Making nutrition a national priority: a few policy process examples
Jan Meerman, Food and Agriculture Organization (FAO) of the United Nations, Rome, Italy Noora-Lisa Aberman, International Food Policy Research Institute (IFPRI), Lilongwe, Malawi
Commissioned by Technical Centre for Agricultural and Rural Cooperation ACP-EU (CTA)
What is holding back progress in nutrition?
Tackling malnutrition effectively requires sustained action across sectors, strong leadership, coalitions and high levels of both institutional and operational capacity. When these needs are met, countries may find themselves positioned to scale up nutrition interventions and meet the challenges of food and nutrition insecurity, high food prices and other shocks. Unfortunately, many governments lack the capacity to implement commitments to achieve these goals. In these countries, nutrition is stuck in a “low-priority cycle” (Natalicchio et al., 2009). Key factors that make nutrition a consistently marginalised issue are:
- The complicated nature of the problem. Given its complex aetiology, addressing undernutrition is a difficult task. Sustainable solutions span multiple sectors (health, agriculture, education and social protection) and require inter-ministerial coordination. The situation is complicated further by the presence of multiple technical paradigms within most countries. The majority of these paradigms focus on a single aspect of treating undernutrition (e.g. food distribution or micronutrient supplementation). This proliferation of approaches fragments implementation on the ground and confounds attempts to develop a cohesive policy upstream.
- Low visibility and low demand. Although undernutrition is a principal cause of death in children and women, its symptoms are often invisible or inconspicuous; undernutrition is thus rarely noticed or recognised by parents, and is often underreported by health surveys and other assessments. This low visibility leads to low demand for improved nutrition services.
- Weak institutional structure. In many countries, nutrition’s “institutional home” is a low-level unit within a line ministry. Typically, these units receive only small and unpredictable contributions from governments and donors, do not attract career programme managers, and have little capacity for policy formulation, oversight and large-scale programme management. In addition, qualified nutrition personnel are often in very short supply.
To politicians who want to be seen as taking rapid, results-oriented action against clearly defined, high-profile issues, such constraints are often deal-breakers. While they are not adequately addressed, investing in nutrition remains a high-risk and unattractive venture for governments. Helping countries build an enabling environment for nutrition is increasingly considered an important type of capacity building within the international nutrition community (Gillespie et al., 2013).
Building nutrition capacity in central government
How can the low-priority cycle be broken? The current consensus is that both political momentum and its translation into programming action can be developed and sustained through deliberate alignment of some key factors and processes, listed below. As most of these are shaped by political economy , substantial social mobilisation, advocacy, strategic communication and policy reform within central government is required:
- Coordination of a single, comprehensive policy narrative between agencies and actors interested in nutrition policies and programmes;
- Formation of a coalition of advocates to push for changes (and influence decision-makers) in the status of nutrition policy development and implementation on national development agendas;
- Coordination of donor funding; donors can play a central role in initiating and supporting transformational processes as part of a longer-term commitment to improving nutrition outcomes through policy dialogue and funding;
- Better institutional placement of a national nutrition “architecture” characterised by credibility, political backing, funds and the power to coordinate multiple actors across sectors (adapted from Natalicchio et al., 2009).
Table 1 suggests a systematic way to evaluate a government’s progress in aligning these key factors, as used in World-Bank-funded pilot peer reviews between Ghana, The Gambia and Senegal in 2011 and 2012 to support the building of an enabling environment for nutrition (see also Box 1).
