世界银行-东帝汶营养和粮食安全综合国家行动计划的指示性成本（英）

Indicative

Costing

ofTimor-Leste’s

ConsolidatedNational

Action

Plan

forNutrition

and

Food

SecurityFEBRUARY

2024AcknowledgementsThe

Indicative

Costing

of

Timor-Leste’s

Consolidated

National

Action

Plan

for

Nutrition

and

Food

Security

wasprepared

by

the

World

Bank

team

consisting

of

Lubina

Fatimah

Qureshy

(Consultant,

HEAHN),

Heather

Grieve(Consultant,

HEAHN),

Kyoko

Shibata

Okamura

(Senior

Nutrition

Specialist,

HHNGE),

Elvina

Karjadi

(Consultant,HEAHN),

Claudia

Rokx

(Consultant,

HEAHN),

and

Jose

TavaresMousaco

(Senior

Health

Specialist,

HEAHN).

Thisreport

benefited

from

the

useful

comments

and

suggestions

provided

by

peer

reviewers

including

Yi-Kyoung

Lee(Senior

Health

Specialist,

HAEH2),

Alief

Aulia

Rezza

(Senior

Economist,

EEAM2),

and

Jonathan

Kweku

Akuoku(NutritionSpecialist,HHNGE).Overall

guidance

was

provided

by

Aparnaa

Somanathan

(Practice

Manager,

HSAHN),

Bernard

Harborne(Resident

Representative,

EACDF),

Somil

Nagpal

(Lead

Health

Specialist,

HEAHN),

and

Achim

Daniel

Schmillen(Practice

Leader,

HEADR).

The

team

is

thankful

for

inputs

provided

by

technical

experts,including

Mari

Shimizu(Health

Specialist,

World

Bank),

Ilsa

Meidina

(Senior

Social

Protection

Specialist,

World

Bank),

and

FarajaChiwile

(Nutrition

Specialist,

UNICEF).

Appreciation

also

goes

to

Rideca

Duarte

(Program

Assistant,

EACDF)who

provided

administrative

and

logistical

assistance,

Usha

Tankha

for

editorial

services,

and

Indra

Irnawan

forgraphicdesigning.The

work

was

financially

supported

by

the

Government

of

Japan

and

the

Bill

and

Melinda

Gates

FoundationthroughtheNutritionMulti-DonorTrustFundforScalingUpNutrition.This

report

is

a

product

of

the

staff

of

the

International

Bank

for

Reconstruction

and

Development/the

WorldBank.Thefindings,interpretations,andconclusionsexpressedinthisreportdonotnecessarilyreflecttheviewsof

the

Executive

Directors

of

the

World

Bank

or

the

governments

they

represent.

The

World

Bank

does

notguarantee

the

accuracy

of

the

data

included

in

this

work.

The

boundaries,

colors,

denominations,

and

otherinformation

shown

on

any

map

in

this

work

do

not

imply

any

judgment

on

the

part

of

the

World

Bank

concerningthelegalstatus

ofanyterritory

ortheendorsementoracceptanceofsuchboundaries.CoverphotobyAnaTeresaSequeira,2024andJuniaChristinaLandwing,2023.Allrights

