ew interventions in global health come with a return as compelling as this one. The Copenhagen Consensus estimates that every dollar spent on multiple micronutrient supplementation, or MMS, for pregnant women will generate a $37 economic return through improved maternal and infant health outcomes. That ratio places the daily prenatal tablet alongside smoking cessation as one of the most cost-effective global health interventions. Several countries facing a high burden of maternal malnutrition have begun incorporating MMS into national nutrition policies and antenatal care programs, reflecting growing evidence of its benefits and efforts to translate that evidence into practice.
And yet, as one participant observed in Berlin during the World Health Summit (WHS), the share of women actually taking it in many of those countries is extremely low. That gap between what we know works and what reaches a woman at her antenatal visit was the subject of a high-level Signal Salon roundtable Diplomatic Courier convened on October 12 alongside WHS, co-hosted with Bayer and Project HOPE and held under the Chatham House Rule. Around the table were senior government officials from high-burden countries, including leaders from national health insurance and planning ministries, alongside representatives of multilateral financing facilities, global health foundations, implementing NGOs, impact investors, and the self-care industry. What followed was unusual for a summit roundtable: ninety minutes spent on the plumbing of how health money actually moves and yet how hard it is to reach the last mile.
A proven product, an unready system
One participant emphasized the long-term stakes, recalling a session at the UN General Assembly weeks earlier in which philanthropist Bill Gates was asked which single disease he would cure if he could. His answer was malnutrition, because the first 1,000 days shape a child’s cognitive and physical development for a lifetime and offer the clearest chance to break cycles of poverty. MMS is a rare case where the intervention is cheap, practical, and well understood, which leaves the harder question of what needs to be true for countries to move from traditional iron-folic acid supplements to MMS at scale.
Another participant offered the line that became a refrain for the afternoon: “Availability will never equal access.” A woman can attend antenatal care and be screened for anemia, but if the supplement is not on the shelf, or no one follows up at her next visit, the system has not solved anything. The cost and consequences of such failures are measurable: millions of stunted babies and anemic mothers, low birth weight and preterm births, high mortality rates, and lost workforce productivity.
Actual usage of the iron-folic acid supplements already distributed in many countries is low according to experts, with adherence around 18 percent in Machakos County in Kenya and indicating that roughly 83 percent of that investment is effectively lost. The reasons are ordinary and fixable. High iron doses can cause side effects that prompt women to stop taking the pill. The supplements are often dispensed with no explanation of why a woman who feels well should take them. Health advice may come from people she has little reason to trust, while husbands, local leaders, and questions about whether a product is halal shape what happens once she gets home. Organizations rolling out MMS in Indonesia and other countries have responded by working through community health workers, women-to-women training, WhatsApp groups, and even songs for women who cannot read, as well as engaging husbands and local government officials alongside clinicians. Beyond availability, adherence depends on effective counselling, community trust and the capacity of frontline health care workers.
Community health workers are particularly critical in bridging the last mile. Often the most trusted link between women and formal healthcare systems, they can help translate awareness into uptake, address misconceptions, reinforce adherence and ensure continuity of care throughout pregnancy. Their role deserves greater recognition—not simply as an extension of healthcare delivery, but as an essential component of successful MMS implementation at scale.
Near the close, a participant described a scene from a recent antenatal day at a primary care clinic. Health workers were setting MMS aside and continuing with iron tablets, convinced that MMS lower iron dose was inadequate for anemic patients and citing national guidelines that said no such thing. All the research in the world, the participant warned, will not matter if the nurse at the counter does not believe in the product.
Learning to speak the language of finance
If the delivery problem begins at the clinic, the financing problem begins in the finance ministry, and several participants described that room with the candor of people who have sat in it. The fiscal reality for most of Africa is stark: tax revenue of around 16 percent of GDP against 34 percent in OECD countries, and health allocations that have barely moved even after the decline in U.S. aid. Meanwhile, according to recent WHO data, health budgets in low- and lower-middle-income countries were reported to be underspent by an average of 13 percent. When a health ministry asks for more money, the first answer it hears is that it has not spent what it already has. Domestic spending on primary care in much of Sub-Saharan Africa runs to roughly $10 per person, against the $60 to $85 the WHO estimates an essential benefit package requires.
