Unpacking the Politics
SUMMARY One of the biggest advances in the field of nutrition in 2013 was a growing consensus on the need to cultivate, strengthen, and sustain enabling environments to support nutrition-related actions. This chapter examines how policy, power, politics, and people come together in a multisectoral context to influence the creation of these critical environments.
The year 2013 was pivotal for international nutrition, with advances coming on many fronts. Most broadly, the challenge of undernutrition came to occupy a more prominent part of policymaking discussions. One key event was the rise of the Scaling Up Nutrition (SUN) Movement. This effort seeks to support national leaders in prioritizing efforts to address malnutrition by aligning policies and legal frameworks and by mobilizing partners, capacity, and resources. SUN membership now includes 45 countries.1
A second advance was that significant funds were pledged to help address the problem of undernutrition. In June, a Nutrition for Growth event (co-organized by the United Kingdom, Brazil, and the Children’s Investment Fund Foundation) resulted in pledges of more than US$23 billion from a range of development partners to promote nutrition.2
Third, the international nutrition community gained better consensus on strategies for combating undernutrition. In June, The Lancet’s Maternal and Child Nutrition Series reported on recent evidence on the trends, causes, and consequences of malnutrition, as well as actions to address it. The articles in the series expanded upon an earlier 2008 Lancet series by reviewing nutrition-sensitive program options (including those within the agriculture sector) and the political economy of malnutrition. Also included was a discussion of the growing threat posed by the double burden of undernutrition and overweight or obesity. Yet another area in which there was growing consensus was when, within the life cycle, to take action. The 1,000 Days movement, for instance, has successfully communicated the growing body of evidence that the period from pregnancy to a child’s second birthday is a critical window of opportunity to combat undernutrition.3 Many in the nutrition community now also agree on the need to focus simultaneously on three levels of action: (1) implementing and scaling up a core package of nutrition-specific interventions; (2) maximizing the nutrition sensitivity of a wider group of development actions (in sectors such as agriculture, social protection, water, and sanitation); and (3) cultivating, strengthening, and sustaining enabling environments to support nutrition-relevant actions.
This chapter focuses on policy, power, and politics. Specifically it deals with how the issue of malnutrition gains traction within the development agenda and how this attention is then turned into effective action through formulating and implementing the right mix of policies and programs in different settings.4
Nutrition: More Money and More Transparency Needed
Mariella Di Ciommo
Financing to address undernutrition comes from several sources, such as national public expenditures, domestic and international private funds, and official development assistance from international donors. Information on resources other than official development assistance is scant, and details on official assistance are incomplete. The available data suggest, however, that current financing is not enough to cover financial need.
Nutrition attracted increased attention in 2013. Membership was boosted, for example, in the Scaling Up Nutrition (SUN) Movement, a global coalition to end undernutrition. Some SUN member countries presented national plans and estimates of costs to address under-nutrition domestically.1 At the June 2013 Nutrition for Growth event, hosted by the United Kingdom and Brazilian governments and the Children’s Investment Fund Foundation, some developing countries committed to increasing domestic resources for nutrition and set targets for reducing stunting (that is, low height-for-age). International public and private donors pledged an additional US$4.2 billion for direct nutrition interventions and US$19 billion for nutrition-sensitive investments by 2020.2
Ninety percent of the world’s stunted children live in 34 countries.3 Recent estimates suggest that investing an additional US$9.6 billion a year in scaling up direct nutrition interventions in these countries would reduce child deaths by one million.4 This additional investment would also reduce stunting and wasting (low weight-for-age), both of which cause physical and mental underdevelopment. Of this amount, US$3–4 billion could come from international sources.5 Investments in nutrition-sensitive initiatives could further improve results.
Reported official development assistance for nutrition, despite being on the rise, remains inadequate. Official nutrition assistance amounted to US$408 million in 2011, constituting 0.3 percent of total official development assistance.6 This amount was far less than both emergency food aid (US$3 billion) and development food aid (US$1.8 billion). Projects in other areas—such as health, agriculture, and humanitarian aid—can have a significant impact on nutrition outcomes, but data limitations make identifying, quantifying, and thus assessing such contributions problematic. Actual official development assistance to nutrition is likely to be higher than what is reported.
Encouragingly, 66 percent of nutrition official development assistance in 2009–2011 went to those 34 countries that are home to most of the world’s stunted children. But disparities exist within the group. Despite representing only 35 percent of estimated financial need, the region of Africa south of the Sahara received 61 percent of official development assistance for these 34 countries. Although Asia accounts for 50 percent of estimated financial need, that region received just 21 percent of annual nutrition official development assistance.
The role of official development assistance should be assessed against both need and additional funding sources (be they international or within developing countries). The estimated US$9.6 billion cost of scaling up direct nutrition interventions is based on estimates of current coverage at the national level and costs by geographic region. Little is known, however, about which resources actually pay for current coverage at the country level. We need better data to draw firm conclusions on whether official development assistance specifically targets countries with the largest financial gap and how that assistance can complement other kinds of resources.
To hold both developing-country governments and donors accountable, we will need clearer reporting of nutrition investments and transparent tracking of progress toward these commitments. Because past experience suggests that pledges are not always fully met, monitoring progress is essential to delivering actual results.
Mariella Di Ciommo is researcher, Data and Analysis team, Development Initiatives, Bristol, United Kingdom.
