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Nutrition in Universal Coverage WHO/NMH/NHD/19.24

© World Health 2019. Some rights reserved.

Suggested citation: in universal health coverage. Geneva: World Health Organization; 2019 (WHO/NMH/NHD/19.24). Licence: CC BY-NC-SA 3.0 IGO.

Cover design and layout: Alberto March (Barcelona, Spain) Photo credits cover: ®Ingimage Printed in Switzerland

2 Nutrition in Universal Health Coverage Acknowledgements

his brief was produced by the World Health Organization (WHO) Department of T Nutrition for Health and Development, under the leadership of Francesco Branca, with valuable inputs from (in alphabetical order): Evelyn Boy-Mena, Lenio Capsakis, Luz Maria De-Regil, Marie Durling, Kaia Engesveen, Dorit Kjaer Erichsen, Diana Estevez, Habtamu Fekadu, Jessica Chi Ying Ho, Emma Feutl Kent, Lawrence Grummer-Strawn, Nadeem Hasan, Penny Howes, Dan Irvine, Lina Mahy, Genevieve Moseley, Juan Pablo Peña-Rosas, Anne Peniston, Ellen Piwoz, Katherine Richards, Kuntal Saha, Karin Stenberg, Niisoja Torto. ®Ingimage

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Nutrition in Universal Health Coverage 3 Key messages

Good nutrition is a basic need, a human right and is fundamental to health and well-being.

Universal health coverage cannot be achieved without ensuring everyone has access to quality nutrition services.

Malnutrition in all its forms increases the risk of and death. More than half of deaths in children under 5 years of age, and one in five adult deaths worldwide can be attributed to dietary risk factors.

The cost of addressing malnutrition and nutrition-related is significant, but losses to the wider economy are even larger, amounting to almost US$ 3.5 trillion annually. Business as usual is no longer an option.

Many nutrition interventions are highly cost-effective to prevent disease and reduce mortality and should be a central part of all comprehensive health systems.

Essential nutrition actions benefit the poorest, most vulnerable and marginalized populations and are, therefore, critical to fulfilling the promise of the 17 Sustainable Development Goals, leaving no one behind.

Primary is an important platform to achieve universal health coverage. However, essential nutrition actions are required at multiple levels of health service delivery, including secondary and tertiary care.

Governments and partners are encouraged to make policy and financial commitments to more fully integrate nutrition interventions into national health systems, as an important component for achieving quality universal health coverage.

Concrete measures are proposed to integrate nutrition-related actions into national health systems, to improve the coverage and quality of essential nutrition actions.

Coherent multisectoral action is required to make meaningful progress towards achieving the nutrition- and health-related Sustainable Development Goals, especially to make universal health coverage a reality.

4 Nutrition in Universal Health Coverage Call to action © World © World Bank

Nutrition in Universal Health Coverage 5 ® WHO

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6 Nutrition in Universal Health Coverage introductionIntroduction

ood nutrition is fundamental for achieving the right to health, embodied in G article 25 in the Universal Declaration of Human Rights (1). No country can achieve universal health coverage (UHC) without investing in essential nutrition actions, and good nutrition for all cannot be achieved without UHC.

UHC is achieved when all people receive the quality health services they need without suffering financial hardship. Out-of-pocket payments for health services push 100 million people into extreme every year (2). Suboptimal diet is the single largest driver of morbidity and mortality in the world, more than or high blood pressure (3). Malnutrition in all its forms significantly increases the risk of infectious diseases such as pneumonia, diarrhoea, measles and ; noncommunicable diseases such as heart disease, cancer and ; and Actors from every maternal and neonatal deaths (4). The cost of treating sector have a malnutrition and nutrition-related diseases is significant, but critical role to losses to the wider economy are even larger, amounting to play in supporting almost US$ 3.5 trillion annually (5). Thus, integrating essential governments to nutrition actions into health systems is foundational to deliver on UHC meeting people’s health needs and achieving UHC. plans

Building on the 2019 High-Level Meeting on Universal Health Coverage, political leaders around the world will gather at the 2020 Global Nutrition Summit, to discuss new financial and policy commitments for nutrition and UHC. As we are in the middle of the United Nations Decade of Action on Nutrition (2016–2025) (6), this is a historic opportunity to accelerate action on nutrition and transform health systems towards the integration of essential nutrition actions, delivering on the promise of people-centred health systems for UHC. We must seize this opportunity to ensure nutrition is part of the discussion on and financing. The clock is ticking, and the time to deliver on the promises of the 2030 Agenda for Sustainable Development (7) is now.

