The Global Financing Facility for Women, Children and Adolescents (GFF) was set up to support the world’s most vulnerable countries in their efforts to strengthen their national health care systems, including improvements to RMNCAH-N (Reproductive, Maternal, Newborn, Child, Adolescent Health-Nutrition), advance universal health coverage (UHC), and achieve the Sustainable Development Goals (SDGs).
JCIE held its third seminar on the GFF with an eye to the upcoming 2021 Nutrition for Growth Summit, scheduled to be held in Tokyo in December. Building on the previous two seminars, which introduced the GFF and its role in addressing the impact of COVID-19 in GFF countries, the third seminar discussed the GFF’s partnership with Cambodia to improve that country’s nutrition for women, children, and adolescents as a case study to better understand the GFF’s approaches and results. The discussion featured three presenters, including Her Excellency Dr. Prak Sophonneary, under secretary of state of Cambodia’s Ministry of Health and deputy project coordinator of the Cambodia Nutrition Project, and two nutrition specialists, Anne Provo from the World Bank, and Leslie Elder from the GFF, who also oversees projects in Cambodia and Vietnam. Approximately 40 policymakers and experts attended from international organizations and from government, academia, civil society, and development agencies in Japan.
Malnutrition Status in Cambodia: Progress and Ongoing Challenges
H.E. Dr. Sophonneary started off the conversation with an overview of the undernutrition status in Cambodia and an introduction to the Cambodia Nutrition Project (CNP), which is led by the country’s Ministry of Health. Some of the main points she covered included the following:
- Despite progress in the last two decades, malnutrition remains a problem in Cambodia, as 32% of children under five are stunting, 10% are wasting, and 24% are underweight, and the prevalence is higher among children in rural settings.
- Breastfeeding rates have improved with 62.5% of newborn`s being breastfed within an hour after birth. Exclusive breastfeeding for newborns in their first six months increased to 74% between 2000 and 2010, but the rate has declined in recent years to 65% due to factors such as more mothers going into the workforce and less focus by the broadcast media to educate and raise awareness about the issue.
- In addition to suboptimal breastfeeding practices, key challenges in recent years include low diversity and frequency of foods for children between ages 6–23 months, limited access to and affordability of nutritional foods, and a wide disparity in access to and the use of health services among the population in rural and remote areas, particularly among ethnic minorities.
The Cambodia Nutrition Project (CNP): Promoting Prioritization & Cross-Sectoral Collaboration
In collaboration with the GFF, the World Bank, and other country donors, Cambodia launched the Cambodia Nutrition Project (CNP) in October 2019 as a five-year project (until 2023), aiming to improve the use and quality of maternal and child health and nutrition services for seven targeted groups in the country. In developing the investment case, the CNP placed priorities on 11 areas, including
1) antenatal care, 2) acute malnutrition, 3) delivery, 4) growth monitoring and promotion, 5) newborn care, 6) infant and young child feeding promotion, 7) postnatal care, 8) outreach, 9) sick newborns, 10) immunization, and 11) low birth weight.
The project targets rural/remote areas and particularly the ethnic minority populations in the seven provinces (population is approximately 1.7 million), and it has three main components:
- improving access and quality of priority services to achieve better nutrition, immunization, and neonatal services
- strengthening accountability for quality services at the community level, with a particular focus on improving nutrition.
- promoting social and behavioral change communication (SBCC) and strengthening monitoring and evaluation to achieve sustainable quality services
The CNP has helped place nutrition improvement as a priority on the government’s agenda. As nutrition is a cross-sectoral issue, the CNP also promotes cross-sectoral collaboration. The Ministry of Health leads the project and works with the National Committee for Subnational Democratic Development Secretary (NCDDS) for part of the implementation as well as with the Land Ministry, Ministry of Economy and Finance, and other relevant entities.
Despite being launched right before the COVID-19 outbreak, the CNP has made substantial progress to date. Going forward, the CNP is expected to reach additional provinces around the country. H.E. Dr. Sophonneary expressed appreciation for Japan’s leadership in supporting nutrition and UHC in Cambodia and her hope for further collaboration between the two countries through GFF and other means.
The World Bank Perspective—The GFF’s Comprehensive Engagement in Cambodia
The next speaker was Anne Provo, the World Bank’s nutrition specialist. She highlighted the CNP as having a bold agenda that brings together partners from multiple sectors and builds upon existing government health sector platforms to “mainstream” maternal and child health in these platforms. She discussed how the GFF’s engagement in Cambodia is a “comprehensive” one that includes not only co-financing, but also the development of an investment case to help with prioritization and the provision of technical assistance.
- Identifying priorities through the development of the investment case: In developing the investment case, the CNP engages multiple stakeholders and conducts systematic prioritization based on data and evidence, and identifies the “who, what, when, and where” to determine “priorities of priorities.” This is a unique process that helps focus on interventions that are truly effective in improving the wellbeing of women and children.
- Mobilizing additional grant resources for RMNCAH-N: Previously, Cambodia’s interventions and financing support for nutrition were fragmented. Despite a strong commitment within the Ministry of Health for the National Nutrition Program, that commitment was not necessarily translated into financing from the Ministry of Economy and Finance and other development partners. The Ministry of Economy and Finance previously tended to prioritize “hard” infrastructure investments over investments in “soft” issues such as RMNCAH-N. However, through robust dialogues with the Ministry of Economy and Finance and the development of the investment case, the Ministry of Health created a single agenda that multiple partners could unite behind under the CNP. It catalyzed the additional grant resources as pooled financing from the German KfW and Australian DFAT, while successfully securing US$12 million from Cambodia’s domestic resources by mobilizing US$15 million grants from the IDA. This financing process helped “mainstream” RMNCAH-N in the country and will be crucial to sustain the government’s commitment to RMNCAH-N in the future.