1 - Scaling Up Nutrition, “Analysis of the Costs of SUN Country Plans,” 2013, http://scalingupnutrition.org/wp-content/uploads/2013/07/Costing-Executive-Summary_July-2013.pdf. As of November 2013, SUN members are Bangladesh, Benin, Burkina Faso, Burundi, Cameroon, Chad, Democratic Republic of Congo, Côte d’Ivoire, El Salvador, Ethiopia, The Gambia, Ghana, Guatemala, Guinea, Haiti, Indonesia, Kenya, Kyrgyz Republic, Lao PDR, Madagascar, Malawi, Mali, Mauritania, Mozambique, Myanmar, Namibia, Nepal, Niger, Nigeria, Pakistan, Peru, Rwanda, Senegal, Sierra Leone, South Sudan, Sri Lanka, Tajikistan, Tanzania, Uganda, Yemen, Zambia, and Zimbabwe. [Back]
2 - Nutrition for Growth, “Nutrition for Growth Commitments: Executive Summary,” 2013, www.gov.uk/government/uploads/system/uploads/attachment_data/file/207271/nutrition-for-growth-
3 - The 34 countries where 90 percent of stunted children live are Afghanistan, Angola, Bangladesh, Burkina Faso, Cameroon, Chad, Democratic Republic of Congo, Côte d’Ivoire, Egypt, Ethiopia, Ghana, Guatemala, India, Indonesia, Iraq, Kenya, Madagascar, Malawi, Mali, Mozambique, Myanmar, Nepal, Niger, Nigeria, Pakistan, the Philippines, Rwanda, South Africa, Sudan, Tanzania, Uganda, Vietnam, Yemen, and Zambia; Z. Bhutta, J. Das, A. Rizvi, M. Gaffey, N. Walker, S. Horton, P. Webb, A. Lartey, and R. Black, “Evidence-Based Interventions for Improvement of Maternal and Child Nutrition: What Can Be Done and at What Cost?” The Lancet 382 (2013): 452–477. [Back]
4 - S. Horton, M. Shekar, C. McDonald, A. Mahal, and J. K. Brooks, Scaling Up Nutrition: What Will It Cost? (Washington, DC: World Bank, 2010), http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/Peer-Reviewed-Publications/ScalingUpNutrition.pdf. [Back]
5 - Bhutta et al., “Evidence-Based Interventions.” [Back]
6 - ODA figures are from the Organization for Economic Co-operation and Development (OECD) Development Assistance Committee’s Creditor Reporting System, www.oecd.org/dac/stats
/idsonline.htm, accessed October 2013. For a more detailed methodology, see M. Di Ciommo, The Aid Financing Landscape for Nutrition (Bristol, UK: Development Initiatives, 2013), http://devinit.org/wp-content/uploads/2013/07/Development-Initiatives-Nutrition-Report-April-2013.pdf. [Back]
A Political Issue
The challenge of addressing malnutrition is inherently political because malnutrition:
- is multicausal in nature. This is clearly illustrated by the conceptual framework used by The Lancet series, which depicts the various determinants of malnutrition in a pyramid, at the base of which lies a bundle of political and governance-related drivers.5
- is a multisectoral challenge. Many sectors need incentives (often from the government) to promote nutrition given that nutrition is not their core business and that undernutrition has a multifaceted etiology. Sometimes acting multisectorally requires sectors to apply a nutrition lens to their own programs, and sometimes it means sectors must be brought together in a more coordinated fashion to implement integrated programs.
- is an institutional orphan. Although nutrition is clearly a multisectoral issue, no country has a ministry of nutrition, and institutional arrangements to address malnutrition vary across governments.
- extends beyond just economics. Economic solutions are not enough. Economic growth (which itself is shaped by politics) is necessary but cannot significantly improve nutrition on its own.6
- requires more than just technical solutions. The Lancet series highlights a core package of 10 nutrition-specific interventions (Figure 1), which—if scaled up to 90 percent coverage in the countries with the highest burden of child stunting—would avert only one-fifth of the burden of stunting in those countries.7
- can be a hidden problem. Stunting and underweight are often “invisible,” even to mothers of malnourished children. Ironically, the more widespread undernutrition is in a village, the more invisible it may be because being low in weight and short in stature become perceived as the norm.8 Such a lack of visibility results in little community voice or bottom-up pressure for change. Given the evidence accumulated in the past two decades on the damage caused in becoming stunted, civil society and the media have a particular responsibility to step in and counteract the dangers of hidden stunting by promoting nutrition.
- requires public-private cooperation to resolve. Nutrition needs both public- and private-sector engagement; the regulation of the private sector (to protect breastfeeding, for example, by preventing violations of the International Code of Marketing of Breast-milk Substitutes) requires political action.
- requires increased political transparency to resolve. There is a pervasive lack of timely, actionable, nutrition-relevant data within high-burden countries, which leads policymakers to be less accountable to citizens. As a result, governments do not respond to either chronic undernutrition or emerging nutrition crises. In addition, it is often unclear how much governments spend on nutrition (within sectoral budgets) and what particular nutrition efforts they fund, further reducing transparency and accountability.
- has multiple benefits, many of which only accrue over time. Addressing malnutrition now will bring significant intergenerational benefits.9 Politically, this represents a challenge because these benefits will not all become apparent while a politician is in office.
Figure 1: NUTRITION-SPECIFIC INTERVENTIONS ARE NOT ENOUGH TO END STUNTING
Source: Z. A. Bhutta, J. K. Das, A. Rizvi, M. F. Gaffey, N. Walker, S. Horton, P. Webb, A. Lartey, and R. Black, “Evidence-Based Interventions for Improvement of Maternal and Child Nutrition: What Can Be Done and at What Cost?” The Lancet 382, no. 9890 (2013): 452–477.
