Nutrition has long been neglected in policy circles. Advocates in developing countries are now learning how to get nutrition on the political agenda and how to take effective action.
In 2006, CARE was winding down a program designed to reduce chronic child malnutrition in 1,200 communities across Peru. A decade or two earlier, such a program would have consisted mainly of distributing food to households. In line with new thinking, however, CARE had focused on addressing the underlying causes of malnutrition—not only access to food, but also care of mothers and infants and provision of health services and sanitation—in a coordinated fashion. When the program ended, an evaluation revealed gratifying results: the intervention had reduced chronic infant malnutrition by 10 percentage points in five years. Normally, the story would end there.
In this case, however, Milo Stanojevich, the director of the Peru CARE office, wasn’t ready to move on. CARE had found a model that worked. Shouldn’t they use it more widely—even across the entire country? “When you finish a project and have an evaluation, you can either pat yourself on the back and put it on the shelf, or you can do something else about it,” he says. “We thought it was the right moment to take our experience and try to influence government policy.”
The government knew it had a nutrition problem: about one out of every four Peruvian children had stunted growth, and the rate was even higher in rural areas. Stunting—being short for one’s age—is now recognized as the most meaningful indicator of chronic malnutrition. Stunted children often have cognitive deficiencies, are susceptible to disease, and earn less as adults than well-nourished children will. The Peruvian government had undertaken various initiatives to fight malnutrition, with disappointing results. Even though the country’s economy was growing briskly, the rate of child stunting had barely budged in a decade.
Stanojevich brought together representatives of other nongovernmental organizations that had run nutrition programs similar to CARE’s and achieved similar successes. The group decided to create a formal coalition—the Child Nutrition Initiative (CNI)—to call for making nutrition central to the fight against poverty and to share evidence about effective ways of improving nutrition. “Most of all,” says Stanojevich, “we needed the highest level of political commitment to make this a national priority.” In other words, they needed to reach the president.
As it happened, 2006 was an election year, so the CNI decided to, in effect, put nutrition on the ballot. Members of the CNI met with the presidential candidates individually to encourage them to adopt a pledge called “5 by 5 by 5.” The idea was to reduce child malnutrition by 5 percent in children under age five in five years and to close the gap in nutrition between children in rural and urban areas. “It turned out to be a really good slogan,” says Stanojevich. “There were 18 candidates in the first round, and we got commitments from 10 of them.”
The first round of voting was held on April 9, 2006. Two months later, a runoff election was held between Alan García and Ollanta Umala—the two leading candidates—and both had signed the pledge. No matter who won, nutrition was on the agenda.
Once seen as a problem that could be solved through narrow healthcare approaches, distribution of food aid, or economic growth, increasingly, malnutrition is now perceived as an issue requiring broad government action, says IFPRI Senior Research Fellow Stuart Gillespie, who, along with several coauthors, published an article on the politics of reducing malnutrition in the British medical journal The Lancet in June 2013.
Motivating governments to take action, however, depends on getting nutrition onto the political agenda—and then getting policymakers to take the right steps. In recent years, actors both inside and outside of government in Peru and other countries as varied as Guatemala, Bangladesh, and Ethiopia have learned how to navigate political realities and exercise leverage, resulting in sometimes striking impacts on children’s nutrition.
“Ironically, the more undernutrition in a village, the more invisible it is, because short and underweight children become perceived as the norm.”
—Stuart Gillespie, IFPRI
Recently, nutrition has garnered more political attention, in part because economic and technical solutions alone have so clearly proven inadequate to reduce child malnutrition, says Gillespie. It was assumed that nutrition in a country improves as its economy grows and incomes rise, but the experiences of India and other countries have discredited this assumption. Economic growth in India over the past decade has been among the fastest in the world—while its rate of child malnutrition has remained stubbornly high.
In addition, Gillespie says, “the causes of malnutrition are largely underpinned by politics and governance.” The determinants of nutrition consist of food security (people’s access to healthy food), caregiving (including appropriate child feeding practices, preventive health care, psychosocial stimulation), and environmental conditions (people’s access to health, water, and sanitation services). Nutrition also requires contributions from many sectors—such as health, agriculture, infrastructure, and education—whose core function is not nutrition. They therefore need to be provided with incentives, often through government, to act in ways that explicitly benefit nutrition.