reserved.Indicative

Costing

ofTimor-Leste’s

ConsolidatedNational

Action

Plan

forNutrition

and

Food

SecurityLubinaFatimahQureshy,

HeatherGrieve,KyokoShibataOkamura,ElvinaKarjadi,ClaudiaRokx,andJoseTavares

MousacoAbbreviationsBdMBolsadaMãeMUACMid-UpperArmCircumferenceBdM-JFCFBolsadaMãe-JerasaunFounComplementaryFeedingNHSNSPNationalHealthSectorNutritionStrategicPlanORSOralRehydrationSaltsCNAP-NFSConsolidatedNationalActionPlanforNutritionandFoodSecurityRAEOARejiaunAdministrativuEspesialOe-cusseAmbenu(SpecialAdministrativeRegionofOecusseAmbeno)EBFExclusiveBreastfeedingEarlyInitiationofBreastfeedingGrossDomesticProductGeneralDirectorateofStatisticsGovernmentofTimor-LesteHumanCapitalIndexEIBFGDPGDSGoTLHCIRUTFSAMReadytoUseTherapeuticFoodSevereAcuteMalnutritionSBCCSocialandBehavioralChangeCounselingIFAIronandFolicAcidSDGsSUNSustainableDevelopmentGoalsScalingUpNutritionMovementIMAMIntegratedManagementofAcuteMalnutritionTLDHSTheTimor-LesteDemographicandHealthSurveyLBWLowBirthweightLMICsMALFFLow-andMiddle-IncomeCountriesTLFNSTLFNSUSDATimor-LesteFoodandNutritionSurveyMinistryofAgriculture,Livestock,FisheriesandForestryTimor-LesteFoodandNutritionSurveyMAMMOEMOHMPWMSSIModerateAcuteMalnutritionMinistryofEducationMinistryofHealthUnitedStatesDepartmentofAgricultureWASHWFPWater,

SanitationandHygieneMinistryofPublicWorksTheUnitedNationsWorldFoodProgrammeMinistryofSocialSolidarityandInclusionWHOWRAWorldHealthOrganizationWomenofReproductiveAgeMTIMinistryofTrade

andIndustryContentsAbbreviations....................................................................................................................................................................................................................

4ExecutiveSummary......................................................................................................................................................................................................

6Chapter1.INTRODUCTION............................................................................................................................................................................................................9Chapter2.NUTRITIONPOLICYINTIMOR-LESTE

.......................................................................................................................................................12Chapter3.APPROACHTOCOSTING

..................................................................................................................................................................................14Chapter4.METHODOLOGY........................................................................................................................................................................................................16Health...................................................................................................................................................................................................................

18Industry...............................................................................................................................................................................................................

25Education...........................................................................................................................................................................................................

26Publicworks.....................................................................................................................................................................................................

28Agriculture........................................................................................................................................................................................................

29SocialInclusion..............................................................................................................................................................................................

30Chapter5.RESULTS

ANDDISCUSSION

.............................................................................................................................................................................31Total

costanditscomposition.............................................................................................................................................................

31Highimpactinterventions......................................................................................................................................................................

32Alternativecostingscenarios................................................................................................................................................................

35Chapter6.CONCLUSIONANDSUGGESTEDNEXTSTEPS..................................................................................................................................36References.......................................................................................................................................................................................................................

39Annexure1......................................................................................................................................................................................................................

41Annexure2......................................................................................................................................................................................................................

426IndicativeCostingofTimor-Leste’s

ConsolidatedNationalActionPlanforNutritionandFoodSecurityExecutiveSummaryThere

is

compelling

ethical

reasoning

to

invest

in

the

physical

and

mental

nourishment

of

a

population;

that

apart,investing

in

nutrition

reaps

substantial

economic

benefits

as

well.

The

gains

are

not

only

short-term

resulting

in

reducedcosts

of

childhood

illness

and

lives

saved

but

also

long-term

that

extend

over

generations

by

improving

a

country’shumancapital,

the

driving

force

ofdevelopment.Timor-Leste’s

2020

human

capital

index

(HCI)

of

0.45indicatesthatthe

productivity

of

its

future

workforce

will

be

less

than

half

of

what

it

could

be

given

the

right

inputs.