Understanding Nutrition-Relevant Policy Processes
Given that politics shapes policy, it is useful to review the historical evolution of attention to nutrition within policy processes. After an initial flurry of writing in the late 1970s and early 1980s, little was written about nutrition-relevant policymaking until 2003.10 Since then, however, several multicountry studies have applied conceptual and analytical frameworks to unravel the main pathways and dynamics of nutrition-relevant policy change. In 2003, for example, the World Bank–United Nations Children’s Fund (UNICEF) joint nutrition assessment described the evolution of key nutrition policy narratives in India, Madagascar, the Philippines, and Tanzania.11 In 2008, one research effort assessed the opportunities and constraints for addressing nutrition as a development priority in Ghana, Mozambique, Nigeria, and Uganda.12 In 2009, another analysis reviewed the history of nutrition policies, drivers of change, and main obstacles and challenges in Benin, Ghana, India, Madagascar, Senegal, and Tanzania.13 In 2011–2012, the Mainstreaming Nutrition Initiative generated several papers on nutrition policy processes, including case studies from Bangladesh, Bolivia, Guatemala, Peru, and Vietnam.14 Yet another research effort focused on the multisectoral coordination for nutrition in case studies of Colombia and Senegal.15 One of the most recent efforts—a six-country study of governance in Bangladesh, Brazil, Ethiopia, India, Nigeria, and Peru—was completed in 2012.16 Research within other fields, such as political science and health systems, has also contributed frameworks, tools, and methods to nutrition-relevant policy.17
To unpack the politics of nutrition policy and practice, a useful starting point is to assess the nutritional situation in a given context, such as a high-burden country. This is done by asking a host of questions: What is known about the drivers of these nutrition outcomes, and what types of policies and programs can control these drivers? How accessible is this information, and what are the dominant ideas, narratives, or stories of change that may influence policy and practice? Does political commitment to address malnutrition exist at the highest level? Is there a basic consensus on the type of nutrition-specific and nutrition-sensitive actions that are needed? Which sectors are involved? How well are they coordinated horizontally (between sectors) and vertically (within sectors, from the national to district levels) to ensure effective implementation of required actions? How are individual, organizational, and systemic capacities configured at different levels? Are financial resources adequate to support relevant action, or can funds be mobilized to do so?
The policy process literature that seeks to answer these questions has identified three issues of particular importance for combatting undernutrition:
- Ensuring horizontal and vertical coherence (between sectors and at different levels within sectors)
- Optimizing the use of information and evidence to shape both policy and pro-nutrition narratives
- Strengthening nutrition-relevant capacity to support policy change
Africa’s New Nutrition Initiatives
Francis Bruno Zotor
Africa is rich in economic resources, and yet the continent is unable to feed itself sufficiently. In 2013, however, a global wave of nutrition initiatives took place that offered new opportunities to improve food and nutrition security in Africa. For example, high-level commitments to address nutritional challenges were made at the Group of 8 Summit in Northern Ireland,1 the Nutrition for Growth summit in London,2 and the Sustaining Political Commitments to Scaling Up Nutrition event in Washington, DC.3 In addition, the scope of the nutrition challenge and a range of possible solutions was presented in the new Lancet Series on Maternal and Child Nutrition.4
It is incumbent on African leaders to welcome and embrace these initiatives. To sustain the momentum that has been created, national governments and multi-lateral and bilateral donors must pledge long-term funding to mitigate Africa’s nutrition challenges along the lines of a number of previous initiatives. These include US President Barack Obama’s 2009 food-security initiative for Africa,5 the First Africa Food Security Conference in Nairobi in 2013,6 the Africa Food and Nutrition Security Day in 2010,7 the Maputo Declaration on agriculture and food security by African heads of state and government (which celebrated its tenth anniversary in 2013),8 and the European Commission’s 2011 initiative called Sustainable Nutrition Research for Africa in the Years to come (SUNRAY).9
In addition, the Scaling Up Nutrition (SUN) Movement has generated considerable momentum, with 45 member countries worldwide as of the end of 2013, including 31 in Africa. Through this movement, significant improvements have been reported by a number of African countries, notably Malawi, Tanzania, and Zambia, where nutrition has been placed at the heart of government priorities.10 Nutrition professionals who wish to see the Scaling Up Nutrition Movement succeed locally have formed an “academic platform,” spearheaded by Ghanaian nutritionists, to provide technical input and to strengthen civil society organizations. In addition, through the African Nutrition Society, nutritionists are promoting professional training in nutrition and nutrition education to aid efforts to meet the UN Millennium Development Goals, support health workers’ efforts to tackle nutrition-related health challenges, and advance the post-2015 agenda to support less-achieving countries in Africa. Moving forward in 2014, we urgently need to build capacity to support the Scaling Up Nutrition Movement at the country level across Africa. The concerted long-term approach represented by these various efforts is the most promising way to achieve sustainable solutions to Africa’s nutrition challenges.
Francis Bruno Zotor is president, African Nutrition Society, Accra, Ghana.