|Criteria (Meerman, 2012a)||Indicator(s)|
|1. Enabling policy environment||Legislated National Nutrition Policy that focuses on preventive, pro-active, community-based and adaptive programmes.|
|Nationally recognised, highly placed institutional home that can work across the sectoral divide and provide clarity regarding coordination and institutional responsibilities.|
|2. Institutional and organisational capacity||Strong supervision and monitoring system in place which provides a ‘single laser-beam of action’ versus a ‘thousand points of light of action’.|
|Documented success stories being used for scaling up, and modification based on experience.|
|Strong national leadership combined with a sector-wide approach or similar system for donors and partners that provides predictable, harmonized, strong and continuous support to country-identified priorities.|
|3. Integration and coordination||Nutrition mainstreamed in national development plans; integrated multi-sectoral approach, including inter-sectoral collaboration.|
|4. Financing||Reasonable financing; predictable national budget and donor-support.|
Incentivising pro-nutrition programming across sectors
Determinants of persistent undernutrition are complex and include health, education and agricultural pathways. A comprehensive national nutrition strategy requires substantial cross-sectoral collaboration or, at least, “convergence” and consensus in regards to target populations (Levinson and Balarajan, 2013). However, in practice, coordinating action between the Ministries of Health, Agriculture, and Education, and possibly also Planning, Communication and Trade, is difficult, not least because of resource allocation and planning. Sectors are competing for their own mandate funding, and monitoring and evaluation (M&E) uses sector-specific criteria that do not typically include improved nutrition outcomes. As such, it can be difficult to motivate nutrition-based mandates (e.g., targeting, M&E of nutrition indicators) across line ministries. The challenge is thus how to activate and sustain a nutrition mandate within government agencies whose performances are evaluated on non-nutrition-oriented activities.
Box 1- Strengthening National Nutrition Programs in West Africa: A South-South Peer Reviewing Initiative in Collaboration with ECOWAS and the World Bank (Meerman, 2012b)
Through its South-South Experience Exchange Trust Fund, the World Bank sponsored pilot peer reviews between Ghana, The Gambia and Senegal in 2011 and 2012 to support countries building an enabling environment for nutrition. The reviews were anchored by the West Africa Health Organization (WAHO) of ECOWAS and emphasised learning through peer influence to improve upon existing achievements and to identify solutions to remaining and/or newly arising challenges. Primary objectives were to (1) inform participating countries regarding successful nutrition policies and programmes that are active in the region but may be unknown, and (2) catalyse strategic action based on that information.
Each exchange involved a delegation of representatives from the visiting country’s primary nutrition planning and implementing agency, relevant line ministries (e.g. Agriculture, Health and Finance), public institutions and universities, local government, civil-society organisations and non-governmental organisations. Non-nutrition actors were included to increase the probability that nutrition would receive heightened consideration in the design of future national and sector-policy instruments.
Reviews began with an in-depth consultation between the delegation and hosting nutrition coordinating unit or department, followed by field visits to learn first-hand about implementation processes, challenges and success stories. Delegations then met with national stakeholders including development partners, line ministries and coordinating committees to discuss multi-sectoral coordination and funding.
A key area assessed was organisational arrangements. All three pilot countries have made considerable progress, developing effective systems for multi-sectoral nutrition policy formulation, implementation, guidance and monitoring. However, the pathways to progress differ as each country has developed strengths in specific areas. Visiting delegations were able to compare and contrast host-country approaches to their own. This meant delegations provided their hosts with recommendations drawn from their own experience and new ideas for strengthening systems back home were developed.
Recent regional and international initiatives are creating new incentives to meet this challenge. One prominent example is the CAADP Nutrition Capacity Development Initiative  . Led by the New Partnership for Africa’s Development (NEPAD ) Agency with technical and financial support from FAO and other development partners, this involves regional workshops (including preparation and follow-up at country level), for West Africa, East and Central Africa, and Southern Africa. Involving 51 countries, they assist countries in situation analyses and developing road maps for integrating nutrition into their National Agriculture and Food Security Investment Plans.
