Malnutrition :how much is being spent ?
An analysis of nutrition funding flows 2004-2007
November 2009

Cover photo: Kazuma Momoi
Back cover photo: Alice Davies / MSF
Cover design and layout: Daniel Jaquet

Malnutrition: how much is being spent? • 1

Executive summary
How much is the world spending on the treatment andprevention of childhood malnutrition? This Médecins
Sans Frontières (MSF) report aims to answer thiscomplex question.
An understanding of the precise levels of funding dedicated to malnutrition is essential for two reasons:• to assess the trends in the financing of malnutrition,
the only costing exercise previously undertaken only
covered the years 2000-2004;• to compare what is being spent with what is needed.

Funding levels are flat and insufficient
Malnutrition should in recent years have benefited
both from the global renewed interest in the problem,and from the emergence of a broad consensus within
the nutrition community enabling the scale up of activities in high-burden countries. Yet this analysis of theinternational funding flows dedicated to nutrition findsthat funding has remained more or less flat, stuck atroughly the same level since 2000-2004.
The previous review, by Morris, Cogill and Uauy andpublished by The Lancet in 2008,1 estimated that the‘total donor investment in basic nutrition in low-income
and middle-income countries probably did not exceed
US$250-300 million a year’ for the period 2000-2004.
For the period 2004-2007, based on data collectedfrom the OECD, ECHO, the World Bank and othersources, we estimate international funding of nutrition
programmes fell within a range of $185 million to $511
million a year. We have concluded that $350 million ayear is the most realistic estimate of funding for nutrition within that range. Exact figures are not possible,
as existing funding reporting mechanisms were foundto contain, within nutrition reporting lines, activities
with little or no nutrition objective.
Our estimate of $350 million at first glance appears
to reveal a modest rise of $50 million in funding since
the analysis published in The Lancet. Not so: if the

1
2
3
4

5

same scope as the study published in The Lancet had
been used, nutrition funding would have remained
unchanged.
Not only is the amount dedicated to malnutrition stagnating, it is also falling drastically short of the needs.
The World Bank’s most recent costing exercise puts
at $12.5 billion the yearly funding needs to enable
the scale up of the nutrition package2 in the 36 highburden countries 3 and the 32 small countries 4 withhigh prevalence rates. Funding dedicated to nutrition
will need to be increased considerably if malnutrition is
to be overcome. This will require political commitment
from donors, recipient countries and internationalorganisations.

Money is not being spenton the right things
We found that barely 1.7% of interventions reported
as ‘development food aid-food security’ and ‘emergency food aid’ in the OECD database actually address
nutrition. 5 If interventions such as these are to beconsidered as a means to address malnutrition, thenfood security and food assistance projects (namely
food transfer, cash or voucher programmes) must be
targeted more precisely on nutrition as a main objective and be designed accordingly.
The World Bank recommended a package of interventions for the treatment and prevention of malnutrition.
Agreement must now be found to determine whichinterventions should be delivered at country level andhow to scale up prioritised interventions. Both areessential if we are to alleviate malnutrition blighting
the lives of so many children and their families. Suchan agreement would ensure a better allocation offunding resources and guide both donors and recipient
countries in determining policy. Much of the nutrition
funding gap could be filled not only by raising extra
resources, but also by improving existing food aid
funding practices.

The Lancet: Maternal and child undernutrition. Effective international action against undernutrition: why has it proven so difficult and what can be done toaccelerate progress? S S Morris, B Cogill, R Uauy. Feb 2008.
$11.8 billion - out of which $1.5 billion is expected to be raised from private resources - for a year of fully scaled-up programmes for the 36 high-burden countries.
Considering the needs of a further 32 countries with high prevalence rates would add 6% to this costing, reaching a total of $12.5 billion. “Scaling up nutrition:
What will it cost?” World Bank. 2009.
36 countries account for 90% of stunted children. They are: Afghanistan, Angola, Bangladesh, Burundi, Burkina Faso, Cambodia, Cameroon, Congo DR, Côte d’Ivoire,
Egypt, Ethiopia, Ghana, Guatemala, India, Indonesia, Iraq, Kenya, Madagascar, Malawi, Mali, Mozambique, Myanmar, Nepal, Niger, Nigeria, Pakistan, Peru, Philippines, South Africa, Sudan, Tanzania, Turkey, Uganda, Vietnam, Yemen, Zambia. Source: Black et al. 2008.
The World Bank identifies 32 countries as having prevalence rates of stunting or underweight children over 20%. They are: Albania, Bhutan, Bolivia, Botswana,Central African Republic, Comoros, Republic of the Congo, Ecuador, Equatorial Guinea, Eritrea, Djibouti, Gambia, Guinea, Guinea Bissau, Haiti, Honduras, Lesotho,
Liberia, Maldives, Mauritania, Mongolia, Namibia, Rwanda, Sao Tome & Principe, Sierra Leone, Somalia, Sri Lanka, Swaziland, Tajikistan, Timor-Leste, Togo,
Zimbabwe.
Included as nutrition activities were all direct and indirect interventions as classified by Institute of Development Studies, in addition to The Lancet list of interventions affecting maternal and child undernutrition, and to the World Bank’s package of interventions used for their costing exercise.