One participant recalled watching delegation after delegation from the health sector arrive at the finance ministry, each with statistics proving its program was the best buy in public health, each with a plan that, summed with the others, exceeded the entire national budget. “You can’t spend GDP,” the participant reminded the roundtable. The health sector excels at advocacy but rarely translates its needs into terms a finance ministry recognizes. For a national payer, the pitch that moves the needle is actuarial: include this in the benefit package, and here is what it will save on emergency obstetric care and the complications that follow poor maternal nutrition.
Ghana offers a compelling illustration. Its national health insurance program pays between $200 and $600 for each neonatal intensive care admission linked to low birth weight or preterm birth. Preliminary modeling shared at the table suggests that a full national rollout of MMS, costed at about $15 million to cover training, behavior change, and integration into the health system, could, according to the model presented be offset by healthcare savings within three to five years. If validated in implementation, that could help make a case for upfront investment, including blended financing, although the timing and mechanism for realizing savings would need further assessment. Pakistan illustrates how far the reframing can go. With one of the world’s highest stunting burdens, about 40 percent of children under five stunted, the country loses an estimated 3 percent of GDP and 4.6 percent of national income, underscoring the broader economic consequences felt in many countries. This led one participant to assert that the issue should be treated as an economic problem, rather than a health one, arguing that MMS belongs in the recurrent budget, paid every year like wages, instead of in a project pipeline where officials must plead for it each cycle.
The levers sit outside the health ministry
A recurring lesson was that the decisions that determine health financing are mostly made elsewhere. Nigeria’s recent moves show what that looks like in practice: a Basic Health Care Provision Fund that channels one percent of consolidated revenue into primary care, split between strengthening facilities and expanding insurance for the poor. Other measures discussed include a review of the benefit package to include MMS and other essentials; a pooled procurement vehicle called Medipool that aggregates demand so manufacturers see a viable market; zero tariffs on pharmaceutical ingredients to encourage local production; and a sugar-sweetened beverage tax bill recently passed by the Senate and now before the House of Representatives. Nearly every one of those levers sits with finance, trade, or planning. The roundtable room agreed that the health sector has to find its way into those conversations.
Participants brought a wide set of tools to the table including debt for health, nutrition bonds, tax incentives and blended financing. Multilateral financiers can de-risk the “invisible middle” of scale-up, the health worker training and system integration that rarely attract funding on their own, noting that governments must be part of an intervention’s design from the start if they are expected to own it later. One investor urged a gradual handover from philanthropic to public financing over something like seven years, rather than a single cliff-edge transition. Industry voices proposed VAT exemptions on maternal care products, employer health plans that cover supplements for female employees, and regulatory reliance so that an approval in one country speeds approval in its neighbors. Others raised Debt2Health swaps and nutrition bonds, pointed to India’s mandatory corporate social responsibility spending as a model, and noted that Pakistani private giving, among the largest in the world, could be channeled through vehicles such as the new private philanthropic programs. Several observed that cuts in official development assistance, painful as they are, have pushed governments to take control of their own health spending under the banner of health sovereignty, and that an intervention as cost-effective as MMS is well placed to win that competition, particularly since antenatal care is one of the few platforms where most countries already have a way to reach the women who need it. Participants emphasized that financing models must be designed with countries from the outset, reflecting national priorities and supporting the transition towards sustainable domestic financing.
The demand side nobody owns
The most provocative question of the afternoon was a simple one: who is the global voice for nutrition? No one at the table could name one. One participant recalled a senior leader, about a decade ago, asking what stunting even was. A bottle of soda, as another put it, reaches every rural village, and people buy it knowing it is bad for them, so a supplement that could change a child’s life should be at least as visible. Indonesia’s MMS campaign reduced the science to a promise any parent could understand. Health literacy for women and their partners, delivered in plain local language and through pharmacists as well as clinics, was described as one of the most practical and high-impact investments available. The point resonated with me well beyond this topic: a health system can stock every shelf with lifesaving resources and still fail if the people it serves have never been given the knowledge to use what is there. Beyond advocacy, sustained uptake requires trusted healthcare workers, effective counselling and community engagement to strengthen women’s understanding of and adherence to MMS.