Stunting

,

an1indicator

of

cumulative

nutritional

development

also

referred

to

as

hidden

hunger,

is

one

of

the

five

indicators

usedin

the

HCI

precisely

because

childhood

stunting

is

associated

with

reduced

learning

years

and

lost

productivity

inadulthood.The

2020nationalstuntingrateinTimor-Leste

was

46.7percent,

one

ofthehighestintheworld.In

keeping

with

Sustainable

Development

Goal

2

(SDG2)

to

End

Hunger

and

Malnutrition

as

a

national

priority,Timor-Leste

introduced

the

SDG2

Consolidated

National

Action

Plan

for

Nutrition

and

Food

Security

(hereafterreferred

to

as

the

CNAP-NFS)

by

way

of

consensus,

which

highlights

the

19

key

nutrition

promoting

priorities

acrossseven

sectors

to

improve

nutrition

outcomes

and

end

hunger.

Demonstrating

a

heightened

understanding

of

thecomplexmultisectornature

ofthe

nutrition

situationand

theneed

for

greater

investmentstoreduce

thevery

highlevels

of

undernutrition,

the

CNAP-NFS

provides

a

holistic

framework

beyond

the

health

sector

and

focuses

onsolutions

to

nutrition

improvement,

including

stunting

reduction.

Each

of

the

priorities

and

indicators

where

theyexistarealignedwithexistingsectorpoliciesandplans.This

costing

analysis

presents

nutrition-specific

and

nutrition-sensitive

cost

categories,

covering

costing

estimates

forthe

period

2023-2030

for

each

of

the

sectors.

The

costing

is

indicative

and

based

on

estimates

of

scaling

up

nutritioninterventions

to

a

targeted

increase

in

coverage

by

2030

based

on

the

best

information

available

in

the

Timor-Lestebudget

books

and

the

National

Health

Sector

Nutrition

Strategic

Plan

(NHSNSP)

2022-26.

In

addition

to

the

core

scenario,two

alternative

cost

scenarios

were

also

applied:

(i)

lower

unit

costs

from

the

literature

and

lower

target

coverage

relativetothecore

scenario,and(ii)15percent

higherunitcostsandtarget

coverage,relative

tothecore

scenario.The

total

CNAP-NFS

cost

estimated

over

eight

years

is

expected

to

be

US$55

million

in

the

core

scenario

(in

arange

of

US$44

million

to

US$61

million

with

the

two

alternative

cost

scenarios),

distributed

across

education,health,

industry,

public

works

(water),

and

agriculture

sectors

.

This

total

cost

translates

into

an

annual

increase

of2US$7

million

in

nutrition

investment

(ranging

between

US$5.5

million

and

US$7.6

million).

The

education

sector(43

percent)

has

the

largest

proportion

of

the

total

cost

due

to

a

large

share

by

school

meals

alone

(32

percent;US$17.9million)whichcostsmore

thantheentirehealthsectorinterventions(28percent;US$15.6million).Healthisfollowedbyagriculture(18percent),publicworks(8percent)andindustry(2.5percent).12Stuntingisanindicatorthatcaptureslineargrowthfailureandisindicatedwhenachildfalls−2SDbelowthelength-for-age/height-for-agemedianstan-dardsset

by

the

WorldHealth

Organization.Stunting

resultsfromprolongedundernutrition

and

is

associated

with

an

increasein

morbidity

and

mortality,reduced

physical

growth

potential,

diminished

neurodevelopmental

and

cognitive

function

and

also

predicts

increased

risk

of

chronic

disease

in

adult-hood,collectivelyleadingtolosteconomicproductivity(seeforexample,deOnisandBranca2016;Shekaretal.,2017).The

original

indicative

costing

included

the

Bolsa

da

Mãe

Jerasaun

Foun

(BdM-JF)

program,

based

on

the

data

provided

by

the

Ministry

of

Solidarityand

Social

Inclusion

(MSSI).

