Research Report No. 156Undernutrition remains one of Sub-Saharan Africa’s most fundamental challenges to human welfare and economic growth. Both for normative and instrumental reasons related to human and economic development, a strong case can be made for the importance of addressing the needs of the undernourished as an issue of public concern and, hence, the desirability of governments to prioritize and make substantial investments in efforts to reduce undernutrition among their citizens. The policies and actions of national governments are a critical component in enabling individuals and households to achieve nutrition security. Central government has the responsibility for establishing institutions and infrastructure and providing resources without which many of the poor, in particular, will remain undernourished. Yet in most nations in Sub-Saharan Africa, a high prevalence of undernutrition in the population is not seen as anomalous or indicative of the inability of the government to fulfill its duties to its citizens. Undernutrition tends to be treated in national policy processes as a business-as-usual issue. There is no drama associated with it; no perception that the issue is critical to the future of the country, the continued political success of government, or to the well-being of its citizens. As a consequence, there is low political demand for action against undernutrition, and most governments in Sub-Saharan Africa do very little to ensure that nutrition-related goods and services are provided to their citizens. This problem is at the center of this report.
This report examines the findings from a qualitative institutional study in Ghana, Mozambique, Nigeria, and Uganda that investigated what it is about national policymaking, nutrition, and nutrition in policymaking that makes it difficult for undernutrition to be targeted as a national development priority. Much more so than for most other development challenges, the routine operations of government through sector-specific actions are unlikely to lead to success in comprehensively eliminating undernutrition. A conceptual framework of the determinants of nutritional status is examined from the perspective of policymaking and the institutional organization of government to assess the various opportunities for and constraints on prioritizing action to address undernutrition in the public sector in these countries. In each country, four interrelated elements of the policy processes related to addressing undernutrition are examined. The first three elements are interdependent—policymaking structures, including both formal institutions and less formal political interests; political actors who engage strategically with particular policy processes; and the narrative or persuasive understanding of undernutrition that is the basis on which choices are made to derive policy in this area. However, by themselves these three elements do not explain policy change. A fourth element, timing, is also critical. The presentation of the study findings in each of the four countries is organized using these elements of the policy process.
Although the four study countries provide some useful contrasts in their policy processes, administrative organization, and levels of economic and political development, the dominant commonality is that none of the countries has effectively prioritized undernutrition in the objectives and resource allocation patterns of government. The following points summarize several of the most important country-level findings of the study.
- In all four countries, undernutrition is generally seen as part of the context within which government works as best it can. High levels of undernutrition do not threaten the legitimacy of the governments of these four countries or invoke a sense of crisis. When addressing undernutrition, the governments tend to focus on bureaucratic arrangements and programming that involves mid-level managers rather than political leaders, with little attention to the issue in any fundamental policy reforms in which they may engage. As a consequence, all four countries consistently underinvest in efforts to reduce undernutrition. Such an approach is maintained even when evidence shows, as in Ghana, that levels of child undernutrition have increased in recent years.
- In all four countries, there is a limited understanding among political leaders and policymakers of both the costs of aggregate undernutrition in the country for national development and the determinants of nutritional status. This failure is evident in the limited linking of any policy narratives on undernutrition to master development narratives in the country.
- In the face of the awkward institutional location of nutrition in government, the governments of Mozambique, Nigeria, and Uganda have developed formal food security and nutrition policies and established food security and nutrition coordination bodies. However, the record of success of these policies and agencies in shifting government resource allocations toward addressing undernutrition is quite poor. There are several reasons why they tend not to be effective. Perhaps most salient is that sectoral ministries in government tend to view themselves as being in competition with one another for resources. Most participants in the budgeting process assume that resources allocated to another sector are lost to their own. Policies and coordinating agencies that have cross-sectoral scope do not fit this sectoral pattern of resource allocation and add a layer of complexity to it.
- Existing sectoral mandates tend to be used to determine what public actions are undertaken to address undernutrition and to assign responsibility for carrying them out. Yet in all of the study countries for all the sectors concerned, whether health, education, agriculture, water and sanitation, or others, nutrition activities tend to be viewed as secondary priorities and improved nutrition outcomes as secondary sectoral objectives.