1 - UK Government, “G8 Summit Round-Up,” June 19, 2013, www.gov.uk/government/news/g8-summit-live. [Back]
2 - UK Government, “UK Hosts High-Level Meeting on Global Nutrition and Growth,” October 14, 2013, www.gov.uk/government/news/uk-to-host-high-level-meeting-on-global-nutrition-and-growth. [Back]
3 - Bread for the World Institute and Concern Worldwide, Sustaining Political Commitments to Scaling Up Nutrition Summary and Highlights (Washington, DC, 2013), www.bread.org/event
4 - The Lancet, Maternal and Child Nutrition, June 6, 2013,
5 - Council on Foreign Relations, “Obama’s Food Security Initiative in Africa,” August 12, 2009, www.cfr.org/food-security
6 - International Institute for Sustainable Development, First Africa Food Security Conference, “Harnessing Ecosystem-Based Approaches for Food Security and Adaptation to Climate Change in Africa,” www.iisd.ca/food/afsc1/, accessed December 27, 2013. [Back]
7 - New Partnership for Africa’s Development (NEPAD), South Africa, “NEPAD Policy Makers Highlight Africa Food and Nutrition Security Day as a Key Platform for Action,” www.nepad.org/foodsecurity/news/2545/sa-nepad-policy-makers%E2%80%A6highlight-
africa-food-and-nutrition-security-day-key-p, accessed December 27, 2013. [Back]
8 - NEPAD, AU 2003, “Maputo Declaration on Agriculture and Food Security,” November 1, 2010, www.nepad.org/nepad/knowledge/doc/1787/maputo-declaration. [Back]
9 - European Commission, European Bioeconomy, SUNRAY, http://ec.europa.eu/research/bioeconomy/food/projects/nutrition
/sunray_en.htm, accessed December 27, 2013. [Back]
8 - Scaling Up Nutrition (SUN), http://scalingupnutrition.org, accessed January 3, 2014; SUN, State of the SUN Movement Progress Report (draft), http://scalingupnutrition.org/wp-content/uploads/2013/09
/SUN_Progress_Report_2013_ENGLISH1.pdf, accessed January 3, 2014. [Back]
A few basic premises underpin the discussion in this chapter. First, political commitment or political will does not fall from the sky; rather, it needs to be proactively built.18 Second, generating political momentum can be a challenging step, but translating such momentum into effective action (and ultimately impact) on the ground is often an even greater hurdle. Given this reality, what will most likely be effective is a view that “policy is what policy does”—that is, the emphasis should be on what needs to be done and how it should be done.19 Third, in addition to politics, power, and policy, there is a fourth “P”—people. Public- and private-sector actors, civil society, academia, the media, frontline workers, and the public at large all have important roles to play in all three of these issues. As stated by James Grant, former UNICEF executive director, “It is the political will of the people that makes and sustains the political will of governments.”20
Ensuring Horizontal and Vertical Coherence
Because undernutrition has a multifaceted etiology with drivers that lie within the mandates of different sectors, and given the absence of any dedicated ministry of nutrition, a degree of harmonization among sectors is particularly important to ensure that policies and programs are as pro-nutrition as possible. This is hard to ensure, however, because sectors have different objectives, and competition is often more common than collaboration.
Nutrition is multisectoral in that the outputs and outcomes of many sectors affect it, but this does not mean that all sectoral actions need to be coordinated. This mistake was made during the multisectoral planning era of the 1970s and 1980s, when too much time was spent choreographing elaborate multisectoral plans without thinking through incentives (why a sector should act) and implementation modalities (how and what it should actually do).21 Nonetheless a degree of horizontal coherence between sectors is required for effective policy and practice.22 Relationships are also vertical (because of the links that exist between national, state, and district levels, for example), and there is a particular need for vertical coherence within larger countries that have decentralized systems of governance.23
It is helpful to review the experiences of countries that have been successful in reducing undernutrition in recent years. These countries—such as Brazil, Colombia, Peru, and Senegal—share certain common ingredients (though causality is difficult to establish rigorously). These include the creation or existence of multisectoral platforms, a culture of inclusiveness (of institutions and actors), appropriate incentives, and lateral (as opposed to simply top-down) leadership. In Peru, for example, a civil society–led multistakeholder coalition extracted pledges from presidential candidates to address child stunting if elected. Peruvian president Alan García was reminded of his promise after he won the vote, and levels of child stunting dropped from 31 percent to 19 percent between 2000 and 2011.24
In Malawi, nutrition has benefited from high-level political endorsement with the Department of Nutrition, HIV, and AIDS (DNHA) being located in the Office of the President and Cabinet. The department has developed a standardized Scaling Up Nutrition (SUN) Movement rollout framework to better align sectors at the district and community levels to improve nutrition. Malawi is ranked higher than any other African country on the new Hunger and Nutrition Commitment Index.25 At the global level, SUN has sought to promote horizontal coherence by establishing multisectoral platforms to catalyze and enable more complementary, coordinated, and integrated action.26
Optimizing the Use of Information and Evidence
To shape the policy space for nutrition effectively, information on trends in nutrition outcomes and their core drivers is required. Also needed is evidence of the damage caused by malnutrition and the benefits of addressing it. Finally, evidence from successful countries and effective programs is also critical. Both the 2008 and 2013 Lancet nutrition series systematically assembled such evidence, and the two rounds of the Copenhagen Consensus process (in 2008 and 2012) ranked nutrition interventions among the most cost-effective in the field of development.27 Yet there is still a need for more evidence of what works in scaling up nutrition-specific interventions, how to embed nutritional considerations in other sectoral actions, and how to make nutrition politically attractive.