2 • Malnutrition: how much is being spent?

Money can be spent more efficiently
Food assistance must focus on addressing recipient
countries needs and not be based on donors’ interest.
Our analysis suggests that donors could maximise thefunds they do spend, by ceasing in-kind donations andinstead providing cash to finance food aid interventions, thereby allowing delivery of the most adaptedinterventions based on medical needs and at a cheapercost. This is particularly true for the U.S., for whomsuch a shift could save approximately $600 million –close to double the global amount estimated to focus
on malnutrition in any given year.

Data collection and reportingneed to be improved
The lack of a transparent funding tracking system toassess how much is dedicated to malnutrition must be
addressed. There is a great need to improve not only
the data collection and classification, but also measures to determine the specific outcomes – in terms of
malnutrition – of interventions described or classified
as ‘food security’ or ‘food aid’. More reliable and robust
indicators, enabling donors to assess their contribution to the treatment and prevention of malnutrition,
are essential to ensure evidence-based and outcomeorientated policy making. In addition, more researchmust be done to assess the levels of funding granted
at domestic level by non-OECD countries.

Malnutrition: how much is being spent? • 3

Context
Global emergency

Positive developments

Malnutrition is a medical and humanitarian emergency
that accounts for 11% of the global burden of disease,
contributing to the death of between 3.5 million
and 5 million children under age five each year, andleading to long-term poor health, disability and poor
educational and development outcomes.6 Worldwide,
178 million7 children are underweight, and 20 million8
suffer from the most deadly form of severe acutemalnutrition each year.

Malnutrition has nevertheless regained the world’s
attention in recent years. The 2007-2008 surge in foodprices, which increased the number of malnourishedchildren, brought home the urgency of the problem.

High malnutrition rates can be found in a limited
number of countries; 90% of stunted children livein 36 countries. A concerted and focused action onthese countries would drastically reduce child mortality
worldwide. Yet according to UNICEF, the problem ofundernutrition is worsening in 16 high-burden countries, with many more countries failing to progress
towards meeting the Millennium Development Goalof reducing undernutrition by half between 1990 and2015.9If we fail to act now, we can only expect more deaths,10more health care spending and further losses in
productivity.

Scientifically-proven, effective interventions to tackle
malnutrition have been documented,11 while the rollout of innovative treatment methods at the community
level has facilitated the development of projects on alarge scale. A number of countries have successfully
implemented national nutrition programmes, paving
the road for a massive scale-up of nutrition interventions in high-burden countries.
This highly dynamic context has triggered the establishment of various initiatives aimed at tackling hunger,
food insecurity and undernutrition. Some are led by
the United Nations,12 others are collaborations between
international organisations, 13 sometimes involving
private sector actors.14
In such a prolific environment, gaining understandingof the precise levels of funding dedicated to malnutrition appears essential for two reasons:• to assess the trends in the financing of malnutrition,
the most recent costing exercise covering the years
2000-2004;• to compare what is being spent with what is needed.
An estimate of the needs was most recently provided
by the scale-up costing analysis completed by theWorld Bank in September 2009 (see box on page 4).
The objective of this report is thus on the one handto assess whether the money spent on malnutrition isrising, stagnating or falling; and on the other, whether
it meets the needs required to reach the goals definedby the international community in the Millennium
Development Goals.15

6 Black RE, Allen LH, Bhutta ZA, Caulfield LE, de OM, Ezzati M, Mathers C, Rivera J & Maternal and Child Undernutrition Study Group (2008) Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 371, 243-260.
7 The Lancet, Black et al. 2008.
8 “Community based management of severe acute malnutrition” Joint statement - WHO, WFP, UNICEF, SCN. May 2007
9 Progress for Children: A Report Card on Nutrition (No. 4), UNICEF. 2006.
10 Severe wasting, stunting and intrauterine growth constitute the most important death risk factor of under-five children. The Lancet, Black et al. 2008.
11 The Lancet series(2008); The Lancet, Volume 374, Issue 9684, Pages 94 - 96, 11 July 2009, Copenhagen Consensus, World Bank.
12 The UN High-Level Task force (HLTF) was set up in 2008 after the global food crisis.
13 Global Action Plan (GAP) for nutrition, a collaborative process among many stakeholders including the World Bank
14 Global Alliance for Improved Nutrition (GAIN)
15 MDG1 includes the reduction by 50% of the proportion of children being underweight, while MDG4 includes the diminution by half of the under 5 mortality rate.
These objectives are to be reached by 2015.

4 • Malnutrition: how much is being spent?

How much is needed for malnutrition?
In 2009, the World Bank completed an estimate16 of thecost of scaling up nutrition programmes. The cost estimation is based on a set of 13 interventions supportedby the latest scientific evidence and identified as necessary for 36 high-burden countries. The interventions –to be implemented according to each country’s capacity– were classified in the following three categories:
Complementary and therapeutic feeding interventions:
For children 6-23 months of age: provision of micronutrient fortified and/or enhanced complementary foods
for the prevention and treatment of moderate malnutrition: $3.6 billion per year. For children under 5 yearsof age: community-based management of severe acutemalnutrition: $2.6 billion yearly.
Micronutrients and de-worming: For children under
the age of five: periodic vitamin A supplements,
therapeutic zinc supplements for the management of
diarrhoea, multiple micronutrients, and de-worming
drugs. For pregnant and lactating women: iron-folic
supplements as well as iodised oil capsules where
iodised salt is not available. Iron fortification of staple
foods and salt iodisation will be made available for thegeneral population. The total cost for these interventions would amount to $1.5 billion yearly.