Good nutrition confers a host of benefits—less childhood illness and death, better cognitive development and performance in school, higher productivity and earnings, and less obesity—so why haven’t governments already embraced it as a priority? Nutrition, Gillespie explains, suffers from an invisibility problem. It’s not infectious, it requires actions by many actors, and the benefits may take longer than a politician’s term of office to manifest themselves. “Ironically,” he says, “the more undernutrition in a village, the more invisible it is, because short and underweight children become perceived as the norm.”
Gillespie and his Lancet coauthors say the keys to creating an environment in which nutrition can be improved lie in marshaling knowledge and evidence, using the tools of political economy and governance, and beefing up capacity and resources. Much of the evidence supporting recent action on nutrition has its roots in a 2008 series of Lancet articles whose ripple effects are still being felt (see box).
The Lancet & the Birth of a Global Nutrition Movement
It was a watershed moment for global nutrition policy: in 2008, following up on a 2003 series of articles on child survival in the British medical journal The Lancet, Robert Black of the Johns Hopkins University School of Public Health led a team to produce another Lancet series specifically on maternal and child nutrition. “In 2003 we didn’t have the space and we didn’t do justice to nutrition,” Black says.
Between 2003 and 2008, much had been learned about child nutrition and intervention points, and the 2008 series gave wide exposure to a couple of seminal ideas: the importance of assuring that children get good nutrition from conception to the second birthday (the “first 1,000 days”) and the consensus that child stunting is the most useful indicator of chronic undernutrition. These ideas, says Black, provided “a focus for programming and advocacy that was not there before.”
The series also shined a rather unflattering spotlight on the global nutrition community. “We were sharply critical of the nutrition community,” says Black, “saying that it needed to be better coordinated and focused to achieve better impact. That was met with some initial resistance: who were we to say they were uncoordinated and unfocused? In short order, though, the nutrition community realized there was some truth to what we said and began to pull together in more concerted ways.”
People in donor and UN agencies and national governments launched some initial discussions on how to coordinate their nutrition efforts, but disagreements arose about how to proceed. Participants found themselves in two camps: those who saw nutrition as a health problem amenable to technical, nutrition-specific solutions and those who saw it as an outcome of underlying forces such as poverty and inequality. The divide threatened the new coalition that was still in its infancy.
In 2009, David Nabarro, the special representative of the UN secretary-general for food security and nutrition, got involved. “We sought to create a much larger tent,” says Nabarro, by including both nutrition-specific actions and nutrition-sensitive approaches. A series of meetings involving donors, civil society organizations, governments, and UN agencies led to the eventual formation of a new movement, known as Scaling Up Nutrition (SUN), for which Nabarro serves as coordinator.
Led by its member countries, the SUN Movement is designed to encourage high-level commitment on nutrition from national leaders, align all actors in support of common targets, increase domestic and external resources for nutrition, and exchange information on what works. The Movement coalesced in 2009 and 2010 around a few early joiners, including Uganda and Zambia, says Patrizia Fracassi from the SUN Movement Secretariat. Over the next couple of years, dozens of other countries joined, and the movement now counts 42 countries as members. “There is a critical mass of people who believe you need high-level political commitment. They want to create momentum,” she says.
SUN countries hold a multistakeholder phone call every six weeks to monitor progress in four main processes: developing platforms that include multiple stakeholders, passing nutrition legislation, aligning different sectors around common goals, and mobilizing resources. The role of the SUN Movement Secretariat, Fracassi explains, is not to carve out a permanent presence in every country, but rather to help countries speed up implementation of their policies and then let them run on their own. “We want to see the Movement in the country and an exit strategy for the SUN Movement Secretariat,” she says. “We want people at every level to feel they are fostering a movement.”