- Technical Assistance: GFF resources have provided expertise and technical support to the government entities in project design, implementation, evaluation, and monitoring. As H.E. Dr. Sophonneary discussed, the GFF has sent experts to support the design of the SBCC strategy. The GFF has also promoted knowledge sharing between Cambodia and other countries such as Indonesia, and has strengthened the Cambodian government’s coordination with other bilateral and multilateral institution partners. In addition, the GFF has supported analytics around innovations, working with the private sector and looking at fortified fish powder and digital technologies, for example.
The GFF’s Global Impact on Nutrition & the Strengths of its Unique Model
As the final presenter, Leslie Elder provided the audience with a broader bird’s-eye view of the GFF’s work on nutrition by discussing their nutrition projects around the world and identifying seven features of the GFF’s approach that offer a unique value to the efforts to improve RMNCAH-N, and to recent efforts to tie malnutrition issues with the growing issue of obesity.
- In 21 of the 36 partner countries that have completed an investment case, all have included some nutrition interventions for women, newborns, children, and adolescents. Among the 31 projects that the GFF co-finances, 7 of the investment cases have a particularly strong nutrition focus, including projects in Cambodia, Democratic Republic of Congo, Guatemala, Indonesia, Malawi, Nigeria, and Rwanda, while the oGFF has a particular focus on addressing maternal and adolescent nutrition.
- The uniqueness of GFF’s approach in these countries includes the following:
- a strong focus on scale and sustainability through a country-driven approach
- promotes a whole-of-government engagement to address cross-sectorial issues such as nutrition
- identifies financing reforms to increase domestic resources for nutrition as well as to improve spending efficiency around nutrition or find ways to track nutrition expenditures
- makes efforts to integrate nutrition as part of strengthening health systems and achieving UHC.
- incentivizes countries to provide nutrition service through performance-based approaches
- works to maximize impact by reaching the most vulnerable populations
- strengthens data systems and strategic use of data to improve accountability
- Recently, the GFF has also been working with the WHO to integrate a “double-duty lens” into some of the GFF-supported investments to address both the issues of undernutrition, stunting, child wasting and malnutrition, and women’s anemia, as well as the growing issues of overweight and obesity, which lead to diet-related noncommunicable diseases. The effort is being made to integrate the actions on both sets of issues and to communicate with evidence, such as how exclusive breastfeeding can provide benefits early and later in life.
Q&A and discussion
Following the presentations, participants had an opportunity to engage in a Q&A and discussion, some of the highlights of which are summarized below:
The project and mobilization of grant resources would not have been possible without the multilateral coordination and ability for all stakeholders to align behind a single agenda. As a pre-condition, the Ministry of Economy and Finance needed to identify some grants in advance to engage with the GFF and other donors.
To convince political leaders and officials of the Ministry of Economy and Finance of the importance of improving nutrition, the team organized multiple workshops and meetings, using clear evidence to explain what nutrition/malnutrition is and how malnutrition impacts the country’s resources, including agriculture and rural development. Because nutrition is a multisectoral issue, the Ministry of Health worked with other ministries and donor countries that in turn helped enhance recognition within the government as a whole that malnutrition is a priority issue.
It took a long time for the project to launch. Advocacy efforts to obtain additional resources for nutrition began in late 2016, during a policy dialogue between the World Bank and the Cambodian government, and the two sides began to think of a project in mid-2017. In 2019, the project was officially approved. In that process, multisectoral support was critical to develop the project. One of the examples was that the Japan Trust Fund of the IPPF, which has an office inside the World Bank, offered key analytical resources for scaling up nutrition projects.
The CNP uses the disbursement-lined indicators (DLI) and other results-based instruments to facilitate timely and systemic disbursement of funds from the Ministry of Economy and Finance to the local governments. There are various incentives to ensure for the Ministry timely disbursements to local governments and partners, for example, they set a target for the Department of Budget and Finance to disburse funds within a certain time. It actually resulted in 80% of the health facilities receiving funds in a timely manner.
The CNP builds on the national nutrition and diet investment plan, and the project will not be successful or sustainable if the plan deviates from the national strategy and policy. The Nutrition Working Group under the Ministry of Health has coordinated with the development partners to ensure that the project is aligned with that national strategy and policy. There were various working groups and forums that included members of all relevant ministries and partners to present data and indicators on the health of women, newborns, children, and adolescents and determine priorities in these areas, as well as within the provinces. Progress was seen in the reduction of maternal and child mortality, but less so in neonatal mortality. Maternal and child undernutrition, particularly in stunting and wasting, also remained high, as well as adolescent fertility.
In the process of developing the investment case, stakeholders were involved in the discussion of what areas to prioritize, where in the country has a larger equity gap, what should be the key interventions, and how to implement the mechanism to mainstream and sustain the projects. It was the in-country stakeholders who reviewed the data and prioritized the investment, and in addition to formal workshops and forums, the Ministry of Health successfully organized multiple technical steering committees to engage a number of technical partners—primarily the WHO, but also the World Bank, UNICEF, and CSOs—to come together to support the creation of technical guidelines to implement projects through multiple processes. Thus, there were many opportunities for CSOs to get involved, and the SUN Civil Society Alliance especially played a key role in reviewing and endorsing guideline materials.