Behaviour change interventions: Will be delivered
through community nutrition programmes and include
breastfeeding, complementary feeding, and hygiene
promotion. The total funding required for community
education would amount to $2.9 billion.
Considering a further $1.2 billion is needed for capacity
and research, the estimated amount of additional
funding needed to address undernutrition therefore
comes to approximately $11.8 billion for a year of fully
scaled-up programmes for the 36 high-burden countries.17 Considering the needs of a further 32 countries
with high prevalence rates would add 6% to thiscosting, reaching a total of $12.5 billion.18
The World Bank considers some funds could be reallocated from existing governments budgets, and that
more could come from private sources. But these could
only fill the funding gap to a minor extent, and the$12.5 billion needed should come essentially frompublic sources, be it through domestic programmes orinternational aid.

The Lancet series
The starting point for this analysis, used as a baseline for comparisons and trends, was the estimateof malnutrition programmes funding included in the
recent The Lancet nutrition series, covering the years
2000-2004. In their analysis, authors Morris, Cogill andUauy acknowledge “the difficulty in isolating a discrete
set of nutrition investments”, as “each donor’s financial management information system is different, withfew routinely reporting on maternal and child nutrition
as a distinct budget line.”

During the course of our research, it appeared that thisinformation needed updating and expanding – somemajor donors, the European Commission for example,
were not included in The Lancet exercise. A closer lookat this baseline figure provided in The Lancet is therefore useful.

16 “Scaling up nutrition: What will it cost?” World Bank. 2009.
17 The World Bank costing exercise estimates that $1.5 billion for the food-related costs could be borne by ‘wealthier affected households…through additional market
purchases…leaving a total for other financing, domestic and external, of $10.3 billion’.
18 36 high-burden countries accounting for 90% of stunted children, and 32 countries with high prevalence rates of child stunting and/or underweight children over 20%.

Malnutrition: how much is being spent? • 5

What The Lancet estimate does and does not include
In their funding analysis covering the years 2000-2004,
authors Morris, Cogill and Uauy analysed the recordsof the creditor reporting system managed by the Development Assistance Committee of the Organisation for
Economic Co-operation and Development (OECD DAC).
This was a welcome attempt to analyse the information but also illustrated the difficulties in so doing. Our
analysis builds and adds to that work.
The database is the main source of information available, providing statistics on bilateral and multilateralaid flows from donors to developing countries. The
OECD DAC provides guidelines to help countries determine the most appropriate project code to classify
data, but the final responsibility for coding lies withthe donor.
In the database, the ‘basic nutrition’ category is themain code dedicated to classify nutrition activities.
Only aggregated amounts classified as ‘basic nutrition’ were considered in the analysis published in The
Lancet. During our research, we came to the conclusionthat we could not rely on aggregated data from the
DAC database and decided to analyse the data further(see methodology).
Instead of just relying on the OECD aggregated data,
we downloaded the source database from the OECD
website.19 In this database, each line corresponds toa funding flow of one donor, which is classified indifferent ‘purpose codes’ according to the DAC classification. We selected the lines corresponding to thecategories in which nutrition programmes could befound. We then reviewed all the lines selected andassessed each activity for its relevance for malnutrition. We found that interventions targeting malnutrition were included under a number of other categories,

so some funding had thus been missed by The Lancet
estimate. At the same time, because interventions
reported in the OECD database under the ‘basic nutrition’ code were not always appropriately classified, andincluded non-nutrition projects, on several instances
The Lancet estimate included monies that should nothave been considered.
In addition, The Lancet estimate either does not include
or underestimates the contribution of some additional
funders of nutrition interventions, such as the European Commission and Médecins Sans Frontières. It
did, however, include a number of other sources in theanalysis. One is the Bill and Melinda Gates Foundation,
which as a private foundation does not report overseas
aid to the OECD.
Deeming the World Bank’s contributions (via the International Development Association) to malnutrition
financing to be ‘grossly underestimated in [the OECDdata used in The Lancet] analysis’, The Lancet authors
included a ‘nutritional portfolio total’ for the World
Bank, communicated to them directly by the Bank.
The Lancet figure for 2000-2004 therefore includes boththe World Bank’s communicated portfolio total and theinterventions financed by the Bank and included in theOECD database. Those funds included in the OECD database as World Bank – a total of $23.3 million – may thus
have been counted twice in The Lancet estimate (seetable below), a poignant illustration of the lack of clarity
surrounding the global financing of nutrition activities.
Authors Morris, Cogill and Uauy acknowledged thisuncertainty by estimating that the international
financing of nutrition ‘probably did not exceed $250300 million per year’.

Average annual commitments for nutrition, 2000-2004. Morris, Cogill and Uauy
OECD database“Basic Nutrition”

World Bank data,
direct communication

Gates
Foundation

Total

Lancet estimate
as published$123.8$120$25$268.8Lancet estimate excluding
World Bank OECD data

$100.5$120$25$245.5Figures in millions of $19 www.oecd.org/dac/stats/idsonline. Consulted in April 2009.