The group converged on three priorities
The first is an MMS learning accelerator that lets high-burden countries learn directly from one another about what has worked, in which setting, and especially how it was financed. As one government participant put it: “Teach us how to fish.” Participants favored bringing together high-burden countries across Africa and Asia, rather than following WHO regional groupings, which can place very different economies side by side. Multilateral partners at the roundtable signaled willingness to facilitate exchange among the countries they already support. The accelerator would focus on three priorities:
-Country-to-country learning on MMS adoption and scale-up;
-Practical exchange on health systems integration, including antenatal care and adherence; and,
-Sustainable financing through domestic resource mobilization and country-led approaches.
The second priority is country-led implementation research to inform how MMS can be effectively introduced and scaled through existing antenatal care and community health platforms, particularly in countries where such research has not yet been undertaken. National research on adherence, coverage, and supply chains is essential to avoid repeating the adherence and delivery challenges seen with iron-folic acid. This will require dedicated financing, particularly as WHO’s work toward formal guidance on MMS is still under way. That research must also reach the health workers and mothers at the end of the chain, or it will stay in reports.
The third priority is near-term, outcomes-based financing. The World Bank and other multilateral development banks are developing an outcomes-focused instrument for maternal health with a dedicated MMS component. The groundbreaking initiative will focus initially on Africa, with interest already expressed by Ethiopia, Nigeria, and Egypt and scaled to other regions. Its design could extend to the wraparound pieces the room kept returning to, from community health workers to health education.
Diplomatic Courier and its co-hosts will share a Signal Brief with participants and work to bring these partners back together. The economic case has been established, with a $37 return already on the table. What the conversation in Berlin made clear is that realizing that return depends less on a new product than on a health worker who trusts the tablet, a woman who understands why she is taking it, consistent access to antenatal care and a community-based follow-up that supports her throughout pregnancy, and, last but not least, a finance ministry that can see the savings in its own ledger.
AI disclosure note: AI [Claude Opus 5.5] assisted in the research and outline of the article before it was drafted by the author.
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Closing the Last Mile in Maternal Nutrition
Photo by Hrant Khachatry via Unsplash.
October 22, 2026
At the World Health Summit in Berlin, health officials, financiers, and implementers mapped what it will take to move prenatal micronutrients from proven to delivered.
F
ew interventions in global health come with a return as compelling as this one. The Copenhagen Consensus estimates that every dollar spent on multiple micronutrient supplementation, or MMS, for pregnant women will generate a $37 economic return through improved maternal and infant health outcomes. That ratio places the daily prenatal tablet alongside smoking cessation as one of the most cost-effective global health interventions. Several countries facing a high burden of maternal malnutrition have begun incorporating MMS into national nutrition policies and antenatal care programs, reflecting growing evidence of its benefits and efforts to translate that evidence into practice.
And yet, as one participant observed in Berlin during the World Health Summit (WHS), the share of women actually taking it in many of those countries is extremely low. That gap between what we know works and what reaches a woman at her antenatal visit was the subject of a high-level Signal Salon roundtable Diplomatic Courier convened on October 12 alongside WHS, co-hosted with Bayer and Project HOPE and held under the Chatham House Rule. Around the table were senior government officials from high-burden countries, including leaders from national health insurance and planning ministries, alongside representatives of multilateral financing facilities, global health foundations, implementing NGOs, impact investors, and the self-care industry. What followed was unusual for a summit roundtable: ninety minutes spent on the plumbing of how health money actually moves and yet how hard it is to reach the last mile.
A proven product, an unready system
One participant emphasized the long-term stakes, recalling a session at the UN General Assembly weeks earlier in which philanthropist Bill Gates was asked which single disease he would cure if he could. His answer was malnutrition, because the first 1,000 days shape a child’s cognitive and physical development for a lifetime and offer the clearest chance to break cycles of poverty. MMS is a rare case where the intervention is cheap, practical, and well understood, which leaves the harder question of what needs to be true for countries to move from traditional iron-folic acid supplements to MMS at scale.
Another participant offered the line that became a refrain for the afternoon: “Availability will never equal access.” A woman can attend antenatal care and be screened for anemia, but if the supplement is not on the shelf, or no one follows up at her next visit, the system has not solved anything. The cost and consequences of such failures are measurable: millions of stunted babies and anemic mothers, low birth weight and preterm births, high mortality rates, and lost workforce productivity.