Beyond information and evidence per se, the history of nutrition also suggests the importance of framing the evidence and employing the right narrative in the right place at the right time to influence action.28 Certain meta-narratives are common. A sampling includes nutrition as an outcome of economic development (frequent), nutrition as a driver of economic development (less frequent), nutrition as a human rights issue, and the hidden hunger narrative of micronutrient deficiency. Historically these narratives have tended to be biased toward food-based solutions, with less recognition placed on health- and care-related drivers of malnutrition. Different narratives have driven political commitment to act, such as zero hunger policies in Brazil, Guatemala, and Peru. In India, the fact that progress in nutrition has lagged markedly behind economic growth over the past two decades has led to greater calls for action on nutrition, including by the prime minister. These calls have also, unfortunately, led to the revisiting of an old debate on whether the international standards for measuring nutrition actually apply to Indian children.29
Without timely and credible information that is effectively communicated to those with the power and the capacity to act, political commitment, accountability, and responsiveness will likely prove elusive. On the transparency of political commitment, recent progress has been made in the form of the Hunger and Nutrition Commitment Index. This index was developed by the Institute of Development Studies to rank countries (and, more recently, donors) in terms of their commitment to addressing undernutrition. It complements other outcome-based indexes such as the United Nations Development Programme’s Human Development Index and IFPRI’s Global Hunger Index. Improvement in nutrition will not be achieved until governments and other actors are given incentives to act and are held accountable for the quality and effectiveness of any nutrition investment. On-the-ground evidence of the large-scale impact on nutrition status is still relatively thin, but what does exist may provide a powerful incentive for action and can be used by civil society to hold governments to account. At the community level, innovations such as community scorecards that track progress in health show great promise.30
Strengthening Nutrition-Relevant Capacity: The Elephant in the Room
Because strategic planning and program design in many development-related sectors often ignore the issue of weak capacity, development goals are often not reached. Nutrition is no different. But strengthening capacity in the field of nutrition is a complex task because nutrition-relevant action must be both multisectoral and multilevel. Several types of capacity must be developed, allowing different actors and organizations to undertake a variety of tasks.
A first step in setting strategies that effectively strengthen capacity is to systematically assess gaps and weaknesses. Capacity assessment tools and protocols have been developed for this purpose.31 They tend to highlight capacities needed at individual, organizational, and systemic levels. At an individual level, capacities range from the leadership and advocacy skills of nutrition “champions” (to generate high-level political commitment) to the capacity of frontline workers in remote villages (to support mothers in feeding and caring for their young children). Case studies suggest that individual and organizational capacity development needs to go beyond the conventional nutrition “toolbox” to encompass such skills as working across disciplinary boundaries, building and working through alliances and networks, leveraging other capacity and resources, and effectively communicating to different audiences.32
A Window Half-Open: Nutrition Policy in Pakistan
Over the past few years, nutrition has become a serious policy concern in Pakistan. With more than 180 million people, and undernutrition rates comparable to India’s, Pakistan has been undergoing a democratic transition in the midst of an insurgency. It can provide insights into the politics of nutrition in a period of change. The country’s new focus on nutrition has been due to a combination of political and administrative reforms, conspicuous natural disasters, and fresh research.1 When constitutional reforms empowered provincial governments, this opened up the opportunity for active policymaking on nutrition where it mattered: provincial governments providing the public goods and services most pertinent to nutrition. The international donor community and national development professionals had already been sensitized to the need for action on nutrition by successive floods in 2010 and 2011, which revealed the scale and depth of undernutrition among the country’s rural communities. These donors and development professionals began engaging with responsive and newly empowered provincial governments to create focal points for nutrition policy. The issue gained further public visibility when the results of a widely cited survey confirmed fears that vulnerability to hunger and undernutrition were prevalent and had remained unresponsive to economic growth.2
Even as the opportunity for raising policy interest in nutrition became apparent, there were also indications that this window may not remain open for long, given that nutrition has not played a prominent role in policymakers’ priorities and parties’ election manifestos. Elections held in May 2013 were hailed as historic, but mostly because they marked a departure from past trends of nonconstitutional regime change. These elections brought to center stage such issues as electricity shortages and terrorism, but undernutrition and its effects on millions of children were perhaps too complex to fit into neat sound bites for knockout political blows. Outright hunger, which might have attracted popular attention, was also conspicuous in its absence from the political debate. This was partly due to the government’s prior success in reducing price volatility (though not price levels) and preventing shortages of the main staple—wheat—by following through on the recommendations made in 2008 by a National Task Force on Food Security.3 Other aspects of food insecurity, such as the lack of dietary diversity, could not be translated into catchy slogans either.
The elections showed that although voters regarded electricity shortages and terrorism as signs of political failure for which they punished incumbents, apparently neither the general public nor elite opinion makers saw hunger and undernutrition as acute enough to command much attention or to rank among their highest priorities. Although the window of opportunity for nutrition policy remained open in 2013, the country’s exercise in democracy made it clear that support for such policy is still limited to a small group of professionals dedicated to the issue. To be successful, these influential few will need to find ways to “sell” their message creatively to politicians, opinion makers, and the public, much like their counterparts in other democratic countries have done. At the moment, this effort is still a work in progress in Pakistan.
Haris Gazdar is senior researcher, Collective for Social Science Research, Karachi, Pakistan.