If at First You Don’t Succeed…
Two decades before nutrition made it onto the development community’s agenda, Thailand developed a successful model for overcoming child malnutrition. During the 1970s a growing awareness of the costs and impacts of poverty emerged among the Thai public as well as academics, planners, and politicians, explains Pattanee Winichagoon of the Institute of Nutrition at Bangkok’s Mahidol University, who has written extensively on Thai nutrition policy. Several Thai doctors who had trained in Europe and the United States in the 1950s and 1960s returned home determined to help the country reduce poverty and malnutrition. They made the case in policy circles that spending to improve nutrition is an investment, rather than an expense. Malnutrition, they argued, is not simply a health problem, but a result of economic inequality. Nutrition, in short, is a development issue and a social indicator.
This way of framing nutrition resonated with policymakers. In 1977, Thai policymakers drafted their first National Food and Nutrition Plan. The plan aimed to improve food availability, nutrition education, and health care and hygiene. Among other things, it called for the construction of about 1,200 child nutrition centers at which malnourished children were fed high-protein supplements, and the delivery of supplementary foods to the homes of children suffering from severe malnutrition. Around the third year of the plan, though, data from selected areas revealed bad news: the plan had failed. In the early 1980s, 50 percent of Thai children were still malnourished—about the same as before the plan started.
It was soon clear that many aspects of the plan had never been implemented because local agencies were not coordinated with one another, planning was top-down and included little community involvement, and budgets and plans had not been tailored to the new system.
But the plan had succeeded in getting Thai policymakers to commit to improving nutrition. The planners went back to the drawing board.
When Thailand rolled out its second National Food and Nutrition Plan in 1982, it was based on a new idea: you need to maximize people’s participation in solving their own problems. This time, Thailand recruited and trained thousands of people to serve as village health volunteers, who would treat minor illnesses and undertake minor procedures, and village health communicators, who would disseminate health and nutrition information. Children were weighed every three months and identified as normal or mildly, moderately, or severely malnourished. Children with moderate or severe malnutrition were weighed monthly and received supplementary food prepared in their village. Communities were encouraged to produce their own nutritious foods through home gardening or fish farming. And school lunch programs were extended to 5,000 schools in poor regions.
Perhaps the most remarkable aspect of the program was its country-wide presence. Each village health communicator was responsible for 10–20 households, and each village health volunteer, for 100–200 households. “They got the ratios right,” says Gillespie. “They had a manageable workload.” By 1989 about half a million village health communicators and 50,000 village health volunteers had been trained and were present in nearly every village in Thailand. As a result, nutrition messages and support reached into almost every household.
This approach generated rapid results. In just a decade, from 1982 to 1991, child malnutrition in Thailand fell from about 50 percent to just 17 percent.
Today, says Winichagoon, the nutrition program is no longer the subject of such intense government focus, but volunteers are still actively involved in providing health services and “communities still have a lot of interest in nutrition.” Thailand still has child stunting rates of 10–15 percent, but this is much less than other countries in the region. “Now we need to work harder to keep issues like maternal nutrition and the importance of nutrition during a child’s first 1,000 days on the agenda,” she says.
While Thailand’s pioneering approach to nutrition in the 1980s received some attention, it attracted no imitators. It would, unfortunately, take decades for nutrition to secure a spot on the political agenda—globally or in other countries.
Reinforcing the Front Line
In India, child stunting is so widespread that it seems nearly normal: the country accounts for more than 40 percent of the world’s stunted children. In Maharashtra—India’s richest and second most populous state—39 percent of children younger than two were stunted in the mid-2000s.
The impetus for change started in 2001 with a local administrator facing a local tragedy. V. Ramani was commissioner of the division of Aurangabad in central Maharashtra. Just 70 kilometers from the capital city Aurangabad, a thriving tourist center, 14 children died of malnutrition. “To be honest, I had barely any knowledge of the issue of child malnutrition in 2001,” says Ramani, an economist by training. He had decided to focus on health and education in the division, and the deaths of the children opened his eyes to a pressing dimension of public health.
To tackle malnutrition, Ramani turned to Maharashtra’s UNICEF office, which had long operated nutrition programs in the region. He also borrowed an idea from a friend in the state of Orissa who was working to reduce malnutrition by gathering monthly data on children’s nutritional status. In 2002, the Marathwada Initiative was launched, centering on regular and frequent measurement of children, counseling of mothers on feeding and caring for children, and nutrition supplements as needed for children who were severely malnourished.