6 • Malnutrition: how much is being spent?

MSF methodology‘Core funding’ and ‘mixed funding’

The main available source of information used for thisstudy was provided by the OECD Development Assistance Committee,20 whose database tracks different
donors’ development assistance flows. The funds areclassified under different purposes and sectors codeson a yearly basis. For the purpose of this report, wehave looked at the years 2004-2007.

Each project line of the OECD database reported as‘basic nutrition’, ‘basic health’, ‘development food aid
and food security’, ‘emergency food aid’ and ‘emergency distress’ was analysed, thereby considerably
broadening the scope of the analysis published in
The Lancet which looked at ‘basic nutrition’ interventions only. All data was transferred to form a databaseof about 57,000 lines. We searched for key words
describing direct and indirect nutrition interventions(such as nutrition, severe, complementary, CTC, zinc,etc.) in order to facilitate the data analysis.

In addition, other sources were consulted:• The World Bank data on funding commitments for
2004-2007 was provided through personal communication and split over four years on the assumption ofa linear disbursement. To avoid double-counting, wehave chosen to remove those figures declared by theWorld Bank in the OECD database.
• European Commission Humanitarian Aid Office (ECHO)
funding includes grants awarded in 2007. In the same
way as with the World Bank data, we considered
the data communicated directly to us by ECHO andexcluded from the OECD database all interventions
financed by ECHO. Interventions financed by other
European institutions (other than ECHO) were left in
the OECD database. Information from previous years
was not made publicly available.
• The Bill and Melinda Gates Foundation grants havebeen taken from the Foundation’s website for theyears 2004-2007.
• UNITAID, established in late 2006, provided budgetsof the orders placed for the provision of Ready-to-Use
Therapeutic Foods as a part of the UNITAID/Clinton
Foundation HIV/AIDS project for 2007. UNITAID’s
budget relies on a number of governmental contributions and levies on airplane tickets.
• Médecins Sans Frontières (all sections) fundingflows are included in this study. The information
corresponds to effective disbursement on nutrition
programming only for 2005-2007 – the cost of supervision and support by headquarters is not included.
Note that for some of these sources (the OECD, World
Bank, the Gates Foundation, ECHO) the figures usedcorrespond to funding commitments. For others (MSF,
UNITAID) they refer to actual disbursements. In each case,the most reliable and homogenous data was selected.

One major difficulty in assessing the levels of funding
dedicated to malnutrition is that reported activities do
not reveal anything about the efficacy and efficiency ofinterventions. In addition, much of the data collected
was found to be loosely classified, with the risk thatfunds reported as targeting malnutrition were in factof little relevance. With the aim of establishing asprecisely as possible how much funding is dedicatedto targeting malnutrition, the data were thus codified
and sorted into two categories.
First, interventions which corresponded directly to any
nutrition activity or project including a nutrition objective were classified as ‘core’ nutritional funding. This
included any activity whose title and description showsnutrition as the single objective, e.g. growth promotion, supplementary feeding, micronutrients, targetedfood aid, nutrition education, etc. Included as nutrition activities were all direct and indirect interventions
as classified by Institute of Development Studies,21 inaddition to The Lancet list of interventions affecting
maternal and child undernutrition, and to the WorldBank’s package of interventions used for their costing
exercise (see box on page 4).
Second, interventions which corresponded to bothnutrition activities and another type of activity (e.g.
other health objectives, food security, and hygiene)
were classified as ‘mixed’ nutritional funding. Food aid
activities that are not pursuing a nutrition objective
were classified under a food aid category.
The figure below gives a graphical representation of
the funding analysis.

Funding Flows - Data from OECD, ECHO, World Bank, Gates, UNITAID and MSF
Funding flows for which nutrition activity is thecentral component and principal objective

Funding flows corresponding to a variety ofoutcomes, among which the share of nutrition
activity can not be estimatedCore Funding

Mixed Funding

20 www.oecd.org/dac/stats/data. Consulted in April 2009.
21 Institute of Development Studies; Greater DFID and EC leadership on chronic malnutrition: Opportunities and Constraints. A Sumner, J Lindstrom, L Haddad. April
2007. “Direct interventions tend to address the immediate determinants of chronic malnutrition while indirect interventions tend to address the intermediate determinants”.

Malnutrition: how much is being spent? • 7

Results
Higher, lower and central estimates
In our attempts to assess the precise amount offinancing dedicated to malnutrition programmes, wefound high levels of inaccuracy or imprecision in theexisting reporting mechanisms.
Having separated activities with a ‘core’ nutritional
objective from activities where nutrition was but oneof several objectives, and for which the precise levelof funding allocated to addressing malnutrition was
therefore impossible to determine, we collated thedata to produce the following three estimates:
A higher estimate, including both core and mixed
funding flows. Such a scenario is equivalent to considering that when nutrition programmes are mixed withother activities, the weight of the latter is negligible.
A lower estimate, including only core funding flows
and excluding all mixed funding. This scenario
assumes that the weight of nutrition activities within
the programmes that also have a non-nutritional
element is negligible.
A central estimate, considering both the higher andlower estimates to be unrealistic, such a scenario
hypothesises that 50% of the amount of the mixed
funding is dedicated to nutrition activities.