1 - L. Haddad, Z. A. Bhutta, and H. Gazdar, “Seeing the Unseen: Breaking the Logjam of Undernutrition in Pakistan,” IDS Bulletin 44, no. 3 (2013), www.ids.ac.uk/publication/seeing-the-
2 - Government of Pakistan, National Nutrition Survey 2011 (Islamabad: Government of Pakistan, Aga Khan University, and UNICEF, 2011). [Back]
3 - Haddad, Bhutta, and Gazdar, “Seeing the Unseen.” [Back]
It is no surprise that poor-quality delivery of nutrition services tends to coincide in time and space with poor-quality nutrition training programs and academic curricula.33 Many capacity-assessment studies are from contexts with a high burden of malnutrition, and they find training and curricula to be outdated, impractical, and misaligned with local nutrition priorities.34
One clear overarching priority—highlighted in both the 2008 and 2013 Lancet series—is the need to strengthen strategic and operational capacity for scaling up nutrition interventions and embedding nutrition considerations in other sectoral actions.35 It is not enough just to strengthen the capacity of national-level policymakers and grassroots-level frontline workers. Also key is to strengthen midlevel actors (such as district-level program managers).36
With nutrition now a high priority for policymakers, it is time to invest national and global resources to support long-term capacity development. These capacity-strengthening investments will be based on funding cycles that extend well beyond the standard three- to five-year time frame characteristic of current donor-based program support.
Much needs to be done. But a concerted focus on capacity strengthening may result in many achievements in a relatively short time frame. For example, the state of Maharashtra in India piloted an effort in 15 mainly tribal districts with high levels of child stunting. The goal was to uncover what could be achieved simply by boosting the capacity and skills of frontline workers of the Integrated Child Development Services program and then giving them the necessary support to do their jobs. As a result of this effort, stunting among young children dropped rapidly—from 39 percent in 2006 to 23 percent in 2012.37
Malawi Builds High-Level Commitment to Nutrition Policy
Edith Mkawa and Felix Pensulo Phiri
The government of Malawi recognizes nutrition as a human rights issue. In November 2004, to ensure that nutrition policies were well coordinated, it established the Department of Nutrition, HIV, and AIDS. The mandate of this department is to provide strategic policy direction, advocacy, coordination, resource mobilization, and capacity building on nutrition issues. Furthermore, in a demonstration of political will and commitment to addressing nutrition, President Joyce Banda herself serves as the minister responsible for nutrition, HIV, and AIDS, and she placed the principal secretary of the department within the Office of the President and Cabinet to oversee and coordinate the program activities and day-to-day operations. In addition, Malawi has established high-level political committees such as the Cabinet Committee on Nutrition, HIV, and AIDS; the Parliamentary Committee on Nutrition, HIV, and AIDS; the Principal Secretaries Committee on Nutrition, HIV, and AIDS; the Government and Development Partners Committee; and the National Nutrition Committee.
Malawi uses the “three ones principle” in addressing nutrition: one coordinating office, one monitoring and evaluation framework, and one strategic plan. The government of Malawi developed its national monitoring and evaluation framework to ensure accountability in the implementation of nutrition activities at all levels. Through its high-level commitment to the national nutrition agenda based on a multisectoral platform, the country has made notable progress in reducing some negative nutrition indicators.1 However, Malawi is currently experiencing a rise in nutrition-related noncommunicable diseases, such as overweight, obesity, hypertension, and diabetes.
Through the Scaling Up Nutrition (SUN) Movement, Malawi made a number of strides in 2013. For example, it strengthened the country’s multisectoral platform by setting up the Civil Society Network and the Cabinet Committee on Nutrition, HIV, and AIDS. It also rolled out sugar fortification with vitamin A and reviewed standards for wheat and maize flour and cooking oil. Implementation of community-based nutrition interventions was scaled up to 50 percent of the districts in the country, with a focus on reducing stunting. Malawi rolled out a nutrition education and communication strategy for 2011–2016, developed a micronutrient strategy for 2014–2018, began a review of the nutrition policy and strategic plan for 2014–2018, and scaled up the community-based management of acute malnutrition and school feeding programs in all districts. The president also established a Nutrition Champion Committee, which includes traditional leaders, and launched the first-ever nutrition project funded by the World Bank and the Canadian International Development Agency. And at the Nutrition for Growth summit in London in June 2013, President Banda committed to gradually increasing budgetary allocations for nutrition from 0.1 percent to 0.3 percent by 2020.
Currently, Malawi is focusing its nutrition policy efforts on community-based management of acute malnutrition, dietary diversification, micronutrient interventions (including supplementation, fortification, biofortification, and dietary diversification), behavior change promotion for maternal and child nutrition, and the Baby-Friendly Hospital Initiative,2 among others.
Edith Mkawa is secretary and Felix Pensulo Phiri is deputy director, Department of Nutrition, HIV, and AIDS, Office of the President and Cabinet, Lilongwe, Malawi.
1 - Malawi, Malawi Demographic and Health Survey 1992 (Zomba, Malawi, and Calverton, MD, US: National Statistical Office and Macro International, 1994), www.measuredhs.com/publications
/publication-fr49-dhs-final-reports.cfm; Malawi, Malawi Demographic and Health Survey 2010 (Zomba, Malawi, and Calverton, MD, US: National Statistical Office and Macro International, 2011), www.measuredhs.com/publications/publication-fr247-dhs-final-reports.cfm. [Back]
2 - The Baby-Friendly Hospital Initiative is an effort by the United Nations Children’s Fund and the World Health Organization to ensure that all maternity centers, whether freestanding or in a hospital, become centers of breastfeeding support. [Back]
Malnutrition is finally being taken seriously by politicians as a major development challenge. A degree of consensus now exists on the need to implement certain nutrition-specific and nutrition-sensitive actions. These actions, in turn, can only spring from a stable and enabling political environment. Various actors and organizations are developing partnerships and collaborations. The energy of the SUN Movement is driving, and being driven by, this momentum and raising the stakes.
