The nutrition landscape has shifted fundamentally since the first Lancet Series on Maternal and Child Undernutrition was published in January, 2008. Since then, almost every major development agency has published a policy document about undernutrition. In a very difficult fiscal climate, official development assistance to the basic nutrition category has increased from US$259 million in 2008, to $418 million in 2011—a rise of more than 60% (although it was $541 million in 2009).1 Furthermore, the G8 countries reported increases of almost 50% in bilateral spending on nutrition-specific and nutrition-sensitive interventions between 2009 and 2011.2 According to Google Trends, “malnutrition”, now matches “HIV/AIDS” in terms of internet interest, whereas 5 years ago, HIV/AIDS received twice as much interest as malnutrition. This shift is attributable to several factors: the food price spikes of 2007–08 sparked renewed media and policy interest in undernutrition, The Lancet 2008 Series provided policy makers with a set of tangible interventions that were effective in various locations, and the 2008 Copenhagen Consensus concluded that nutrition interventions were among the most cost effective in development.3
The Scaling Up Nutrition (SUN) movement, which started in September 2010, is the most important symbol of the increased interest in nutrition.4 By the middle of May, 2013, the movement had grown to include 35 countries that are committed to the scale-up of direct nutrition interventions and the advancement of nutrition-sensitive development, including 21 of the 34 highest burden countries where 41% of the global burden of child stunting is located (or 56% if India is omitted). As SUN nears its 1000th day, several countries have made advances in terms of building multistakeholder platforms, aligning nutrition-relevant programmes within a common results framework, and mobilising national resources, but it is too soon to evaluate the effect of SUN on rates of undernutrition reduction.
Key messages
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Emerging country experiences show that rates of undernutrition reduction can be accelerated with deliberate action.
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Politicians and policy makers who want to promote broad-based growth and prevent human suffering should prioritise investment in scale-up of nutrition-specific interventions, and should maximise the nutrition sensitivity of national development processes.
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Findings from studies of nutrition governance and policy processes broadly concur on three factors that shape enabling environments: knowledge and evidence, politics and governance, and capacity and resources.
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Framing of undernutrition reduction as an apolitical issue is short sighted and self-defeating. Political calculations are at the basis of effective coordination between sectors, national and subnational levels, private sector engagement, resource mobilisation, and state accountability to its citizens.
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Political commitment can be developed in a short time, but commitment must not be squandered—conversion to results needs a different set of strategies and skills
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Leadership for nutrition, at all levels, and from various perspectives, is fundamentally important for creating and sustaining momentum and for conversion of that momentum into results on the ground.
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Acceleration and sustaining of progress in nutrition will not be possible without national and global support to a long-term process of strengthening systemic and organisational capacities.
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The private sector has substantial potential to contribute to improvements in nutrition, but efforts to realise this have to date been hindered by a scarcity of credible evidence and trust. Both these issues need substantial attention if the positive potential is to be realised.
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Operational research of delivery, implementation, and scale-up of interventions, and contextual analyses about how to shape and sustain enabling environments, is essential as the focus shifts toward action.
As interest in nutrition has changed, so too has our thinking. The large economic returns to nutrition-specific interventions (paper two in this Series5), are clear6 and we recognise the potential of nutrition-sensitive interventions (paper three7) and the importance of an enabling environment for reduction of undernutrition—the focus of this report.8 Most of the concepts and ideas that we develop about enabling environments apply to both undernutrition and the growing problems of overweight and obesity as documented in the first paper in this Series. We focus mainly on undernutrition because as the 2010 Global Burden of Disease estimates show, undernutrition remains the number one risk factor in sub-Saharan Africa, and the fourth in south Asia.9 We use evidence generated within academic and scientific institutions and that generated in more real-world, action oriented, transdisciplinary ways that embed nutrition within wider social and political contexts.10 We used this mixture of evidence types partly because of the paucity of the first type of evidence and partly in recognition that the second type is often more appropriate because it is more practical, politically feasible, and therefore actionable. However, the second type of evidence is not as easy to independently verify or systematise with standard systematic review protocols.
Beyond the nutrition-sensitive programmes and interventions discussed in paper three, other macro-level drivers exist that lie at the end of long causal pathways. Seemingly quite remote from the nutritional wellbeing of children, many such drivers are nonetheless crucially important to shape both national and global political landscapes for nutrition, and basic-level determinants of nutrition status. These aspects are particularly important because each of the various determinants of nutritional outcomes can be vulnerable to sudden changes within, or caused by, these drivers. Examples include climate change, trade, the rate and pattern of economic growth, food and energy prices and volatility, and land-use policies. Previous empirical work at the country level has shown that household income growth is a necessary, but not sufficient driver, of nutrition status.11 In a cross-country study of the drivers of nutritional change over time,12 four factors emerged as the most robust predictors of reductions in undernutrition worldwide: secondary education for girls, reductions in fertility, accumulation of household assets, and increased access to health services. In view of the scarce evidence for these drivers we do not discuss the related scientific literature. Rather, we reiterate that through the approaches for shaping enabling environments for nutrition, described here, we might be better able to advocate for attention to nutrition within these broad development debates.