The OECD Development AssistanceCommittee database
The Lancet analysis puts the total commitments
reported in the OECD DAC database under the ‘basic
nutrition’ purpose code at an average $124 million ayear for the period 2000-2004.
Our own analysis of the period 2004-2007, findingthat some interventions targeting malnutrition are
inappropriately classified under other OECD codes,
extends the accounting exercise to five purpose
codes. At the same time, many activities reported as‘basic nutrition’, could not be referred to as nutrition
activities per se – we found projects financing thebuilding of a dining room, generic poverty alleviation
or ecological forestry, for example. $45 million out of
the $160 found in this classification had no nutrition
objective.
Having classified the data, we reached a central estimate for funding allocated by OECD countries to nutrition: $171 million a year for the period 2004-2007.
More than half (53%) of the total flows dedicated tomalnutrition were in fact found under codes other than‘basic nutrition’ – an illustration of the extent to whichinterventions are misreported, and hence the tracking
exercise rendered more difficult.

The results obtained are given in the table below.
The total amount of funds dedicated to nutrition thus
ranges between $185 and $511 million annually during
the period 2004-2007. Based on our central estimate,
the annual commitment was more likely to be close to$350 million annually, over the period 2004-2007.

Higher, lower and central estimates by main donors
OECD DAC					(excl. World		
Gates
Bank & ECHO) World Bank
FoundationECHOUNITAID

MSF

Commitment
2004-2007

Commitment
2004-2007

Commitment
2004-2007

Commitment
2007

Disbursement
2007

Disbursement
2005-2007

Total

Lower estimate

74.4

-

26.2

39.9

4.4

40.3

185.2

Central estimate

171.2

48.1

26.2

58.0

4.4

40.3

348.2

Higher estimate

268

96.3

26.2

76.1

4.4

40.3

511.3

Figures in millions of $

8 • Malnutrition: how much is being spent?

Commitments to OECD
DAC under five purpose codes (excluding World Bank and ECHO contributions)			OECD DACPURPOSE CODE				
Yearly commitments
2004-2007		$ millions% of total

Yearly commitments actuallyCentral, lower and higher estimates
dedicated to malnutrition			
core+mixed				Central estimate
Higher andlower estimate$ millions% of total$ millions% of total

Basic nutrition

160
2%
115
43%
81
47%
						

High: 115
Low: 46

Basic health

1 285
14%
70
26%
36
21%
						

High: 70
Low: 2Development foodaid and food security

1 399
16%
23
9%
12
7%
						

High: 23
Low: 1

Emergency food aid

1 845
20%
33
12%
28
16%
						

High: 33
Low: 23

Emergency distress

4 333
48%
27
10%
14
8%
						

High: 27
Low: 2

Totals

9 022
100%
268
100%
171
100%
						

High: 268
Low: 74

Some remarks:• Activities for which nutrition is the central expected
outcome accounted for barely 1.9% ($171 million outof $9,022 million) of all funds reported in the OECD
DAC database for the five categories.
• Within the ‘basic nutrition’ OECD purpose code,
activities for which nutrition is the main expected
outcome represent barely 29% of the total ($46
million out of $160 million). The rest includes a rangeof activities where nutrition is not predominant.
• Within the ‘basic health’ purpose code, only $2
million out of the $1,285 million of funds reported
were allocated to activities for which nutrition is themain expected outcome. For ‘emergency food aid’and ‘development food aid and food security’, theproportion is similarly low. This illustrates how mostfood aid or food security activities do not exclusively
pursue a nutrition outcome and were excluded fromthis study – this is the case for school feeding interventions, for example, when the principal objective iseducational (school attendance). Another example isprovided by monetised food aid programmes which
are designed to generate cash for other activities,
and which may or may not be used for nutrition
activities.
• Only 62% ($46 million out of a total $74) of activities for which nutrition is the main expected outcome
were reported in the ‘basic nutrition’ purpose code.
38% of the funding targeting malnutrition was thus
spread over the other project codes.

The World Bank
The World Bank funds are channelled through two
main development institutions: the International Bankfor Reconstruction and Development, which provides
loans to middle-income developing countries, and theInternational Development Association, which offersinterest-free loans or grants to the poorest countries.
The figures presented in this analysis are those
provided directly by the World Bank.22 In order to avoid
double-counting, we have removed all World Bank
commitments from the OECD database.
The World Bank’s global coding system collapses bothfood security and nutrition projects under the samecode. It is therefore impossible to extract nutrition
projects from the overall data, so we have considered
all World Bank commitments as being ‘mixed’ funding.
The yearly commitment across the fiscal years 20042007 averages $96 million. 23 For the years 20002006, the same source gives a yearly commitment by
the Bank of $90 million, contrasting with the figure
published in The Lancet study of $120 million.

22 Personal communication with, inter alia, Meera Shekar, Lead Health and Nutrition Specialist, HDNHE World Bank.
23 Personal communication with World Bank. 2009.