Actual usage of the iron-folic acid supplements already distributed in many countries is low according to experts, with adherence around 18 percent in Machakos County in Kenya and indicating that roughly 83 percent of that investment is effectively lost. The reasons are ordinary and fixable. High iron doses can cause side effects that prompt women to stop taking the pill. The supplements are often dispensed with no explanation of why a woman who feels well should take them. Health advice may come from people she has little reason to trust, while husbands, local leaders, and questions about whether a product is halal shape what happens once she gets home. Organizations rolling out MMS in Indonesia and other countries have responded by working through community health workers, women-to-women training, WhatsApp groups, and even songs for women who cannot read, as well as engaging husbands and local government officials alongside clinicians. Beyond availability, adherence depends on effective counselling, community trust and the capacity of frontline health care workers.
Community health workers are particularly critical in bridging the last mile. Often the most trusted link between women and formal healthcare systems, they can help translate awareness into uptake, address misconceptions, reinforce adherence and ensure continuity of care throughout pregnancy. Their role deserves greater recognition—not simply as an extension of healthcare delivery, but as an essential component of successful MMS implementation at scale.
Near the close, a participant described a scene from a recent antenatal day at a primary care clinic. Health workers were setting MMS aside and continuing with iron tablets, convinced that MMS lower iron dose was inadequate for anemic patients and citing national guidelines that said no such thing. All the research in the world, the participant warned, will not matter if the nurse at the counter does not believe in the product.
Learning to speak the language of finance
If the delivery problem begins at the clinic, the financing problem begins in the finance ministry, and several participants described that room with the candor of people who have sat in it. The fiscal reality for most of Africa is stark: tax revenue of around 16 percent of GDP against 34 percent in OECD countries, and health allocations that have barely moved even after the decline in U.S. aid. Meanwhile, according to recent WHO data, health budgets in low- and lower-middle-income countries were reported to be underspent by an average of 13 percent. When a health ministry asks for more money, the first answer it hears is that it has not spent what it already has. Domestic spending on primary care in much of Sub-Saharan Africa runs to roughly $10 per person, against the $60 to $85 the WHO estimates an essential benefit package requires.
One participant recalled watching delegation after delegation from the health sector arrive at the finance ministry, each with statistics proving its program was the best buy in public health, each with a plan that, summed with the others, exceeded the entire national budget. “You can’t spend GDP,” the participant reminded the roundtable. The health sector excels at advocacy but rarely translates its needs into terms a finance ministry recognizes. For a national payer, the pitch that moves the needle is actuarial: include this in the benefit package, and here is what it will save on emergency obstetric care and the complications that follow poor maternal nutrition.
Ghana offers a compelling illustration. Its national health insurance program pays between $200 and $600 for each neonatal intensive care admission linked to low birth weight or preterm birth. Preliminary modeling shared at the table suggests that a full national rollout of MMS, costed at about $15 million to cover training, behavior change, and integration into the health system, could, according to the model presented be offset by healthcare savings within three to five years. If validated in implementation, that could help make a case for upfront investment, including blended financing, although the timing and mechanism for realizing savings would need further assessment. Pakistan illustrates how far the reframing can go. With one of the world’s highest stunting burdens, about 40 percent of children under five stunted, the country loses an estimated 3 percent of GDP and 4.6 percent of national income, underscoring the broader economic consequences felt in many countries. This led one participant to assert that the issue should be treated as an economic problem, rather than a health one, arguing that MMS belongs in the recurrent budget, paid every year like wages, instead of in a project pipeline where officials must plead for it each cycle.
The levers sit outside the health ministry
A recurring lesson was that the decisions that determine health financing are mostly made elsewhere. Nigeria’s recent moves show what that looks like in practice: a Basic Health Care Provision Fund that channels one percent of consolidated revenue into primary care, split between strengthening facilities and expanding insurance for the poor. Other measures discussed include a review of the benefit package to include MMS and other essentials; a pooled procurement vehicle called Medipool that aggregates demand so manufacturers see a viable market; zero tariffs on pharmaceutical ingredients to encourage local production; and a sugar-sweetened beverage tax bill recently passed by the Senate and now before the House of Representatives. Nearly every one of those levers sits with finance, trade, or planning. The roundtable room agreed that the health sector has to find its way into those conversations.