Part of Ramani’s challenge was changing how the existing child nutrition system did business. Since the 1970s India has had a large-scale program designed to improve children’s health and nutrition, known as Integrated Child Development Services (ICDS). The Marathwada Initiative worked to shift the focus of the ICDS workers from simply providing food to actively measuring children to determine their nutritional status. It also sought to lay the groundwork for more cooperation between the ICDS and the health sector.
The Marathwada Initiative lowered rates of severe malnutrition by 62 percent in two years. In 2004, Ramani was transferred to the state government, and once again, reports surfaced of child deaths from malnutrition in a tribal community.
“Two facts came to my notice immediately,” says Ramani. “First, there was a tendency to lay the primary responsibility for the oc-currence on the other department. Second, no up-to-date authentic data existed for analyzing the event and pinpointing possible causes. With the Marathwada experience fresh in my mind, I saw the consequences of a lack of coordination between these two key departments: they could not even agree on the numbers, let alone evolve a joint strategy to deal with the problem.”
Field workers were required to register, weigh, and monitor the growth of every child in their jurisdiction—no small task in a state the size of Maharashtra.
Ramani, with the support of other officials inside and outside the government, proposed the idea of a statewide Nutrition Mission to Vilasrao Deshmukh, the state’s chief minister. As it happened, Deshmukh was from Aurangabad Division and was thus familiar with the nutrition successes there. “He understood the implications,” says Ramani.
In April 2005 the mission was launched. UNICEF provided support in the form of money and training for both ICDS and health workers. “We promoted a healthy convergence between the Department of Women and Child Development [which ran the ICDS] and the Department of Public Health,” says Ramani.
Also key, he says, was “a determination that no child in need in Maharashtra should remain unserved by the public service delivery system.” Field workers were required to register, weigh, and monitor the growth of every child in their jurisdiction—no small task in a state the size of Maharashtra, whose 100 million inhabitants make it bigger than most countries.
Ghana Gets Serious
In December 2011 Ghana’s first lady, Ernestina Naadu Mills, launched the country’s entry into the Scaling Up Nutrition (SUN) Movement. For Ghana and the other 41 countries that have joined, the SUN Movement may be the push that is needed to get real progress on improving nutrition. Edith Tetteh, deputy of the National Development Planning Commission, is Ghana’s SUN liaison.
Tetteh points out that Ghana is where kwashiorkor—advanced child malnutrition—was identified in the 1930s by a doctor working in an Accra hospital. The word has since entered the nutrition lexicon. But malnutrition in its various forms remains a problem in Ghana. “If you are sick and you have a diagnosis and for 80 years you do not have a cure, that means you are not serious,” says Tetteh. “With the SUN Movement, the country has decided to really do something about child undernutrition.”
The advent of SUN, says Tetteh, has stimulated the writing of a National Nutrition Plan and brought together the various sectors involved. Ghana is working on advocacy and information campaigns at the policy, media, and grassroots levels. Because the National Development Planning Commission reports directly to the president, the SUN activities are well positioned politically. And nutrition efforts are extending into schools, agricultural extension, health clinics, and other sites.
Ghana managed to reduce child stunting from 30 percent in 1988 to 23 percent in 2011. Whether the country can bring this rate down much further will depend on how well it can continue to marshal the elements Stuart Gillespie and his coauthors identified in their Lancet article—knowledge and evidence, political economy and governance, and capacity and resources—and convert high-level commitment into changes in households across Ghana.
The training of the frontline ICDS and health workers in how best to feed infants and young children was essential, says Ramani: “I think the training brought home to them that they were doing a very important job, and they were noticed for the first time.”
At the end of the mission’s first phase, in 2010, Ramani left to become an independent consultant, but the mission itself continues. Stunting in Maharashtra fell from 39 percent in 2006 to 23 percent in 2012.
