Elsevier

The Lancet

Volume 382, Issue 9891, 10–16 August 2013, Pages 552-569
The Lancet

Series
The politics of reducing malnutrition: building commitment and accelerating progress

https://doi.org/10.1016/S0140-6736(13)60842-9Get rights and content

Summary

In the past 5 years, political discourse about the challenge of undernutrition has increased substantially at national and international levels and has led to stated commitments from many national governments, international organisations, and donors. The Scaling Up Nutrition movement has both driven, and been driven by, this developing momentum. Harmonisation has increased among stakeholders, with regard to their understanding of the main causes of malnutrition and to the various options for addressing it. The main challenges are to enhance and expand the quality and coverage of nutrition-specific interventions, and to maximise the nutrition sensitivity of more distal interventions, such as agriculture, social protection, and water and sanitation. But a crucial third level of action exists, which relates to the environments and processes that underpin and shape political and policy processes. We focus on this neglected level. We address several fundamental questions: how can enabling environments and processes be cultivated, sustained, and ultimately translated into results on the ground? How has high-level political momentum been generated? What needs to happen to turn this momentum into results? How can we ensure that high-quality, well-resourced interventions for nutrition are available to those who need them, and that agriculture, social protection, and water and sanitation systems and programmes are proactively reoriented to support nutrition goals? We use a six-cell framework to discuss the ways in which three domains (knowledge and evidence, politics and governance, and capacity and resources) are pivotal to create and sustain political momentum, and to translate momentum into results in high-burden countries.

Introduction

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

  • Emerging country experiences show that rates of undernutrition reduction can be accelerated with deliberate action.

  • 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.

  • 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.

  • 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.

  • 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

  • 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.

  • 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.

  • 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.

  • 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.

Section snippets

Characterisation of enabling environments

What does an enabling environment for undernutrition reduction look like? In recognition of the general consensus that income growth is necessary but not sufficient for undernutrition reduction,7, 13, 14 we undertook a systematic review of the nutrition-relevant policy process and governance literature (panel 1). After a surge of activity in the late 1970s to early 1980s, a two decade gap ensued in research of nutrition policy processes, punctuated by one book in 1993, until interest re-emerged

Narratives, knowledge, and evidence

The 2008 Lancet Nutrition Series showed how effective marshalling of evidence can create momentum by identifying a set of interventions that were effective at reducing undernutrition in various contexts, identifying a window of opportunity—1000 days—as a focal point, and imparting a sense of priority and feasibility by showing how undernutrition is concentrated in a small set of high-burden countries. The 2008 Series also emphasised the fragmented nature of the international nutrition community

Knowledge and evidence

Building of momentum for undernutrition reduction is not an easy task, nor is it sufficient; such momentum needs to be translated into ground-level results. Again the three dimensions of an enabling environment come into play: knowledge and evidence about how to scale up interventions in an effective way, the political economy behind the interplay between national and subnational levels of government, and the capacity and resources needed to scale and expand coverage of programmes while

Looking ahead

In the past 5 years, the nutrition community has made major progress, but it should be judged against the effect emerging in the next 5 years and beyond. Momentum needs to be sustained and converted into lasting effects. SUN will reach its 1000th day when this Lancet Series is launched in June, 2013. Since SUN's own launch in September 2010, the movement has substantially elevated and energised the discourse on nutrition and has changed institutional arrangements. In some countries, the

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