In

view

of

the

cancellation

of

the

BdM-JF

program

in

January

2024,

this

report

presents

revised

estimates

that

exclude

theestimatedcontributionoftheBdM-JF.fromthetotalcostspresentedinExecutiveSummaryandSection5ofthereport.IndicativeCostingofTimor-Leste’s

ConsolidatedNationalActionPlanforNutritionandFoodSecurity7The

CNAP-NFS

is

an

ambitious

plan

to

reach

the

SDG2

targets

while

significantly

contributing

to

SDG3—

GoodHealthandWellbeing.Inlightoftheurgencyforreducingthehighmalnutritionburdeninthecountry,

thecostinganalysiswasalsoappliedtoasetofhighimpactnutrition-specificinterventionsrecommendedbyLancetmaternaland

child

nutrition

series

in

2008

and

2013

(hereafter

referred

to

as

the

“Lancet

Package”)

that

have

strong

evidencefor

reducing

maternal

and

child

undernutrition

and

micronutrient

deficiencies.

The

Lancet

Package

that

overlapswiththeCNAP-NFSinterventionswillcostUS$14millionovertheeightyears.Nutrition-specificinvestmentsrelateto

spending

on

the

direct

determinants

of

nutrition,

dietary

intake

and

health,

and

include

such

interventionsas

micronutrient

supplementation,

and

maternal

infant

and

young

child

feeding

counseling.

Financing

of

theseinterventions

flows

throughthe

health

sector,with

the

exception

of

food

fortification,

which

falls

under

the

Ministryof

Trade

and

Industry.

Investments

in

these

interventions

in

the

Lancet

Package

are

also

considered

cost-effective.The

inclusion

of

two

additional

nutrition-specific

CNAP-NFS

investments,

dietary

diversity

counseling

and

ironandfolicacidsupplementationforallwomenofreproductive

age,whichare

globallyrecommended

bytheWorldHealthOrganization(WHO)butcurrentlyhavealimitedevidencebase,willaddUS$3million.In

order

to

ensure

a

sustained

impact

over

the

long

term,

many

of

the

above-mentioned

nutrition-specificinterventions

will

need

to

be

complemented

with

investments

in

nutrition-sensitive

sectors.

Nutrition-sensitiveinvestmentsbearanindirectimpactonnutritionoutcomesbyinfluencingtheunderlyingdeterminants

ofnutrition.Interventions

in

these

sectors

(for

example,

water,

education,

and

agriculture)

that

complement

the

high

impactinterventionsinthehealthandtradeandindustrysectorstoimprovenutritionoutcomeswillneedtobeidentified.It

is

also

essential

to

identify

current

sources

of

finance

and

the

funding

gap

to

understand

how

much

of

the

costcouldbefinancedbytheGovernmentandhowmuchcouldbecontributedbydevelopmentpartners.Aside

from

presenting

an

indicative

estimate

of

what

it

would

cost

to

implement

the

CNAP-NFS

in

Timor-Leste,this

analysis

should

be

treated

as

a

guide

to

understanding

what

data

gaps

exist

to

refine

estimates

further.

Thismodel

uses

the

best

available

information

from

the

Timor-Leste

budget

books

and

existing

baselines

and

targetsfor

output

indicators,

which

form

the

parameters

for

estimates.

However,

in

order

to

improve

upon

the

costingestimatesgoingforward,werecommendthefollowing:

Establishing

clear

baselines

across

sectors:Baselines

of

output

indicators

were

not

always

available

for

boththe

nutrition-specific

and

nutrition-sensitive

sectors.

For

the

latter,

the

task

is

more

challenging

as

it

is

even

less

clearwhichactivitylevelindicatorsneedtobetrackedtogetbaselineoutputindicatorsforthesesectors.

Establishingcleartargetsacrosssectors:

Settingcleartargetsinallconcerned

sectorsisoneofthefirststepsto

strengthen

impacts

of

nutrition

investments.

While

the

NHSNSP

2022-26

for

2026

served

as

a

basis

to

set

thetarget

coverage

to

be

achieved

in

the

health

sector

by

2030,

targets

were

either

not

available

or

were

unclear

formany

of

the

nutrition-sensitive

interventions

included

in

the

analysis.

