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Investment Case for MNCH

An evidence-based approach to creating an investment case for maternal, newborn and child health in Bangladesh, Nepal, Indonesia and the Philippines



In mid-2011 the Australian government funded the second phase of work to create an investment case (IC) for maternal, newborn and child health (MNCH) in four nations in south and east Asia - Nepal, Bangladesh, Indonesia and the Philippines.

The objective was to raise the profile of MNCH in the planning and budgeting processes of health and non-health authorities at sub-national level, with a view to improving related fund allocation and service delivery, and in the medium-term, health outcomes.

With this support, UNICEF and its partners supported sub-national health and government authorities to introduce an evidence-based, equity-focused approach to MNCH prioritization, planning, budgeting, program implementation and evaluation. It also supported activities at national level in each country to improve knowledge of the obstacles to MNCH planning and funding, and in some countries to introduce related solutions. A final project report was prepared and is available here.

Background and Purpose


In each of the four focus countries there remain outstanding problems with MNCH. While Nepal and Bangladesh have made excellent progress on the Millennium Development Goal (MDG) targets, there are persisting disparities in access to services, low levels of domestic funding for MNCH, governance issues and weak capacity for sub-national planning. In Indonesia and the Philippines, progress on the MDG targets has been less impressive, and there are similar problems with inequality, domestic funding, governance and the low priority given to MNCH.

The IC project’s major goal was to leverage attention to and government funding for MNCH at sub-national and national levels in each of the four countries, using locally-owned and generated data to highlight problems and find solutions.

The immediate purpose at inception (in 2008) was to influence progress on the MDG 4 and 5 targets on child mortality and maternal health, by increasing coverage of MNCH services and improving quality of care and related policies. The longer-term goal was to provide policymakers and planners on all levels with a systematic approach to problems in MNCH, and to producing evidence to:

document the extent to which related indicators are equitably distributed;

identify constraints hampering the scale-up of cost-effective MNCH interventions;

design and evaluate policies/interventions/strategies addressing those constraints, and

estimate the expected impact and costs associated with the strategies proposed.

In addition to the above four areas of focus, the work included national advocacy for MNCH, improved planning, budgeting, monitoring and evaluating the use of public funds for MNCH. These activities were undertaken through various studies and higher level work with central health, planning and finance authorities in all countries.



The IC programme of work was conceived as an approach to improving MNCH outcomes at national and sub-national levels.

It involves the gathering of data and analysis of key indicators to inform planning, budgeting, policy and action, and calculation of the costs and benefits of high impact interventions affecting MNCH and nutrition.

It focuses on health and nutrition problems among the most vulnerable children and families and identifies systemic bottlenecks and barriers that contribute to this vulnerability, using a model described by Tanahashi in 1978, and specific strategies to overcome them.

Data analysis occurs first at district level, with potential benefits arising by improving service quality, the foundation of, capacity for and engagement in decision-making, and through reorienting the delivery of services. Implementation of the resulting interventions and approaches resolves the bottlenecks that result in MNCH disparities, increases the level and equity of intervention coverage, and thus decreases child and maternal mortality, morbidity and malnutrition. Where the identified bottlenecks relate to systems issues, the approach is also a health systems strengthening one in its underlining of broader issues that prevent progress, and identification and implementation of related strategies and interventions.

Earlier iterations of the IC approach involved use of a detailed budgeting tool to calculate the marginal (extra) funds needed to overcome these bottlenecks. By synthesizing several district analyses, there was additional potential for impact on national policy and programme design, and on the allocation of resources by international partners. This "marginal budgeting for bottlenecks" tool was mostly not included in the second phase of the Australian-funded IC project in south and east Asia, but it remains popular in some countries in Africa.


Components of the IC / Evidence-Based Planning Approach



The following elements are included in the approach:

Situation analyses (usually prepared at baseline) (In Indonesia and the Philippines, more comprehensive situation analyses were prepared to assist final project design Interim Briefing Notes also summarized the situation on Indonesia and the Philippines in 2013.

District level planning

Identification of bottlenecks

Prioritisation and selection of interventions

Implementation of these interventions (???missing UGM Report)

Follow-up monitoring

Impact evaluation


Replication and policy formulation

A detailed description of these processes is included in a report on country-level activities prepared by UNICEF’s project partners.