Malnutrition: how much is being spent? • 9

The European Commission
Humanitarian Aid Office (ECHO)The European Union is a major contributor to nutrition
and food aid humanitarian interventions. These activities are funded through the DG ECHO general humanitarian aid budget and include a share for ECHO specificfood aid budget lines targeting life-saving activities andlivelihood activities.
Determining precisely on what the European Commission’s funds are spent is not possible through the OECD
DAC database, as the project titles include a budget
code line that made precise analysis impossible. As
with the World Bank data above, therefore, the figures
presented in this analysis are those provided directly by
ECHO.24 Data was however only available for 2007.
In order to avoid double-counting, we have removed
all ECHO commitments from the OECD database. Our
central estimate puts the 2007 contribution of ECHO tonutrition at $58 million – this represents barely 5.7%of ECHO’s total budget of $1 billion.25 ‘Core’ nutrition
funding totalled $40 million, with another $36 million
spent on nutrition interventions, associated with otheractivities and objectives (i.e. ‘mixed’ funding).
ECHO also finances the World Food Programme to thetune of $215 million (almost a quarter of its total budget),of which barely 6% is actually dedicated to nutrition, thevast majority going to food assistance projects. A further$40 million is given to UNICEF, of which only 22% goesto support nutrition interventions.
Note that other (non-ECHO) European Commission grants
were counted in the overall OECD database. The central
estimate puts at a further $20 million the annual contribution of European agencies other than ECHO (mostly
through the European Development Fund) to nutrition.

Médecins Sans Frontières (MSF)

bilateral or multilateral donors have been removed fromthe OECD and ECHO databases. We have chosen to
include only those projects with a core nutrition objective, excluding projects where nutrition is a secondary
component. The cost of supervision and headquarters
support are not included in the figures.
Over the years 2005-2007, MSF disbursed more than
$40.3 million per year on nutrition programmes. Someof the activities supported by the organisation takeplace in contexts of acute needs. They included therapeutic treatment, supplementary feeding and targeted
feeding programmes as main activities.

UNITAID
UNITAID is a specialised organisation that contributes
to scaling up access to treatment for HIV, Malaria andTuberculosis. UNITAID supports nutrition activities aspart of a joint project with the Clinton Foundation HIV/AIDS Initiative on paediatric HIV/AIDS and preventionof mother-to-child transmission, and provides ready-touse therapeutic foods (RUTF) to address malnourishedpatients’ nutritional needs.
In 2007, UNITAID allocated $4.4 million to the purchaseof RUTF. Since then, UNITAID’s contribution has almost
doubled, with more than $8 million budgeted in 2009.26

Bill and Melinda Gates Foundation
The Bill and Melinda Gates Foundation is the largest
private grant-making foundation and has a very large
portfolio of grants supporting global health.
All data regarding Bill and Melinda Gates Foundation’s
grants is accessible from their website. For each grant
the following are available: the name of the grantee, thegrant’s duration, purpose, region served and amount.
Data for each nutrition grant was extracted and transferred on an excel spreadsheet.

MSF as a medical emergency organisation has been
deeply involved in nutrition, particularly the treatment
of severe acute malnutrition. In 2007, MSF treated over
120,000 children affected by severe acute malnutrition,
making it the biggest actor in the world in the field of
severe acute malnutrition care.

Over the years 2004-2007, no fewer than 10 grants wereawarded in this sector for a total of $105 million, representing $26 million yearly. Gates funding of nutrition
increased from 2004 to 2006, then fell in 2007 before asharp increase in 2008 – a rise so steep that including
data for 2008 would increase the 2004-2008 average
to $46 million per year. Yet 2008 data has not been
included in this study, whose scope extends to 2007.

MSF data presented in this study includes direct
programme funding for the years 2005-2007. To avoid
any double-counting, MSF nutrition projects funded by

The Gates Foundation supports two different broad areas
as a part of their nutrition portfolio. The most important

24 Personal communication with ECHO A6 Information and Communication.
25 €732 million. The € to US exchange rate applied is 1,37 for 2007.
26 UNITAID is funded by the collection of air ticket taxes and regular contributions by countries.

10 • Malnutrition: how much is being spent?

encompasses support to think tanks and research institutes in various areas: agricultural research (such as ricefortification), market-based models to increase accessto fortified complementary food for children, researchon undernutrition, workshop on growth standards andmicronutrients, etc.
The second broad category represents 40% of the budget.
This includes support to operations in the area of foodfortification, including vitamin A, iron and zinc fortification.
Fortification would thus appear to draw the core fundingof Gates Foundation in the area of nutrition. Universities
and research institutes are the main recipients of thisfunding, attracting 43% of the budget, with support for
United Nations institutions and the Global Alliance for
Improved Nutrition (GAIN) coming second.

Who are the major donors?
Using the central estimates based on data provided
directly by donors or included in the OECD database, thefollowing ranking is obtained:• the European Commission ($78 million in 2007, with
DG ECHO at $58 and other agencies at $20 million)• World Bank ($48 million)• Canada ($30 million)• United States ($30 million)• UNICEF ($30 million)• Bill and Melinda Gates Foundation ($26 million)• United Kingdom ($25 million)• Spain ($15 million)• Asian Development Fund ($13 Million)• Norway ($5 million).
MSF allocates $40.3 million annually which ranks theorganisation as the third main contributor to nutrition
activities.
These figures, averages over the past four years, disguisecertain trends – with the proviso that the scope of thisstudy is limited to four years, and that many of the dataclassified as nutrition activities do not appear to havea main nutrition activity. Since 2004, major contributors
such as the United States or the United Kingdom appear
to have reduced their efforts on nutrition funding, whilea few others like Spain, Canada and UNICEF have greatly
reinforced their commitment. Although data from 2008
was not included, the information made available to us
suggests that donors such as UNICEF, the Gates Foundation, and Spain for example have further increased theircommitment.