Another important example is the Scaling Up Nutrition (SUN) Movement. SUN’s primary objective is to mobilise support for increased investment in nutrition interventions, including via food security and agriculture, health, and social protection. SUN has generated impressive political momentum internationally; countries that join must undertake a variety of pro-nutrition activities, namely developing or retrofitting national policies, strategies and plans of action to include “nutrition-sensitive” programming across sectors; nominating a high-level Focal Point to ensure that national nutrition efforts are multi-sectoral in scope and coordinate external support; and forming or strengthening a multi-stakeholder platform that includes relevant line ministries (SUN, 2013).
Meeting the challenge of implementation
SUN countries nominate a SUN Donor Convener who encourages the alignment of financial and technical assistance to national plans (http://scalingupnutrition.org/about/how-countries-can-get-involved). Institutional arrangements that favour cross-sectoral collaboration are becoming more common, but if donors remain institutionally bound, even well-funded and powerfully placed coordinating nutrition secretariats will have difficulty working across line ministries to make “nutrition-sensitive” rhetoric a reality.
A key challenge to implementation is assessment of nutrition impact in sectors such as agriculture, where performance indicators do not historically include nutrition. Conventional nutritional analysis of a target population includes assessment of micronutrient status, collection of anthropometric data, and context-specific understanding of proximal and distal causes of malnutrition. Staff with such expertise are often limited to a small nutrition division or unit within the Ministry of Health and may have limited or no reach into the Ministry of Agriculture. As such, sustained M&E of stunting and other “gold-standard” nutrition indicators within agriculture poses a problem, as nutrition specialists would need to analyse the success of nutrition activities within food security and other agriculture-based programmes regularly. This would require (i) full cooperation and disclosure from project managers and other actors based in agriculture and (ii) a considerable input from the nutrition team. In many countries, neither variable is guaranteed. One partial solution is measurement of household dietary diversity as opposed to child growth, as the former is more easily included in agriculture-based projects. However, it is an insufficient indicator of improved nutrition at an individual level. One additional option is using independent M&E teams to carry out baseline, intermediate and end-line nutrition and food security assessments at geographically representative sentinel sites (Levinson and Herforth, 2013).
Role of operational research
Several consortia and agencies are currently conducting country-based operational research on strengthening nutrition capacity across sectors. While not generally providing technical assistance themselves, they help in informing national policy processes and projects at a decentralised level. One example is the project Partnerships and Opportunities to Strengthen and Harmonize Actions for Nutrition in India, or POSHAN. POSHAN’s activities include (i) stakeholder mapping of actors engaging in nutrition and nutrition-relevant policy and practice in India; (ii) analysing access to and effectiveness of national and sub-national nutrition knowledge-sharing mechanisms; (iii) reviewing policies and programmes that directly address or indirectly support nutrition; and (iv) analysing the multi-sectoral and multi-agency coordination (or lack thereof) of direct and indirect nutrition interventions. POSHAN target populations include government, civil society and academia, all often “siloed” because of mismatched timeframes for action, separate bureaucratic structures, and sectorally-bound incentives. The complex Indian nutrition landscape is illustrated in Figure 1, from a POSHAN stakeholder mapping exercise.
Blue links: Advocacy;
Red links: Technical information alone; size of circle denotes perceived influence of the actors in relation to maternal and child nutrition.