As the multisectoral nature of the nutrition challenge is taken onboard politically, issues of governance, accountability, and capacity become ever more important. The multisectorality of nutrition also means that implementation of effective nutrition programs is more complex than, for example, a vaccination program. In the context of nutrition, more attention needs to be paid to the “how” questions—especially how to implement effective large-scale programs where they are needed. Implementation or delivery science is becoming more prominent in development discourse, including in recent speeches by World Bank president Jim Yong Kim.38 But again the politics of delivery should also be considered. Past delivery failures need to be addressed by focusing on the “missing middle”39—the complex web of incentives, rules, and power relationships that link nutritionally vulnerable populations to service providers and different layers of government.
In terms of financial resource mobilization, generally speaking, the costs of required action are clearer than in the past,40 and significant pledges of increased funding were made in 2013. But more will be needed. Some of these extra resources could be raised through public-sector reallocations or could come from the private sector. Others could arise through relatively untried innovations, such as creative government-donor matching funds.41
Ultimately, political will is a political choice—to place priority on raising healthier children. Improvements in the quantity, quality, and communication of appropriate information can raise the profile of malnutrition as a development challenge and keep the momentum high. As the demand for such information grows, and as nutrition becomes more widely recognized by the media and the public as a societal issue, politicians will more likely choose to promote nutrition.
Stuart Gillespie is senior research fellow, Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Brighton, United Kingdom.
1 - Scaling Up Nutrition, http://scalingupnutrition.org/, accessed November 26, 2013. [Back]
2 - Government of the United Kingdom, “World Leaders Sign Global Agreement to Help Beat Hunger,” www.gov.uk/government/news/world-leaders-sign-global-agreement-to-help-beat-hunger-and-malnutrition, accessed October 30, 2013. [Back]
3 - 1,000 Days, www.thousanddays.org/, accessed November 8, 2013. [Back]
4 - S. Gillespie, L. Haddad, V. Mannar, P. Menon, and N. Nisbett, “The Politics of Reducing Undernutrition: Building Commitment and Accelerating Progress,” The Lancet 382 (2013): 552–569. [Back]
5 - The concept was originally developed by the United Nations Children’s Fund (UNICEF) nearly a quarter of a century ago. UNICEF, Strategy for Improved Nutrition of Women and Children in Developing Countries (New York: 1990). [Back]
6 - L. Haddad, H. Alderman, S. Appleton, L. Song, and Y. Yohannes, “Reducing Child Malnutrition: How Far Does Income Growth Take Us?” World Bank Economic Review 17 (2003): 107–131. [Back]
7 - The Lancet Maternal and Child Nutrition Series (2013) identified 34 countries (mainly in South Asia and Africa south of the Sahara) as home to 90 percent of the world’s stunted children. For these countries, Bhutta et al. modeled the effects of scaling up (to 90 percent coverage) a package of 10 nutrition-specific interventions for which there is clear evidence of effectiveness. Such a scaling up would reduce stunting by 20.3 percent, resulting in 33.5 million fewer stunted children. See Z. A. Bhutta, J. K. Das, A. Rizvi, M. Gaffey, N. Walker, S. Horton, P. Webb, A. Lartey, and R. Black, “Evidence-Based Interventions for Improvement of Maternal and Child Nutrition: What Can Be Done and at What Cost?” The Lancet 382, no. 9890 (2013): 452–477. [Back]
8 - UNICEF, “Nutrition: The Big Picture,” www.unicef.org/nutrition/index_bigpicture.html, accessed October 30, 2013.[Back]
9 - C. G. Victora, L. Adair, C. Fall, P. C. Hallal, R. Martorell, L. Richter, and H. S. Sachdev, “Maternal and Child Undernutrition: Consequences for Adult Health and Human Capital,” The Lancet 371 (2008): 340–357. [Back]
10 - S. R. Gillespie, M. McLachlan, and R. Shrimpton, Combating Malnutrition: Time to Act (Washington, DC: World Bank, 2003). [Back]
11 - Gillespie, McLachlan, and Shrimpton, Combating Malnutrition. [Back]
12 - T. Benson, Improving Nutrition as a Development Priority: Addressing Undernutrition in National Policy Processes in Sub-Saharan Africa, IFPRI Research Report 156 (Washington, DC: International Food Policy Research Institute, 2008). [Back]
13 - M. Natalicchio, J. Garrett, M. Mulder-Sibanda, S. Ndegwa, and D. Voorbraak, Carrots and Sticks: The Political Economy of Nutrition Policy Reforms, Health, Nutrition, and Population Discussion Paper (Washington, DC: International Food Policy Research Institute and World Bank, 2009). [Back]
14 - D. L. Pelletier, E. A. Frongillo, S. Gervais, L. Hoey, P. Menon, T. Ngo, R. J. Stoltzfus, A. M. Ahmed, and T. Ahmed, “Nutrition Agenda Setting, Policy Formulation, and Implementation: Lessons from the Mainstreaming Nutrition Initiative,” Health Policy and Planning 27 (2012): 19–31. [Back]