27 Personal communication with World Food Programme. 2009.

Non-OECD countries
The scope of this study includes the main OECD donors andsome private funding initiatives. Other private or governmental funding on nutrition could not be included, due tothe complexity of tracking funding from these sources. No
reporting system exists to centralise this information.
Further research is needed to assess non-OECD countries’
contributions to tackling nutrition. High-burden countries– and particularly middle-income countries whose weightin the financing of multilateral organisations is increasing– have the capacity to contribute to the international
funding of malnutrition. Between 2004 and 2007 forexample, non-OECD countries contributed an annual $140
million27 to World Food Programme appeals.
In addition, this study focuses solely on internationalaid – and thus does not consider nationally funded
programmes. Yet these are potentially massive contributions to treating and preventing malnutrition. India’snational nutrition programme, for instance, is funded by
the federal state budget up to $1.4 billion a year.
Other high-burden countries may, like India, be in aposition to fund part of their national nutrition schemes,
thus bearing a share of the estimated funding needs as
detailed in the World Bank costing exercise. Additional
research is required in this respect.

Who are the major recipients?
Using the central estimates, close to 40% (or $68.3
million per year) of nutrition funding flows were allocated to sub-Saharan Africa, within which the mainrecipient countries included Sudan, Ethiopia, Somalia,
Niger, Kenya, Zimbabwe and the Democratic Republicof Congo.
17.7% of funds were allocated to South and Central Asia
– of which two thirds were channelled to India, Bangladesh and Afghanistan – and 10.3% to Asia/Pacific region,
with Indonesia receiving 75% of these funds.
This shows that recipient regions have changed little over
the years, although major nutrition emergencies can alter
the ranking in the short-term. There is strong correlation
between regions receiving funding dedicated to nutritionand countries that are the main food aid recipients.
It is worth noting that almost 23% of the funds do
not have any precise destination country (labelled as‘unspecified’, and representing multi-country allocationsof bilateral or multilateral aid), further clouding any
attempt to track comprehensively the flows of international funding dedicated to malnutrition.

Malnutrition: how much is being spent? • 11

Discussion and recommendations
Is the amount that is being spent risingor falling and is it sufficient?
Our estimate of $350 million a year at first glance
appears to reveal a modest rise in funding since theanalysis published in The Lancet put funding at $250300. Not so: if the same scope as the study publishedin The Lancet had been used, nutrition funding would
have remained unchanged.
Had the MSF analysis reproduced the exact methodology used in The Lancet analysis, the 2004-2007
annual levels of funding attributed to malnutrition
would have reached $366 million. However, given that
the World Bank is now more active in reporting to theOECD DAC database, the amounts contributed by the
Bank and double-counted in The Lancet methodology
have increased considerably (from $23 million in 20002004 to $88 million in 2004-2007). If one excludes
these double-counted World Bank commitments, andotherwise follows The Lancet methodology, the overalllevels of funding attributed to malnutrition for 20042007 reach $282 million – a figure thus unchanged
since The Lancet estimate of $250-300 million per yearfor 2000-2004.
This report however both expands the scope of theanalysis to other budget codes and includes further
institutions that have funded nutrition activities thatwere not included in the OECD database or reported
in The Lancet. Including ECHO, MSF and UNITAID in
the analysis has thereby increased funding levels by
more than $100 million a year. It is therefore likely that
global nutrition funding flows have stayed constant ataround $350 million a year.
In comparison to needs, funding is at a critically low
level. The World Bank costing exercise estimates needat $12.5 billion a year. In order to achieve a massive
scale-up of nutrition activities in high burden countries,
nutrition funds need to be expanded by more than 30
times their present level.28
Recommendation: Funding dedicated to nutrition mustrise considerably if we are to address the short- andmedium-term challenges in high-burden countries.
Most of the extra funding is expected to come frompublic sources, be it domestic programmes or international aid. Funding should be balanced between acuteand chronic needs and increased by around 30 times incomparison to the 2007 level. This will require politicalcommitment from donors, recipient countries and international organisations.

Is the money being spenton the right things?
Malnutrition29 is primarily a matter of public health– nevertheless, other sectors such as ‘food aid’ and‘food security’ may also form part of the response toaddress it. When looking at malnutrition, it is generally
admitted that various determinants act in synergy with
one level influencing another.30 The wide variety in thenature of interventions being funded is an illustrationof the two different paths31 to address malnutrition:
one, more immediate, focusing on health and nutrition
services, and the other, more long-term, targeting birth
spacing, food and agricultural policies, and education.
We found that programmes classified as ‘food aid’ or‘food security’ do not always seek to achieve a nutrition outcome – in fact barely 1.7% of interventions
reported as ‘development food aid-food security’ and‘emergency food aid’ in the OECD database actually
address nutrition.32 If interventions such as these are
to be considered as a means to address malnutrition, then food security and food assistance projects(namely food transfer, cash or voucher programmes)
must focus more precisely on nutrition as a main objective and be designed accordingly.
During its costing exercise, the World Bank recommended a novel package of interventions for thetreatment and prevention of malnutrition. Agreement
must now be found to determine which interventions
must be delivered at country level and how to scale up
prioritised interventions. Both are essential if we areto alleviate malnutrition blighting the lives of so many
children and their families. Such an agreement wouldease a better allocation of funding resources and guideboth donors and recipient countries in determining
policy.