Establishing

feasible

targets

will

also

rest

onhavinginformationonbaselineindicators.

Obtaining

sub-activity

level

details:

The

delineation

of

budget

line

items

needed

for

the

costing

was

basedon

activity

level

information

(where

available)

from

the

Timor-Leste

budget

books.

However,

many

of

the

activitylines

did

not

reflect

nutrition

budget

alone.

Therefore,

greater

granularity

at

the

subactivity

level

will

enable

moreprecisioninidentifyingbudgetandexpenditureforthenutrition-relevantsectors.8IndicativeCostingofTimor-Leste’s

ConsolidatedNationalActionPlanforNutritionandFoodSecurity

The

analysis

has

certain

limitations:

it

does

not

cost

the

contribution

of

the

different

ministries

to

nutrition-enabling

or

governance

activities

as

these

costs

could

not

be

demarcatedin

the

budget

line

items,

and

it

excludesthe

nutrition-enabling

contribution

of

State

Administration

and

the

Ministry

of

Finance

for

the

same

reason;

thestudyfocusesinsteadonthenutrition-specificandnutrition-sensitivecontributionoftheothersectors.To

addressfiscalconstraintswesuggest:

Explore

alternative

strategies

for

nutrition-sensitive

social

protection:

As

global

evidence

suggests,nutrition-sensitive

social

assistance

is

one

of

the

best-buy

investments

in

reducing

stunting

and

malnutrition,

henceminimizing

economic

productivity

loss

of

Timor-Leste’s

future

human

capital.

The

government

should

considermaintaining

investment

in

children

and

women

by

ensuring

that

social

assistance

supports

are

provided

duringthe

critical

first

1000-day

window

(from

conception

until

the

child’s

second

birthday)

and

by

guaranteeing

theinclusion

of

the

poor

and

vulnerable.

Such

evidence-driven

approaches

could

allow

for

allocative

efficiency

oflimitedresourceswhilemaximizingtheinvestmentreturns.

Consider

an

optimization

exercise

to

allocate

the

budget

across

interventions:Thegovernmentcouldconsiderusing

Optima

Nutrition,

a

quantitative

tool

that

helps

to

optimize

the

allocation

of

current

or

projected

budgetsacross

nutrition

programs.

The

model

also

contains

a

geospatial

component

that

can

determine

funding

allocationsthatminimizestunting,wasting,anemiaorunder-fivemortalityatboththenationalandregionallevels.Givenfiscalconstraints,

such

an

exercise

can

help

to

identify

the

interventions

and

the

allocations

for

those

investments

thatwouldusetheavailablefundsinacost-effectiveway(OptimaConsortiumforDecisionScience2021).IndicativeCostingofTimor-Leste’s

ConsolidatedNationalActionPlanforNutritionandFoodSecurity91.IntroductionThereiscompellingethicalreasoningtoinvestinthephysicalandmentalnourishmentofapopulation;thatapart,investing

in

nutrition

reaps

substantial

economic

benefits

as

well.

A

healthy

population

is

more

productive

andhas

a

direct

bearing

on

the

Gross

Domestic

Product

(GDP).

The

returns

on

health

investments

are

not

immediateand

within

health;

the

productivity

benefits

of

investing

in

child

nutrition,

for

example,

emerge

over

a

longer

timeframe

mainly

when

the

childrenenter

the

workforce.Budget

constraints

can

overshadow

these

benefits,

with

otherinvestments

that

have

quicker

paybacks

out

competing

child

nutrition.

Such

an

approach,

however,

is

short-sighted.Itoverlooksthefactthatnotonlydoesaddressingmalnutritionresultinshort-termgainsintermsofreducedcostsof

childhood

illness

and

lives

saved

but

its

long-term

gains

extend

over

generations

by

improving

a

country’s

humancapital,thedrivingforceofdevelopment.Timor-Leste’s

2020

Human

Capital

Index

(HCI)

of

0.45

indicates

that

the

productivity

of

its

future

workforce

will

beless

than

half

of

what

it

could

be

given

the

right

inputs.