Nutrition in Universal Health Coverage 7 Malnutrition is real, is every where and has consequences

alnutrition is a significant problem in every country. Nearly one in three people around M the world has at least one form of malnutrition (8). Despite continuous improvements in health outcomes and economic development, rates of malnutrition remain unacceptably high and progress towards reducing its burden is too slow. Part of the reason for this is that nutrition has not been systematically addressed in health systems. There are three key characteristics of malnutrition:

1 It can take many forms, namely 2 It is ubiquitous, as malnutrition undernutrition (including wasting, in all its forms can be found stunting and micronutrient everywhere and often coexist deficiencies) and overweight, within individuals, households, obesity or diet-related communities and countries. noncommunicable diseases (8). This is referred to as “the double burden of malnutrition” (see Fig. 1).

3 It has immediate, lifelong and intergenerational consequences, jeopardizing the development of people, communities and nations.

A child with severe acute malnutrition is nine times more likely than a well-nourished child to die from common infections such as malaria, pneumonia or diarrhoea (13).

Stunting before the age of 2 years is associated with poorer cognitive and educational outcomes in later childhood and adolescence. It has been estimated that adults who were stunted in childhood earn up to 20% less compared to their non-stunted counterparts (14).

Rates of overweight and obesity worldwide have increased sharply in recent decades. From 1975 to 2016, there was a tenfold increase in overweight and obesity among children and adolescents (10). The prevalence of adult obesity has nearly tripled over the same period, with close to 2 billion adults now overweight or obese, contributing to

8 Nutrition in Universal Health Coverage Malnutrition is real, is every where and has consequences

Good nutrition is 4 million deaths per year and the loss of 120 million healthy imperative for all. years of life across the globe (10, 15, 16). It protects from illness, shortens the Children who are overweight or obese are at a higher risk of recovery time and developing type 2 diabetes, high blood pressure, asthma and reduces the risk of other respiratory problems, sleep disorders and liver disease death. later in life (17). In any of its forms, malnutrition affects the health and well-being, physical and cognitive development, and productivity of people, impacting the overall economic development of countries. Fig. 1 illustrates the double burden of malnutrition worldwide.

Fig. 1. The double burden of malnutrition

Sources: Data for children under 5 years of age for 2018, from reference (9); other data for children aged 5–9 years, adolescents and adults for 2016, figures were calculated based on data in reference (10) and as featured in reference (11); and data on women with anaemia are from reference (12).

Nutrition in Universal Health Coverage 9 Universal health coverage is essential to ensuring healthy lives and promoting well-being for all at all ages

niversal health coverage means that all people can use the health services they need U – promotion, prevention, treatment, rehabilitation and palliation – services that are of sufficient quality to be effective and do not expose people to financial hardship (18).

UHC embodies three related objectives: 1 2 3 equity in access to the quality of health people should be health services – services should be protected against everyone who needs good enough to financial risk, services should get improve the health ensuring that the cost them, not only those of those receiving of using services does who can pay for them; services; and not put them at risk of financial harm.

UHC is the cornerstone to achieving the The concept of universal health health-related Sustainable Development coverage is rooted in the belief that Goals, including SDG2 and SDG3 (19). the highest attainable standard of Many national governments view progress physical and towards UHC as a guiding principle for is a fundamental the development of health systems, and human right human development more broadly.

10 Nutrition in Universal Health Coverage Universal health coverage is essential to ensuring healthy lives and promoting well-being for all at all ages

As countries strengthen their national health towards or elimination of out-of-pocket systems and roll out their UHC roadmaps, payments such as user fees. By striving their journeys are marked by a progressive towards these objectives, UHC cultivates expansion of who is covered, what services healthy societies and economies, and protects are covered and how much of the cost is individuals and communities from shock covered, through progressive reduction during times of crisis.

