Nutrition Policy Playbook: Picking the Best Benefits Package

Despite the approaching 2025 deadline for the Global Nutrition Targets, nutrition interventions remain fragmented and poorly integrated into the health system. Many countries continue to struggle with integrating comprehensive nutrition strategies into their health benefits packages to achieve universal health coverage (UHC). For country policymakers seeking to use off-the-shelf international guidelines as they incorporate nutrition into their benefits packages, there are many choices: the World Health Organization (WHO) guidelines on nutrition and maternal-child health, the World Bank’s review, and a list from UNICEF’s report. We’re excited to share with you a new and comprehensive crosswalk resource which compares seven international guidelines or lists and their constitutive 50 interventions to each other.

Bottom Line Up Front: The consistency in recognizing essential and highly cost-effective nutrition interventions across different guidelines is encouraging, but the absence of detailed implementation strategies remains a significant barrier. Countries still need clear, actionable guidance to effectively integrate these interventions into their health systems.

Integrating nutrition is not straightforward

Integrating nutrition into the health system is not straightforward, as there are three key challenges—fragmentation, benefit package design writ large, and nutrition’s marginalization in a medically dominated field.

The fragmentation of vertical and ministerial silos: Traditional funding streams often come with specific mandates, leading to fragmented efforts and commitment. Any vertical program, not only nutrition, that seeks to integrate with the health system faces this problem of fragmentation. By falling into the cracks of different government ministries or departments and single-focus vertical programs, nutrition requires unique approaches to intersectoral governance.  Worse, vertical programs that are donor dependent—of which there are several—also face challenges integrating with government systems, achieving sustainability, and securing domestic government resources, among other issues. (We’ve briefly scanned the global nutrition financing landscape in our previous blog here.)

Nutrition is often neglected in the health system: Even as some of the most-cost effective nutrition interventions are delivered through the health system, nutrition is arguably neglected within the health system. There are a few possible reasons for this neglect. One could be the medical profession focuses more on treating diseases, rather than on preventive care, nutrition, and food security. Indeed, Paul Farmer in previous works described his approach to prescribing food to patients while treating diseases such as tuberculosis or HIV/AIDS in impoverished regions, areas often deemed outside of the purview of clinical medicine. Another could be that primary care as well as public health, through which most nutrition interventions are covered, tend to have smaller budgets relative to medical specialties.

UHC and health benefit packages: UHC is widely accepted as an overarching framework, but the specific benefits that constitute UHC are debated. How should countries design and update or adapt benefit packages in general (not just for nutrition), and how should they determine which nutrition interventions should be covered? Designing a benefit package is an crucial tool to maximize efficiency, or in other words, securing more “health for the money”, by targeting the health services and products that yield the highest health value. While always essential, this becomes even more critical during  periods of fiscal constraints and ongoing crises. Importantly, designing packages require institutional capacity and subject-matter expertise in a particular disease or condition area, in this case, nutrition. Another way to frame this question is: Where does nutrition fit in the health benefit package more broadly? What essential nutrition interventions belong in a health benefit package? How cost-effective are they?

Decoding international guidelines on nutrition: we made a crosswalk so you don’t have to

For national policymakers looking to bring nutrition front and center of their health benefits package, international guidelines are a lifesaver. When in doubt, just pull the international guideline off the shelf and go. Unfortunately, there are at least 7 different guidelines on offer for nutrition alone, including the WHO guidelines on nutrition and maternal-child health, the World Bank’s review, and UNICEF’s report. We found these guidelines by expert guidance and referrals, as there was no standard location or reference housing all the guidelines (again reflecting the challenge of fragmentation across organizations).

So we’ve done the legwork and meticulously compiled these different guidelines and standards on nutrition to create a comprehensive crosswalk with over 50 different interventions. This crosswalk allows policymakers to seamlessly incorporate proven nutrition measures into their health system. Each column refers to a different guideline, and the rows refer to the interventions that comprise the guideline.

Which interventions are cost-effective?

To complement the crosswalk of guidelines, we incorporated information on cost-effectiveness of these nutrition interventions as described in the Disease Control Priorities Project, 3^rd Edition (DCP3). DCP is a valuable resource that has historically reviewed the scientific evidence on cost-effectiveness in order to make recommendations on the most cost-effective interventions for a variety of diseases. (The DCP4 is underway, led by Professor Ole Norheim at BCEPS and with new analytics tools being updated as we speak.) DCP project helps to translate economic evidence into a better priority setting approach for Universal Health Coverage (UHC) (and with CGD historically involved through the Millions Saved and the What Works Working Group– see here and here).

We have lined up the data on cost-effectiveness from DCP3 to each nutrition intervention for easy comparison. See the annex for the list of nutrition interventions by incremental cost-effectiveness ratio. While the DCP is being revised as we speak and the DCP3 figures are thus dated (from 2017), they nevertheless serve as a useful benchmark, particularly for older interventions which we do not expect to have changed much in the past decade, such as breastfeeding.

The lower the cost-effectiveness ratio, the more value for money—and more cheaply saving the life is better. The incremental cost-effectiveness ratios (ICER) range from $26 per life year (disability adjusted) for integrated management of severe acute malnutrition to breastfeeding promotion at $1206 per life year (disability adjusted). Whether or not a country considers to adopt these interventions depends on their budget and their ICER threshold, such as the crude WHO rule of thumb (however contentiously debated) at 3 times a country’s GDP. By that standard, all of these interventions should be adopted by middle-income countries and in many low-income countries as well.

Figure 1. Nutrition interventions by their cost-effectiveness ratio as reported in the DCP3

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The spreadsheet also contains more information from the DCP3, including data on their health impact, feasibility of implementation, primary causes addressed, and annual incremental costs for scaling interventions. For more information on the detailed DCP3 columns which are obtained from the original DCP3 spreadsheet, you can refer to the original source here and here for Chapter 3 of the DCP3 as well as check out the new DCP4 FairChoices DCP Analytics Tool here.)

Key takeaways: what the crosswalk tells us

Here are our key takeaways after embarking on this crosswalk exercise and our version 1.0 of this crosswalk:

• First, the crosswalk table indicates that international guidelines regarding essential nutrition interventions are consistent—with the majority of interventions shared across at least two of the guidelines. The key interventions of breastfeeding, micronutrient supplementation, and integrated management of malnutrition are universally recognized.

• Second, there are at least 10 interventions are cost-effective, as highlighted in the crosswalk, including integrated management of severe malnutrition and assessment and management of child wasting, which emerge as the most cost-effective on the list. These two are also high priority for the new Child Nutrition Fund. (As a further caveat, the remaining interventions without an ICER on the list may also be cost-effective, but we are unsure. For this v1.0 of the crosswalk, we have not gone beyond what the DCP3 (2017) obtained from its additional literature reviews, and we are unsure whether cost-effectiveness was a criteria used in building the guidelines by the agencies.)

• Third, despite the existence of these guidelines, there is a lack of detailed guidance on how to integrate nutrition interventions into existing health systems or the implications of different delivery models on efficiency and feasibility, even when the specific interventions are known. This leaves policymakers and practitioners with gaps in how to integrate these interventions into health benefit packages, and importantly, how to transition from statements to reality—actually delivering these services to those who need them.

Our work does not stop here. We’ll continue to work on bridging these gaps and providing new knowledge about how to ensure successful integration. Stay tuned for more work on folding nutrition into benefit packages!

With thanks to Emily Smith, Han Sheng Chia, and colleagues at USAID, the World Bank, UNICEF, and others.

Annex. List of 50 nutrition interventions from seven nutrition guidelines, ranked by cost-effectiveness from the DCP3 when available