Political economy analysis

Health Expenditure Per Capita

Source: World Development Indicators (2014)

It is implicit that activities intended to strengthen MNCH in any context must take into account the political and economic context. If the scientific evidence for, and the cost-effectiveness and affordability of improving MNCH have been so clear, for so long, why are related outcomes not better? Why, despite apparent political commitment and rhetoric, do many countries in south and east Asia have low absolute and relative levels of government expenditure on health, especially MNCH? Why does out-of-pocket expenditure form a higher proportion of total health expenditure in Asia than in any other global region? How can health and MNCH be prioritized and resourced when countries are rapidly decentralizing decision-making to sub-national level, despite capacity and political issues? Political economy analysis can provide insights into these issues for the benefit of governments and development partners.

As part of the IC approach UNICEF conducted an analysis of the political economy of health and MNCH in each of the four nations. Individual country analyses are available for Nepal, Bangladesh, Indonesia and the Philippines, and a summary UNICEF Working Paper here. Full versions of these analyses are also available by contacting the authors.

Financing of MNCH in South and East Asia


In addition to acknowledging political economy influences on the prioritization and funding of health and MNCH, the allocation, distribution and utilization of financial resources are important considerations.

Work done in Indonesia focused on the tracking of finances allocated by national and sub-national governments, highlighting obstacles at various levels.

In the Philippines, the IC project stimulated national interest in revising the benefit package including in the national social health insurance package (Article 1 - Article 2 - Article 3 - Article 4). With UNICEF support, PhilHealth, is now working on finalization of this package, along with assessing how to include support for infants born prematurely and for disabled persons. This work has been highlighted at global level.


Additional country-specific activities


In the Philippines, the IC approach has been embedded within the so called "National Mayor’s Health Leadership and Governance Program", which is being implemented by the national Department (Ministry) of Health (DOH), the Zuellig Family Foundation and UNICEF. The Program is a one-year, two module-program and provides leadership training for mayors, municipal health officers and officials of the DOH in several hundred municipalities.

Also in the Philippines, following typhoon Haiyan in late 2013, UNICEF and the DOH in collaboration with University of Queensland launched an initiative on evidence-based planning for resilient health systems (rEBaP). By applying the IC approach in a post-emergency setting, this initiative aims to make health systems in the Philippines more resilient and equity focused.

In Nepal, the 5-district IC project leveraged adoption of an evidence-based approach to district-level planning in a further 15 districts, with support from other UN agencies and donors. There is a strong likelihood of the approach being adopted nationally in Nepal.

In the province of Papua in Indonesia, the project established a province-level technical support team that continued to expand the concept in new districts beyond 2014, supported by a provincial government decree and local funding.

In centralized Bangladesh, three districts piloted local-level planning using an evidence-based planning and bottleneck analysis approach, and the project has embedded these strategies in 11 other districts using non-project resources, expanding their initial focus on immunization to include MNCH.

Independent evaluation


The IC project was formerly evaluated by an independent consultant who worked to assess the context and progress throughout its implementation over 2011-2014. A summary report is available here. Individual country analyses are available for Nepal, Bangladesh, Indonesia and the Philippines.

Academic Papers


UNICEF, the University of Queensland and project partners prepared a number of academic and other reports based on the IC work undertaken in the four countries since 2008. These are summarized briefly below, with links to the full text or abstracts, where available.

Developing and Costing Local Strategies to Improve Maternal and Child Health: The Investment Case Framework. Eliana Jimenez-Soto, Sophie La Vincente, Andrew Clark et al. Available at: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001282

Overcoming Stagnation in the Levels and Distribution of Child Mortality: The Case of the Philippines. Raoul Bermejo, Sonja Firth, Andrew Hodge et al. Available at: http://journals.plos.org/plosone/article?id=info:doi/10.1371/journal.pone.0139458

http://www.biomedcentral.com/1471-2458/13/601Investment case for improving maternal and child health: results from four countries: Eliana Jimenez-Soto, Sophie La Vincente, Andrew Clark et al. Available at: http://www.biomedcentral.com/1471-2458/13/601


 Indonesia  Bangladesh
 Briefing Note – Indonesia 2013  IC project impact evaluation – Bangladesh
 Countdown to 2015 – Indonesia  PEA – Bangladesh – two pager 3Jun15
 Inception Report on Indonesia – Mar13  
 PEA – Indonesia – two pager 3Jun15  
 Nepal   Philippines
 IC-project-impact-evaluation-Nepal  Briefing Note – Philippines 2013
 PEA – Nepal – two pager 3Jun15  Countdown-to-2015-Philippines
   PEA – Philippines – two pager 3Jun15
   UQ-UOM – EBaP Final Report – Philippines
   Inception Report on the Philippines – Mar13


Other Downloads

IC project completion report for website

IC project impact evaluation full project




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