.
By: Juan Carlos Mora Betancourt