Human

capital

is

quantified

using

the

HCI

to

assess

howmuchcurrentinvestmentinhealthandeducationcontributestotheproductivitypotentialofthenextgenerationofworkers.

It

includes

the

proportion

of

children

under

5

years

who

are

not

stunted

as

one

of

its

five

indicators

sincestunting3is

widely

considered

a

good

proxy

for

chronic

undernutrition

or

cumulative

nutritional

deprivation

thatbegins

in

the

womb,

often

referred

to

as

hidden

hunger.

The

2020

stunting

rate

in

Timor-Leste

was

46.7

percent.4The

other

four

indicators

of

the

HCI

are

probability

of

child

survival

till

age

5,

expected

years

of

school,

quality

oflearning,andadultsurvivalrate.TheCopenhagenConsensus2004markedtheturningpointinbringinghungerandmalnutritiontotheforefrontof34RefertoFootnote1./indicator/SH.STA.STNT.ZS?locations=TL10IndicativeCostingofTimor-Leste’s

ConsolidatedNationalActionPlanforNutritionandFoodSecurityBox1.

NutritioncategoriesNutritioncategoriesNutrition-Specific:ProgramsandinterventionsAdolescenthealthandpreconceptionnutritionThesearehighimpactdirectnutritioninterventions.MaternaldietarysupplementationMicronutrientsupplementationorfortificationBreastfeedingandcomplementaryfeedingDietarysupplementationforchildrenDietarydiversificationFeedingbehaviorsandstimulationTreatment

ofsevereacutemalnutritionNutrition-Sensitive:AgricultureandfoodsecuritySocialsafetynetsEarlychilddevelopmentWaterandsanitationTheseareindirectnutritionactionshavingnutrition-relevantobjective,outcomeand/oraction.HealthandfamilyplanningservicesEnabling:RigorousevaluationsThesearesystem-enhancinginterventionsthatimprovegovernanceandincreaseeffectivenessofnutritioninterventions.AdvocacystrategiesHorizontalandverticalcoordinationAccountability,incentivesregulation,legislationCapacityinvestmentsDomesticresourcemobilizationSource:

Adaptedfrom

Blacketal.2013,seealsoAnnexure

1,whichprovides

the2013Lancetframeoworkforactionstoachieveoptimumnutritionandhowthedifferenttypesofnturitioninterventionsarelinked.development

policy

discourse

and

urged

the

world

to

invest

in

interventions

to

improve

nutrition.

Attention

therebyturned

to

understanding

what

constitutes

adequate

investments

in

nutrition.

The

2008

and

2013

Lancet

Series

onmaternalandchildnutrition(hereafterreferredtoas“LancetSeries”)recommendedasetofcore

interventionsthatwould

have

a

high

impact

on

nutrition

outcomes,

in

particular,

stunting.

The

evidence

base

for

these

and

otherinterventionshasbeenupdatedrecentlyina

Lancetsystematicreviewandmeta-analysis(Keatsetal.2021).The

2013

Lancet

Series

categorized

nutrition

actions

into

direct

or

“nutrition-specific”

interventions

primarily5implemented

under

the

health

sector

which

are

considered

high

impact

interventions,

and

indirect

or

“nutrition-sensitive”

interventions,

falling

under

a

number

of

other

sectors,

which

complement

nutrition-specific

interventionsand

improve

their

effectiveness.

To

elaborate,

“nutrition-specific”

investments

relate

to

spending

on

the

directdeterminants

of

nutrition,

dietary

intake

and

health

and

include

such

interventions

as

micronutrient

supplementationand

maternal,

infant

and

young

child

feeding

counseling.

Financing

of

these

interventions

flows

through

the

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