ACTOR LIST: AIIMS, All India Institute of Medical Sciences; BPNI, Breastfeeding Promotion Network of India; Britannia; Britannia Industries Limited; Cabinet Sec, Cabinet Secretary; Care, Care; CHETNA, Center for Health Training and Nutrition Awareness; CINI, Child In Need Institute; Citizen's Alliance, Citizen's Alliance Against Malnutrition; CNNIBN, Cable News Network IBD; Coalition, The Nutrition Coalition; Dept Biotech, Department of Biotechnology, Ministry of Science and Technology; Dept Sanitation, Ministry of Drinking Water and Sanitation; DFID, UK Department for International Development; FAO, Food and Agriculture Organization; GAIN, Global Alliance for Improved Nutrition; Gates, Bill and Melinda Gates Foundation; Hindustan Times; IAP, Indian Academy of Pediatrics; ICMR, Indian Council of Medical Research; IFPRI, International Food Policy Research Institute; IIPS, International Institute for Population Sciences; ILSI, International Life Sciences Institute; Legislature; Media; MI, Micronutrient Initiative; MoAgri, Ministry of Agriculture; Mobile Creches; MoFood, Department of Food & Public Distribution of the Ministry of Consumer Affairs, Food & Public Distribution; MoHFW, Ministry of Health and Family Welfare; MoWCD, Ministry of Women and Child Development; MSF, Médecins Sans Frontières; MSSRF, M. S. Swaminathan Research Foundation; Naandi Found, Naandi Foundation; NAC, National Advisory Council; NDTV India; NFI, National Foundation for India; NHSRC, National Health Systems Resource Centre; NIN, National Institute of Nutrition; NIPI, Norway - India Partnership Initiative. Aberman et al., 2012
Recognising that national policy processes are important in reducing malnutrition in developing countries is not new. However, the current momentum generated internationally and within specific country contexts for creating “enabling environments for nutrition” is unprecedented. This article highlights some issues from a rich and complicated discourse, namely (i) why nutrition remains a low priority item on many countries’ policy agendas, (ii) what must happen to facilitate pro-nutrition policy reform and subsequent programmatic action, (iii) the complex challenges presented by working across sectors at national level and in the field, and (iv) examples of recent initiatives which aim to meet these challenges.
 Political economy can be defined as how the distribution of power and power dynamics in a given country affects decision-making for public policy and provision of public goods and services.
 The Comprehensive Africa Agriculture Development Plan (see: http://www.nepad-caadp.net/)
 NEPAD’s Agriculture and Food Security Programme is guided by the CAADP framework (see http://www.nepad.org/foodsecurity)
Aberman, N., Pradhan, M., Cyriac, S., Kohli, N., Singh, K., Kadiyala, S. et al. 2012. The nutrition stakeholder network in India: An overview of results from a participatory mapping exercise. Available at: http://www.transformnutrition.org/files/2011/11/India-Nutrition-Stakeholder-Network_Overview.pdf
Gillespie, S., Haddad, L., Mannar, V., Menon, P., Nesbitt, N. and the Maternal and Child Study Group. 2013. The politics of reducing malnutrition: building commitment and accelerating progress. The Lancet 382 (9891), 552-569. doi: 10.1016/S0140-6736(13)60842-9.
Levinson, F.J. and Balarajan, Y. 2013. Addressing malnutrition multisectorally: what have we learned from recent international experience? UNICEF Nutrition Working Paper, UNICEF and MDG Achievement Fund, New York, USA http://www.aecid.es/galerias/noticias/descargas/2013/Addressing_malnutrition_multisectorally_MDG_F_Item1_Final-links.pdf
Levinson, F.J. and Herforth, A. 2013. Monitoring and Evaluating the Food Security and Nutrition Effects of Agricultural Projects, FAO, Rome, Italy. http://www.fao.org/fileadmin/user_upload/agn/pdf/Levinson_Herforth_Paper.pdf
Meerman, J. 2012a. Strengthening National Nutrition Programs in West Africa: Concept Note for a South-South Peer Reviewing Initiative in Collaboration with ECOWAS and the World Bank. The World Bank, Washington, DC, USA (internal document).
Meerman, J. 2012b. Strengthening National Nutrition Programs in West Africa: Project Completion Report for a South-South Peer Reviewing Initiative in Collaboration with ECOWAS and the World Bank. The World Bank, Washington, DC, USA (internal document).
Natalicchio, M., Garrett, J., Mulder-Sibanda, M., Ndegwa, S. and Voorbraak, D. (eds). 2009. Carrots and Sticks: The Political Economy of Nutrition Reform. World Bank and International Food Policy Research Institute, Washington, DC, USA. http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/281627-1095698140167/CarrotsAndSticksFINAL.pdf
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