In 2017, 33% to 49% of the world’s population did not have full coverage of essential health services (20) ® Dazzle Jam

Nutrition in Universal Health Coverage 11 No country can achieve universal health coverage without investing in essential nutrition actions

overnments have an opportunity to diet and nutrition far exceeds global G to deliver on UHC by making policy financial investment in nutrition. While in and financial commitments to integrate 2017, 56% of deaths in children under 5 nutrition interventions into national UHC years of age were attributable to child and plans. However, each country is different maternal malnutrition (21), and 22% of all and plans for integrating essential nutrition adult deaths were related to dietary risks, actions must be tailored to the local context. the World Bank estimates that less than Factors to consider include (i) the causes 2% of government expenditure on health of malnutrition in each country; (ii) the services was on nutrition (5). According appropriate interventions for national and to data within the WHO subnational contexts; (iii) who currently Expenditure Database, among 28 countries has access to health services and who does that report expenditure data for all main not; and (iv) the extent of financial hardship disease areas within the system of health incurred through out-of-pocket payments accounts, only nine countries allocate more for health services. than 2% of general government health expenditures to nutrition and only four As countries make progress towards countries allocate more than 5% (22). achieving UHC, all policy-makers will be confronted with the same question: which Among all health interventions, experts in interventions should be included in the agree that: national health system? • Many nutrition interventions are highly This requires careful prioritization across all cost-effective to prevent disease and potential health interventions, maximizing mortality (23); and health outcomes within the available • nutrition interventions particularly budget. Countries are encouraged to benefit the poorest, most vulnerable and marginalized groups (4, 21, 23–25). prioritize health interventions that are both cost-effective and serve the poorest and is an important platform most vulnerable groups first, so that no for the delivery of UHC. In many settings one is left behind. it is an individual’s first point of contact The current burden of disease attributable with a continuous, comprehensive and

12 Nutrition in Universal Health Coverage No country can achieve universal health coverage without investing in essential nutrition actions

coordinated health service. It offers a services at the level of Actors from people-centred approach to health and primary health care, every sector well-being, that focuses on the needs and including secondary and have a critical preferences of individuals, families and tertiary care platforms. role to play communities (26). The promotion of proper in supporting nutrition was established as one of the UHC does not mean governments to minimum requirements of primary health that all possible deliver on UHC care in the 1978 Declaration of Alma-Ata nutrition interventions plans (27), and the 2018 Declaration of Astana has are immediately made renewed political commitment to primary available free of charge. Rather, it means health care and UHC (28). As every country that a basic health system including context and health system are different, essential nutrition actions will be prioritized operationalizing primary health care for (see Fig. 2) and new interventions will UHC will look different from country to be added to the health system as more country in terms of financing, services and resources become available. Case studies structure. Importantly, essential nutrition 1 and 2 provide examples of recent actions must also be delivered beyond interventions in Pakistan and Viet Nam.

Fig. 2. Example package of essential nutrition actions throughout the life cyclea

a From the recent WHO publication on essential nutrition actions (29). Nutrition in Universal Health Coverage 13 Case Providing maternal nutrition services at subnational level in Punjab 1 study Province, Pakistan (30)

Pakistan is the sixth-largest country in the world, with a population of more than 200 million, and is projected to be the fourth-largest by 2050. The nutritional status of the population is generally poor throughout the country, especially among children under 5 years of age, women aged 15–49 years and older people.

The Government of Pakistan has mandated the provision of free antenatal care services, including iron and folic acid supplementation. These services are available at both government-run health facilities and the community level, where lady health workers, Pakistan’s cadre of salaried workers, deliver them.

The country has a decentralized government administration, with programme implementation and spending on health services devolved to the provincial level. In 2013, the Government of Punjab – the largest province in the country – decided to bring four programmes under the same umbrella, to ensure greater coordination and collaboration, thus creating the province’s Integrated Reproductive, Maternal, Neonatal, Child Health and Nutrition programme. Maternal nutrition is one of the 10 components of this programme.