15 - J. Garrett and M. Natalicchio, Working Multisectorally in Nutrition: Principles and Practice from Senegal and Colombia, IFPRI Research Monograph (Washington, DC: International Food Policy Research Institute, 2012). [Back]
16 - A. Mejia Acosta and J. Fanzo, Fighting Maternal and Child Malnutrition: Analysing the Political and Institutional Determinants of Delivering a National Multisectoral Response in Six Countries: A Synthesis Paper (Brighton, UK: Institute of Development Studies, 2012). [Back]
17 - For political science, see T. W. Clark, The Policy Process: A Practical Guide for Natural Resources Professionals (New Haven, CT: Yale University Press, 2002); and J. W. Kingdon, Agendas, Alternatives, and Public Policies (New York: Harper Collins, 1995). For health systems, see J. Shiffman and S. Smith, “Generation of Political Priority for Global Health Initiatives: A Framework and Case Study of Maternal Mortality,” The Lancet 370 (2007): 1370–1379. [Back]
18 - Gillespie, McLachlan, and Shrimpton, Combating Malnutrition. [Back]
19 - E. J. Clay and B. Schaffer, eds., Room of Manoeuvre: An Exploration of Public Policy in Agriculture and Rural Development (London: Heinemann Education Books, 1984). [Back]
20 - G. J. V. Nossal, “Recent Trends in Global Immunisation,” in Hot Topics in Infection and Immunity in Children, Vol. 7, edited by N. Curtis, A. Finn, and A. J. Pollard (New York: Springer-Verlag, 2011), 10. [Back]
21 - J. O. Field, “Multisectoral Nutrition Planning: A Post-Mortem,” Food Policy 12, no. 1 (1987): 15–28. [Back]
22 - Garrett and Natalicchio, Working Multisectorally in Nutrition. [Back]
23 - K. Lapping, E. A. Frongillo, L. J. Studdert, P. Menon, J. Coates, and P. Webb, “Prospective Analysis of the Development of the National Nutrition Agenda in Vietnam from 2006 to 2008,” Health Policy Plan 27 (2012): 32–41. [Back]
24 - A. Mejia Acosta, Analysing Success in the Fight against Malnutrition in Peru, IDS Working Paper 2011:367 (Brighton, UK: Institute of Development Studies, 2011). [Back]
25 - Institute of Development Studies, UK Aid, and Irish Aid, Hunger and Nutrition Commitment Index (HANCI): Key Data for Malawi, 2013, http://opendocs.ids.ac.uk/opendocs/bitstream
26 - Scaling Up Nutrition, “A Framework for Action,” April 2010, http://scalingupnutrition.org/wp-content/uploads/pdf/SUN_Framework.pdf. [Back]
27 - S. Horton, H. Alderman, and J. Rivera, The Challenge of Hunger and Malnutrition (Copenhagen: Copenhagen Consensus Center, 2008). [Back]
28 - Gillespie, McLachlan, and Shrimpton, Combating Malnutrition. [Back]
29 - S. Gillespie, “Myths and Realities of Child Nutrition,” Economic and Political Weekly 58, no. 34 (August 24, 2013): 64–67. [Back]
30 - M. Bjorkman and J. Svensson, “Power to the People: Evidence from a Randomized Field Experiment on Community-Based Monitoring in Uganda,” Quarterly Journal of Economics 124 (2009): 735–769. [Back]
31 - S. Gillespie, Strengthening Capacity for Nutrition, IFPRI Discussion Paper 106 (Washington, DC: International Food Policy Research Institute, 2001); and C. Potter and R. Brough, “Systemic Capacity Building: A Hierarchy of Needs,” Health Policy Plan 19 (2004): 336–345. [Back]
32 - Gillespie, McLachlan, and Shrimpton, Combating Malnutrition. [Back]
33 - R. D. Hampshire, V. M. Aguayo, H. Harouna, J. A. Roley, A. Tarini, and S. Baker, “Delivery of Nutrition Services in Health Systems in Sub-Saharan Africa: Opportunities in Burkina Faso, Mozambique, and Niger,” Public Health Nutrition 7 (2004): 1047–1053. [Back]
34 - S. Khandelwal, R. Dayal, M. Jha, S. Zodpey, and K. S. Reddy, “Mapping of Nutrition Teaching and Training Initiatives in India: The Need for Public Health Nutrition,” Public Health Nutrition 15 (2012): 2020–2025. [Back]
35 - G. T. Heikens, B. C. Amadi, M. Manary, N. Rollins, and A. Tomkins, “Nutrition Interventions Need Improved Operational Capacity,” The Lancet 371 (2008): 3–4; and Gillespie, McLachlan, and Shrimpton, Combating Malnutrition. [Back]
36 - Pelletier et al., “Nutrition Agenda Setting.” [Back]
37 - UNICEF, Improving Child Nutrition: The Achievable Imperative for Global Progress (New York: 2013), 31.
38 - Jim Yong Kim, remarks delivered at the annual meeting plenary session, October 11, 2012, www.worldbank.org/en/news/speech/2012/10/12/remarks-world-bank-group-president-jim-yong-kim-annual-meeting-plenary-session, accessed November 1, 2013. [Back]
39 - K. Watkins, “Jim Kim’s ‘Science of Delivery’: What Role for Politics?” August 13, 2013, www.odi.org.uk/opinion/7703-jim-kims-science-delivery-role-politics. [Back]
40 - Bhutta et al., “Evidence-Based Interventions.” [Back]
41 - S. Spratt, Aid for Nutrition: Using Innovative Financing to End Undernutrition (Brighton, UK: Action Against Hunger and Institute of Development Studies, 2012); and UNITAID, “Innovative Financing,” www.unitaid.eu/en/how/innovative-financing, accessed September 25, 2013. [Back]