Doing Development Differently: increasing domestic investments for nutrition

Building sub-national performance-based matched-funding arrangements in Kenya

 

On February 4, 2020, following significant consultation and engagement, Nutrition International signed performance-based funding agreements with the County Governors of Busia, Makueni, Nandi, and Vihiga.

By Joel Spicer, President and CEO

In 2015, we began asking ourselves some uncomfortable questions about how we were investing our resources at Nutrition International: when development organizations like ours put a dollar on the table, was it ‘additional’ to what would have been spent anyway – or did governments then shift a dollar away from nutrition to something else? Did the availability of health and nutrition funding from donors and partners reduce or remove the pressure on some governments (national and sub-national) to put more of their own money on the table? How could we get the most for every donor dollar we spent – not just in terms of human impact but by encouraging local authorities to invest more too?

To dig into these and other questions, we started in Kenya. Nutrition International initiated a series of financing roundtables, consultations, and team-to-team meetings with an array of county and national officials, including bilateral meetings with county governors. By 2019, we had co-created and developed a new investment model with counties: sub-national, performance-based matched-funding arrangements. This approach was specifically designed to leverage verifiable increases in domestic funding for high-impact nutrition interventions and system strengthening activities – and to tie our funding to performance.

The investment model

We developed this approach in Kenya due to its decentralized system of governance and the critically important role of the 47 county governments in the success of nutrition programs. County governments have considerable budgetary autonomy in determining how they plan, budget, allocate, and spend funding from national government transfers as well as locally raised revenue. The extent to which nutrition is a local priority determines the extent to which it is locally funded.

The approach had several upstream elements. Firstly, with funding from the United Kingdom and Canada, Nutrition International supported Kenya in drafting a five-year multi-sectoral National Nutrition Action Plan (2018-2023) which identifies – and costs – priority actions for eliminating malnutrition in the country.

We then worked with sub-national governments to translate the national priorities to the local county context. This was a truly multi-sectoral initiative which involved the departments of health, agriculture, finance, education, and other nutrition sensitive sectors. We also secured early buy-in by working directly with County Assembly members (those who approve the county’s budget and expenditure).  In this way, we were able to bridge the technical, financial and political while remaining focused on the most important part of the equation: people. The resulting County Nutrition Action Plans (CNAPs) identify priority nutrition activities to be implemented by various sectors, their outputs and – again – their cost.

From these costed action plans, Nutrition International worked with county governments to prioritize a subset of high-impact activities that focused on results as well as system building, with the goal of strengthening the counties’ capacity to plan, manage and sustain these programs. We also worked together to identify each county’s baseline funding, so additionality could be measured.

The counties then committed to increasing funding beyond this baseline over the next three years without negatively impacting outcomes in other social sectors. They created dedicated budget lines for nutrition and established a special account within Kenya’s Financial Management Framework to manage the matched funds. Once the county funds have been transferred, Nutrition International matches the above baseline investments on a 1:1 basis, using funding provided by Global Affairs Canada.

The results

On February 4, 2020, following significant consultation and engagement, Nutrition International signed performance-based funding agreements with the County Governors of Busia, Makueni, Nandi, and Vihiga. Combined, these counties have committed nearly CAD $2M in domestic nutrition investment between 2020 and 2023 – CAD $1.6M of which is additional funding. This represents a five-fold increase in domestic funding for high-impact, low-cost nutrition actions that work. Combined with Nutrition International’s 1:1 match of the additional funding, CAD $3.6M in total will be invested in these four counties through 2023.

Since the signing, and despite the impacts of COVID-19 on government budgets, all four counties have transferred their first quarter funds and triggered match funding from Nutrition International. Negotiations are currently underway with six additional counties who have committed to joining the model by July 2021, and we are supporting a further six to create CNAPs, which will form the basis of future performance-based matched-funding arrangements.

The road ahead

Despite evidence of success, Kenya still suffers from a huge burden of preventable malnutrition. More than many countries, it has the power, the people, and the means to put an end to this. Forward-thinking governors were rightly concerned not only about preventable maternal and child deaths, but also about rising obesity and deaths due to non-communicable diseases. Malnutrition is a great destroyer of immune systems, and the foundation of any health system is the immune system strength of the people in it. When a pandemic like COVID-19 preys upon the most vulnerable, the benefits of investing in nutrition become doubly clear and increasing the priority for nutrition investments at local level is more important than ever.

As we proceed, we will keep the following six lessons in mind:

  • Upfront engagement is key. Nutrition actions must be tailored to the local context by counties themselves.
  • Local governance matters. National nutrition plans offer good guidance, but sub-national commitment drives action on the ground.
  • Nutrition must be made political or it will never be a priority. Governors and their teams who helped co-create the action plans are key nutrition ambassadors, within their counties and for other counties and other countries.
  • Evidence and impact must drive prioritization. Counties operate in resource-constrained environments and funds must be prioritized based on evidence for impact in vulnerable groups.
  • People must remain at the centre. Programs must bridge the technical, financial and political while remaining focused on the most important part of the equation: people.
  • Now is the time for greater ambition. COVID-19 has shown us that global health is a local matter and that strong immune systems are the foundation of strong health systems. Now is the time to scale up this model and ensure there is more money for nutrition as well as more nutrition for the money.

At Nutrition International, we will expand our work with sub-national governments across Kenya and beyond to increase domestic investments for nutrition and build stronger, more resilient communities. Communities that are better able to withstand future shocks, be they health, environmental or economic. We will also continue to partner with leading nutrition donors, such as Canada and the United Kingdom, to build sustainable programs that deliver measurable results for every dollar invested.

Spicer Joel headshot

Joel Spicer

President and CEO

Joel Spicer, President and CEO, oversees Nutrition International as an established leader in global health, an innovator, visionary, and a Canadian with significant experience in international development that cuts across borders, sectors and agencies. He has an MPH in International Health (Health Policy and Management), and an M.Sc. in Development Studies. Joel joined Nutrition International in 2014. In September 2016, he received the Harvard T.H. Chan School of Public Health Emerging Public Health Professional Award.

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