28 Even if in 2008, based on UNICEF, Gates, and EU available data we can assume that donors have increased their commitment, further steps need to be taken bydonors to reduce the difference between the requirements and the funds allocated.
29 Undernutrition is most often the result of acute or sustained inadequate access by people of all ages (including in utero babies) to dietary intake and/or illness.
It can refer to stunting whose consequences include physical and mental impairments (e.g. low height for age, poor psychomotor development, lower cognitive
development and ability) with long-term effects on learning and working capacities; wasting (thinness); and nutritional oedema and/or deficiencies of micronutrients(vitamins and minerals). Undernutrition exacerbates vulnerability to diseases and may lead to premature death.
30 Malnutrition causal analysis scheme (immediate, underlying, basic causes) http://fex.ennonline.net/18/causal.aspx
31 “Repositioning nutrition as central to the development. A strategy for large scale action.” World Bank. 2006.
32 Included as nutrition activities were all direct and indirect interventions as classified by Institute of Development Studies, in addition to The Lancet list of interventions affecting maternal and child undernutrition, and to the World Bank’s package of interventions used for their costing exercise.

12 • Malnutrition: how much is being spent?

Much of the nutrition funding gap could be filled not
only by raising extra resources, but also by improving
existing food aid funding practices.
The nutrition outcome of funds allocated to ‘food
assistance’ and ‘food security’ should be reinforced.
This would ensure that funds already invested effectively contribute to addressing malnutrition.
Recommendation: Amounts allocated by donors tofood aid and food security should be optimised fortheir nutrition impact, and must include a nutrition
outcome. In order to better shape policy, there is aneed to endorse a series of proven interventions to
be delivered in high-burden countries. These interventions should be designed according to strategies
defined in coordination with recipient countries withtechnical support from agencies. The package to bedelivered and funded should be defined according toeach context.

Could the funds be spent
more efficiently?
We found that a shift in U.S. food aid purchasing
policies could plug a considerable proportion of thegap. If, instead of relying on in-kind transfers, where
food produced in the U.S. is shipped abroad, the U.S.
chose to adopt a policy of locally purchasing food, thiswould free up about $600 million. The U.S. Government
Accountability Office33 estimates that in sub–SaharanAfrica, the cost of U.S. in-kind deliveries is 34% higher
than local or regional purchase.
Indeed, according to the OECD DAC database, out ofa total $2 billion a year of food aid committed by the
U.S. government, more than $1 billion goes to freightcosts supporting U.S. national carriers’ interests. Using
the figures given by the Government Accountability
Office to estimate the cost differential between in-kindand local purchase for each region, we found that local
purchase could save approximately $600 million a year
– a considerable sum that could easily be reallocatedto the neediest countries every year.34

Recommendation: Governments should cease in-kind
donations and instead provide cash to finance foodaid interventions and allow delivery of the mostadapted interventions based on medical needs andat a cheaper cost. Food assistance must focus onaddressing recipient countries needs and not be basedon donors’ interest. The U.S. government in particularshould speed up the reform of its food aid assistanceand reallocate funds which are currently designed moreas a support to national interests35 than to address
malnutrition.

What should be done
about data collection and reporting?
This study has shown that it is difficult to track annual
funding dedicated to malnutrition. Contributions arescattered across different activity sectors, including
those other than malnutrition, such as health, food aid
and food security. The codification done by the OECDis perhaps the most accessible and developed system
to date. Nevertheless, improvements to the monitoring
system are required.
At the same time, activities are all too often funded ina joint envelope with other activities, which prevents
transparent accounting of the funds exclusively
committed to nutrition. To overcome this uncertainty,
we have used lower, central and higher estimates.
That only 36% ($185 out of $511 million) of the total
funding dedicated to nutrition can be said without
doubt to pursue nutrition objectives is a measure of
the uncertainty surrounding the amounts being spent
today.
Recommendation: Nutrition funding should be
earmarked to allow accountability and transparent
tracking of activities funded. This should be done atdonor level to allow follow-up on nutrition within theOECD database. In addition, more research must be
done to assess the levels of funding granted by nonOECD countries.

These funds could be invested on a package of foodassistance in high-burden countries or on the supplyof nutritionally adequate food for young children, thus
contributing to the reduction of child mortality.

33 United States Government Accountability Office (GAO). May 2009. Local and regional procurement can enhance efficiency of the U.S. food aid, but challenges may
constrain its implementation.
34 This move would actually require a change in U.S. law.
35 The bulk of U.S. food aid is supplied by national companies and shipped on U.S. flag carriers. According to the 1954 cargo preference act, 75% of gross tonnageof U.S. funded food aid is to be transported on U.S. flag vessels.

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