Center for Global Development: Scaling up sustainable nutrition in a health system that buries it

Nutrition is increasingly being treated as an add-on in global aid while getting buried and underprioritized in health system reforms. The Center for Global Development (CGD) tells Nutrition Insight about an alternative “diagonal” approach, where nutrition is integrated into this system as a core.

Diagonal approaches to nutrition investments can bridge the gap between vertical (aid) and horizontal (health system) models, posit Asti Shafira, research assistant, and Janeen Madan Keller, deputy director of global health policy and policy fellow, at the nonprofit think tank. 

“While awareness of the value of nutrition investments has been increasing, how nutrition investments are financed and delivered within health systems has received comparatively less attention. Our research dives into different delivery models — and explores why this needs to change,” says Shafira.

“We argue that nutrition interventions — such as vitamin A and micronutrient supplementation — often tend to be delivered in vertical silos within health systems and are often walled off from broader health efforts.”

On the other hand, Madan explains that while horizontal approaches stay within budget and are system-based, they seem to have no accountability for nutrition outcomes.

The two believe that a “diagonal” approach is one way to bridge the gap between vertical and horizontal approaches. 

“It essentially helps embed nutrition interventions into health system strengthening efforts, ensuring both systemwide benefits and accountability for measurable nutrition outcomes. It’s about ensuring nutrition is both a system-wide priority and a measurable result,” says Madan.

Additionally, to preserve accountability for nutrition outcomes when interventions are folded into broader health system reforms, Shafira suggests one path could be to integrate nutrition interventions into Universal Health Coverage packages, performance indicators, and financing frameworks.

“Without explicitly baking in accountability, there tends to be little attention paid to nutrition outcomes.”

Nutrition accessibility, affordability and funding

Shafira and Madan stress there is a need for vertical models as global health budgets shrink and strain nutrition commitments. In July, the 63-year-old US Agency for International Development — the largest donor of international aid — shut down, leaving people on the ground confused and at risk of hunger. 

Nutrition interventions are often delivered in vertical silos within health systems and isolated from broader health efforts.UNICEF’s new 2025 Child Nutrition Report reveals that unhealthy food environments are driving overweight and obesity worldwide, with South Asia facing a triple threat with additional undernourishment and anemia. Childhood obesity is now a global crisis and has overtaken undernutrition, it warns.

According to the latest State of Food Security and Nutrition in the World report, more people were found to be able to afford healthy diets. However, inflation and budget cuts are jeopardizing gains. It also finds fewer people experienced hunger in 2024 than in the years before, but progress was not consistent globally.

At the same time, the Healthy Diet Basket finds that a nutritious diet is unaffordable for 2.8 billion people worldwide. Over 80% of the people in African countries cannot afford a healthy diet consisting of the cheapest, most basic foods.

This year, the Nutrition for Growth Summit in Paris, France, raked in a total of US$27.55 billion, though concerns about the future remained. The World Bank stressed that scaling up nutrition interventions requires a US$128 billion investment over ten years.

Dynamics that keep nutrition in margins

An FAO expert previously told us that nutrition is virtually “invisible” in the global finance architecture. He warned that the most significant risk appears to be trying something new rather than failing to feed people. 

Nutrition financing in health depends on external aid, especially in low-income countries, which explains low national spending.“One reason why nutrition often falls through the cracks is that it is multisectoral — it straddles multiple sectors beyond health, including agriculture, education, and social protection, to name a few,” comments Shafira.

“Even within the health sector, nutrition has largely remained underprioritized in broader conversations on health systems and health financing. This is despite the fact that nutrition, health, and universal health coverage are closely interconnected: achieving good nutrition outcomes depends on strong health systems.” 

Nutrition financing in the health sector largely depends on external aid, especially in low-income countries, says Madan. This underlying dynamic explains why national spending on nutrition has remained low.

“This reality is partially attributable to the unintended consequences of external grant financing, which provides few incentives for governments to finance nutrition. This generally mirrors trends in the broader global health financing landscape.”

Madan says that, as a result, nutrition is often poorly integrated into health systems. This also explains why it is not explicitly prioritized in financing for universal health coverage and tends to be left out of health benefits packages, despite strong evidence of impact and cost-effectiveness.

The FAO economist called for stronger links between the development and finance worlds that require shared narratives, political will, and better data. He highlighted solutions such as debt swaps, promoting national or local independence, and pairing return-on-investment with SDGs.

Nutrition often falls through the cracks because it is multisectoral, spanning sectors like agriculture, education, and social protection.“While donor support has helped accelerate nutrition efforts, prevalent models tend to deliver fragmented, off-budget projects that can sometimes undermine country systems and ownership of nutrition strategies,” says Shafira.

She says that donor support is ideally on-budget with country-led financing at the core. “In other words, donors need to align behind national strategies rather than create and operate through parallel ones, or we risk repeating decades of inefficiency.”

Quick wins versus long-term sustainability

At the same time, vertical programs that focus on specific disease outcomes can have quick wins, says Shafira. However, they are supported by off-budget funding and often result in fragmented delivery and duplication. Eventually, this undermines government ownership.

She adds that to maintain and increase nutrition investments, they need to align with primary healthcare and with government priorities.

“Our research illustrates the potential of ‘diagonal’ models, such as leveraging overlaps with regards to population targets (co-delivering Vitamin A with immunizations), resources (harmonizing community health worker systems), service delivery (mainstreaming nutrition counseling into primary care), and pooling financing vehicles (like the Global Financing Facility or linking donor and domestic funds),” says Madan.

“These kinds of overlaps ensure vertical wins become entry points for system strengthening rather than long-term fragmentation.”