These efforts have brought significant results. Out of Pakistan’s six provinces, Punjab has the highest percentage of women receiving antenatal care from a skilled provider (92% in 2017–2018)(31). The proportion of deliveries assisted by a skilled birth attendant increased from 53% in 2012–2013 to 71% in 2017–2018, and the proportion of deliveries in facilities also saw a considerable rise (from 49% in 2012–2013 to 69% in 2017–2018)(31, 32). An integrated Punjab health information system has been developed for effective monitoring and evaluation and is being rolled out.

Case Delivering on quality to improve health and nutrition in Viet Nam (33) 2 study

Little Sun social franchise system – a government programme designed and supported by Alive & Thrive – is ensuring that delivery of infant and young child feeding services is responsive to patients’ needs, by providing standardized services, training to health workers, and monitoring to ensure counselling is uniform. Little Sun builds upon existing, functional health-care infrastructures and decentralizes services to ensure sustainability and access. By supporting Little Sun, the Ministry of Health in Viet Nam, through the National Institute of Nutrition, is strengthening the system, building capacity of health providers, improving facilities, developing counselling materials, and implementing high-quality, standardized training, to improve nutrition and health in early childhood.

A 2016 evaluation showed an increase in exclusive breastfeeding in Viet Nam from 19% to 58% in programme areas where Little Sun Franchises were operating (34).

14 Nutrition in Universal Health Coverage Concrete measures to improve the coverage and quality of essential nutrition actions

he road towards UHC is not straightforward. Recognizing that each national context T and health system is different, there are concrete measures governments and their partners can take to integrate relevant nutrition actions into the six pillars of national health systems. These are outlined in Fig. 3.

Fig. 3. Integration of nutrition-related actions into national health systems

Nutrition in Universal Health Coverage 15 Universal health coverage should be health-system focused but multisectorally driven

niversal health coverage primarily U focuses on the health sector. However, health outcomes are determined by a variety of social, economic, physical and environmental factors. Thus, multisectoral action is needed to make meaningful progress towards health and nutrition 1. sustainable, resilient food systems outcomes, to achieve the nutrition- and for healthy diets; health-related Sustainable Development 2. aligned health systems providing Goals (7), and especially to achieve UHC. universal coverage of essential The United Nations Decade of Action on nutrition actions; Nutrition (2016–2025) (6) builds on this to 3. social protection and nutrition seek commitment for urgent, sustained education; and coherent nutrition actions under the 4. trade and investment for improved following six integrative, cross-sectoral nutrition; thematic areas: 5. safe and supportive environments for nutrition at all ages; and 6. strengthened nutrition and accountability.

While each of these thematic areas informs and frames action, they should not be seen as silos: coherent policies and programmes need to be linked to several areas at the same time.

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®Ingimage16 Nutrition in Universal Health Coverage Universal health coverage should be health-system focused but multisectorally driven

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Nutrition is a core part of health, and universal health coverage cannot be achieved without ensuring everyone has access to high-quality nutrition services

NutritionNutrition in Universal HealthHealth CoverageCoverage 17 references

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Nutrition in Universal Health Coverage 19 This brief provides the reader with information and key messages to transform health systems towards the integration of essential nutrition actions as an important component for achieving quality universal health coverage (UHC). It reinforces the understanding that malnutrition in all its forms threatens the achievement of the Sustainable Development Goals by 2030. Six concrete steps are proposed to integrate nutrition- related interventions into national health systems, which will improve the coverage and quality of essential nutrition actions, leaving no one behind. This brief is intended for stakeholders involved in national health systems, nutrition action and UHC, including decision-makers in government ministries, as well as community leaders, members of civil society and United Nations System agency representatives, among others. It calls on them to engage in global discussions on UHC; make policy and financial commitments for the integration of nutrition interventions into national UHC plans; and to progressively expand the list of available nutrition actions as more resources become available. For more information, please contact:

Department of Nutrition for Health and Development World Health Organization Avenue Appia 20, CH-1211 Geneva 27, Switzerland Fax: +41 22 791 4156 Email: [email protected] www.who.int/nutrition