Turning the Tide
The successes in Thailand and Maharashtra point to a few important elements. In both cases, individuals pressed for action, giving visibility to a neglected issue. Transform Nutrition, a research initiative led by IFPRI’s Gillespie, is studying, among other things, how such nutrition “champions” arise and operate. His Lancet article reports on research showing that “a handful of catalytic individuals, well-connected and trusted in their formal and informal social networks,” can be key to exchanging information, changing perceptions, and resolving conflicts, especially given how fragmented the competing interests can be. Both cases also brought nutritional knowledge and interventions down to the household level. Hands-on efforts to communicate with mothers and to measure and treat children were highly labor intensive, but effective. Although interventions in Thailand centered on the health sector, in Maharashtra the coordination of disparate departments was crucial.
These various elements also came into play in Peru, when Alan García won the 2006 presidential election. “When the new prime minister, Jorge del Castillo, made his inaugural speech to Congress,” says Stanojevich, the director of CARE’s Peru office, “he ratified the commitment and stated that it was a national priority. We were jubilant.” The Child Nutrition Initiative saw an opening, proposing “10 Recommendations for the First 100 Days” to spell out exactly how the government could reduce child malnutrition and, notably, made the recommendations public.
The task also involved educating top officials. “We had to say, ‘If you want to make a difference, you’re not going to pass out food, you’re not going to build schools or health centers,’” says Stanojevich. “You need to improve services, you need to educate mothers on how to feed their children properly, you need to improve hygiene, water, and sanitation and raise economic development in the community so there’s more income.” The Child Nutrition Initiative’s proposals were able to gain traction because the group had hard evidence to back them up.
The government initiated a national nutrition strategy called Crecer (“to grow”), addressing malnutrition through a focus on water and sanitation, nutritional practices, and infectious disease. It reorganized 82 existing government programs into 26 initiatives. Peru also reoriented its conditional cash transfer program, known as Juntos (“together”), toward combating malnutrition.
Efforts to encourage different government ministries and levels of government to work together did not result in immediate outpourings of trust and goodwill. Nonetheless, as the national government promoted its strategy for malnutrition, the regions started developing their own localized versions, with support from civil society organizations and donors.
In 2007 the government upped the targeted reduction in child malnutrition from 5 to 9 percentage points. In 2011 the new president, Ollanta Umala, raised the target again, saying he aimed to lower malnutrition to 10 percent.
“One day nobody is talking about malnutrition, and four years later it’s the number-one priority in the country and everyone is talking about it,” says Stanojevich. “It’s one of those classic tipping points, where you push and push and all of a sudden it just goes off on its own.”
Peru has not yet reached Umala’s target of 10 percent, but progress has been remarkably rapid. In the five years from 2007 to 2012, child stunting rates nationwide fell by more than 10 percentage points, from 28.5 percent to 18.1 percent. In rural areas, where malnutrition is more severe, the proportion of children who are stunted declined from 45.7 percent to 31.9 percent—nearly 14 percentage points.
A Role for Citizens
“We’ve seen real upswings in civil action for nutrition all over the world.”
—David Nabarro, United Nations
There’s a sense in the nutrition community that nutrition as an issue may be peaking in terms of attention. “We’ve seen real up-swings in civil action for nutrition all over the world,” says David Nabarro, the UN special representative. “There’s huge energy in Tanzania, Zambia, India, Indonesia. What was perceived as invisible is shifting.” This year on June 8 UK Prime Minister David Cameron hosted a Nutrition for Growth summit designed to get aid donors to pony up funds for fighting hunger and malnutrition in 20 target countries. The event brought in commitments totaling more than $23 billion ($19 billion for nutrition-sensitive approaches and more than $4 billion for nutrition-specific approaches).
Far from summit meetings and prime ministers, Milo Stanojevich sees the need to solidify political gains by focusing on more local and small-scale action. “You can only do so much by using the tactics we used,” he says. “What we would like to do now is organize women in the rural areas so they become aware of malnutrition. They already have a lot more knowledge, but we also want them to monitor and advocate so we have more active citizen participation. This way citizens can organize and ask their local governments for attention to the issues that are important to them.”
For more information on this topic:
- Maternal and Child Nutrition, The Lancet, special series, June 2013
- Scaling up in agriculture, rural development, and nutrition, edited by J. F. Linn, IFPRI 2020 Focus Briefs, June 2012