Participants brought a wide set of tools to the table including debt for health, nutrition bonds, tax incentives and blended financing. Multilateral financiers can de-risk the “invisible middle” of scale-up, the health worker training and system integration that rarely attract funding on their own, noting that governments must be part of an intervention’s design from the start if they are expected to own it later. One investor urged a gradual handover from philanthropic to public financing over something like seven years, rather than a single cliff-edge transition. Industry voices proposed VAT exemptions on maternal care products, employer health plans that cover supplements for female employees, and regulatory reliance so that an approval in one country speeds approval in its neighbors. Others raised Debt2Health swaps and nutrition bonds, pointed to India’s mandatory corporate social responsibility spending as a model, and noted that Pakistani private giving, among the largest in the world, could be channeled through vehicles such as the new private philanthropic programs. Several observed that cuts in official development assistance, painful as they are, have pushed governments to take control of their own health spending under the banner of health sovereignty, and that an intervention as cost-effective as MMS is well placed to win that competition, particularly since antenatal care is one of the few platforms where most countries already have a way to reach the women who need it. Participants emphasized that financing models must be designed with countries from the outset, reflecting national priorities and supporting the transition towards sustainable domestic financing.
The demand side nobody owns
The most provocative question of the afternoon was a simple one: who is the global voice for nutrition? No one at the table could name one. One participant recalled a senior leader, about a decade ago, asking what stunting even was. A bottle of soda, as another put it, reaches every rural village, and people buy it knowing it is bad for them, so a supplement that could change a child’s life should be at least as visible. Indonesia’s MMS campaign reduced the science to a promise any parent could understand. Health literacy for women and their partners, delivered in plain local language and through pharmacists as well as clinics, was described as one of the most practical and high-impact investments available. The point resonated with me well beyond this topic: a health system can stock every shelf with lifesaving resources and still fail if the people it serves have never been given the knowledge to use what is there. Beyond advocacy, sustained uptake requires trusted healthcare workers, effective counselling and community engagement to strengthen women’s understanding of and adherence to MMS.
The group converged on three priorities
The first is an MMS learning accelerator that lets high-burden countries learn directly from one another about what has worked, in which setting, and especially how it was financed. As one government participant put it: “Teach us how to fish.” Participants favored bringing together high-burden countries across Africa and Asia, rather than following WHO regional groupings, which can place very different economies side by side. Multilateral partners at the roundtable signaled willingness to facilitate exchange among the countries they already support. The accelerator would focus on three priorities:
-Country-to-country learning on MMS adoption and scale-up;
-Practical exchange on health systems integration, including antenatal care and adherence; and,
-Sustainable financing through domestic resource mobilization and country-led approaches.
The second priority is country-led implementation research to inform how MMS can be effectively introduced and scaled through existing antenatal care and community health platforms, particularly in countries where such research has not yet been undertaken. National research on adherence, coverage, and supply chains is essential to avoid repeating the adherence and delivery challenges seen with iron-folic acid. This will require dedicated financing, particularly as WHO’s work toward formal guidance on MMS is still under way. That research must also reach the health workers and mothers at the end of the chain, or it will stay in reports.
The third priority is near-term, outcomes-based financing. The World Bank and other multilateral development banks are developing an outcomes-focused instrument for maternal health with a dedicated MMS component. The groundbreaking initiative will focus initially on Africa, with interest already expressed by Ethiopia, Nigeria, and Egypt and scaled to other regions. Its design could extend to the wraparound pieces the room kept returning to, from community health workers to health education.
Diplomatic Courier and its co-hosts will share a Signal Brief with participants and work to bring these partners back together. The economic case has been established, with a $37 return already on the table. What the conversation in Berlin made clear is that realizing that return depends less on a new product than on a health worker who trusts the tablet, a woman who understands why she is taking it, consistent access to antenatal care and a community-based follow-up that supports her throughout pregnancy, and, last but not least, a finance ministry that can see the savings in its own ledger.
AI disclosure note: AI [Claude Opus 5.5] assisted in the research and outline of the article before it was drafted by the author.