- The actors who are directly involved with nutrition advocacy and the coordination of nutrition activities present some common patterns across the countries. International partners tend to be important in nutrition-focused activities and their coordination. This situation is especially the case in Mozambique, but can be seen in all of the countries. On the other hand, there is seemingly little engagement by national civil society groups in nutrition advocacy. This failure likely reflects a combination of a lack of attention to engaging existing civil society groups on this issue and a lack of public awareness of the costs of undernutrition and how to address the problem.
- The study countries differ in the level of expertise that they have in addressing problems of nutrition. Mozambique has very few professional nutritionists, whereas Nigeria has many hundreds of them. However, there is little evidence that the prospects for the undernourished in Nigeria are any better than in Mozambique. The manner in which available human capacity in nutrition is used is certainly as important as the presence of trained nutritionists. Moreover, where policymaking is centralized and relatively ordered, a few motivated nutritionists are adequate to provide policymakers with necessary nutrition analyses and technical inputs to guide the formulation of policy and the allocation of resources. However, where policymaking is decentralized and develops in a bottom-up manner, as is the ambition in Uganda, the constraints on human capacity in nutrition are much broader. For local governments to take action to address the needs of the undernourished among their citizens, they must be provided with considerably more information on the costs of the problem at the community and subcounty level and what needs to be done to reduce it. For this effort, local governments need more technical support from nutritionists.
With between one-quarter and one-third of all children in these countries stunted in their physical growth and cognitive development, the human costs of undernutrition are immense. Although small positive steps can be identified in all four countries, none of the governments has succeeded in putting in place policy mechanisms to reduce sustainably the numbers of the undernourished in their populations. Certainly, none has effectively prioritized undernutrition in its policy objectives and allocations of resources.
In part, this failure is due to the poor fit of undernutrition as a public policy problem in the sectoral organization of government. The underlying determinants of improved nutritional status fall across several sectors, including health and agriculture. Given this poor fit and the consequent problems for establishing leadership on the issue of undernutrition in government, national advocacy coalitions should be formed around the issue. The absence of effective nutrition advocacy coalitions in the study countries appears to be an important constraint on building the commitment of government to assist the undernourished attain nutrition security. Yet the creation of such coalitions is problematic. To some degree, leadership for and participation in such advocacy efforts depends on the personal qualities of the participants. However, if established, there are several actions that such coalitions should take:
- Consistently link nutrition policy narratives to those of the master development framework for the country. The problem of undernutrition should be couched within a framework that demonstrates to a country’s leaders how their master development objectives are not likely to be attained if the constraints imposed by undernutrition on needed development are not removed.
- Make sure that the government continues to recognize its duty to ensure that its citizens are properly nourished. Normative reasons for addressing undernutrition are compelling.
- Make it clear to senior government leaders that improving nutrition requires a broader set of action across multiple sectors than those needed to attain food security. Cultivate policy champions, particularly senior political and bureaucratic decisionmakers. This is particularly important in countries with more disordered and personalized policy processes, such as Nigeria.
- Raise the awareness of the general public of the burden that undernutrition imposes on their well-being and what can be done effectively to reduce this burden. While it is useful in its own right to increase understanding of the importance of good nutrition and what constitutes good nutritional care, doing so also provides a foundation for political dialogue centered on the problem of undernutrition at more local levels. Over time, such efforts will increase expectations on government that it has a responsibility for ensuring that all citizens are properly nourished.
Advocates for nutrition must present clear and consistent messages of the roles that the government and sectors within it should play in reducing undernutrition in a concerted and harmonized manner. The objective is that government agencies will recognize the important contributions that they can make to assist the undernourished and to build a sense of responsibility on the part of government for seeing that these contributions are made across all of the sectors concerned.
The perception of undernutrition as being part of the normal order of things must be altered. Advocacy groups should generate a perception of crisis related to undernutrition to foster significant, urgent, high-profile action by government. Although such a qualitative change in the perception of nutritional conditions cannot be sustained in the long term, at least incremental changes in the profile of the policy problem can be exploited so that more effective actions are taken to assist the undernourished. Because undernutrition is a solvable problem that, in part, requires public action to address sustainably, governments should and can be held accountable for the persistence of undernourished women and children in the population, the unnecessary suffering they experience, and the limited potential they have to live long, healthy, productive, and creative lives.