SCN News No 36 - UNSCN

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38 FEATURES www.unsystem.org/scn Commitment, Consensus and Strategic Capacity: An Evidence-Based Agenda David Pelletier and the Mainstreaming Nutrition Initiative 1 The nutrition community may debate and disagree about many things, but we do agree on a few key points. Malnutrition impairs human, social and economic development and is the major cause of the burden of disease in the developing world. It generally does not receive the level of attention it deserves within governments, international agencies and many other organizations, even though effective solutions are available. We also tend to agree that our responses to the problem should be based on evidence. Normally the evidence we seek relates to the efficacy and effectiveness of interventions. In contrast, the Mainstreaming Nutrition Initiative (MNI) is an action research project that has gathered evidence on the factors that help and hinder the movement of nutrition agendas at the country level. This is the type of evidence required if nutrition is to receive the attention we feel it deserves. For the past two years MNI staff from International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) and collaborating institutions have partnered in various ways with governmental and non-governmental organizations in Bolivia, Guatemala, Peru, Bangladesh, Pakistan, Vietnam, Uganda and Ethiopia. We have been participantobservers in various phases of the nutrition policy process in these countries, from commitment-building to implementation and evaluation. We also have interviewed a wide range of people from a number of other developing countries and international organizations, participated in international meetings and examined grey literature to understand the issues from diverse perspectives. Although the Initiative is still underway and lessons are still being learned, it is timely to share some of the findings with a larger audience. The findings that follow are based on experiences in nineteen countries: The Philippines, Thailand, Bangladesh, Benin, Burkina Faso, Ethiopia, Kenya, Madagascar, Malawi, Mali, Mauritania, Senegal, Tanzania, Uganda, Bolivia, Chile, Guatemala, Haiti and Peru, as reported by government officials and staff from international agencies, NGOs and universities, or researcher institutions. What shapes nutrition agendas? The study identified a wide range of factors that influence the movement and shape of nutrition agendas, but they can be grouped into the following categories: social conditions, catalytic events, structural factors, points of contention, strategies and tactics (Figure 1 and Table 1). Societal conditions and catalytic events These two themes represent factors that have created opportunities and challenges to the national nutrition agenda. Societal conditions refer to events and processes that tend to persist for many years and affect many aspects of the development agenda in a country, with direct or indirect effects on the nutrition agenda. Catalytic events are typically shorter in duration, and are more closely related to the nutrition agenda itself. They are sometimes created by actors in the national nutrition system in the normal course of nutrition research, testing of interventions, piloting or implementing of nutrition programs, responding to crises, or conducting policy dialogue. Societal conditions and catalytic events often provide opportunities for advancing the nutrition agenda. They focus attention on conditions closely related to food security and nutrition (e.g., drought in Tanzania, Ethiopia, Kenya, basic needs development and primary health care in Thailand, social inclusion in Bolivia and Guatemala). They create not only a larger policy discourse within which nutrition can be strategically framed by nutrition actors (e.g., currency devaluation in Senegal, results-based budgeting in Peru), but also venues for policy discussions where nutrition actors can seek a seat at the table and position nutrition within the larger policy issues of the day (e.g., MDG discussions in many countries, the HIV pandemic in Kenya, Uganda and Malawi). Catalytic events which are more closely related to nutrition and more readily influenced or used by nutrition actors. (e.g., publicizing a model community-based program in Thailand, attendance of The Mainstreaming Nutrition Initiative (MNI) is World Bank-funded project of the International Centre for Diarrhoeal Diseases, Bangladesh and collaborators at Cornell University, the International Food Policy Research Centre, the University of South Carolina and participating developing countries. http://mainstreamingnutrition.org/default.aspx. Purnima Menon, Tien Ngo and Dominic Frongillo contributed to the study reported here. Tahmeed Ahmed, Shamshir Ahmed (ICDDR,B) and Edward Frongillo (USC) also are core members of the MNI Team. SCN NEWS # 36 back to contents
www.unsystem.org/scn FEATURES 39 Figure 1: Five categories of factors affecting nutrition agendas Societal Conditions Catalytic Events Structural Factors & Behaviors Points of Contention • Disasters • War • Civil unrest • Economic downturns • Sector reforms • Elections • HIV etc. • Food crises • Nutrition surveys • Small-scale projects • Positive experiences: Salt iodization Vitamin A suppl • PRSP windows • National or international conferences • Visits by high profile actors • MDG-1 • Lancet series etc. • Institutional arrangements for leadership, coordination, implementation • Limited authority & budget control • Divergent perspectives, interests and power • Fragmented, shifting & short-term funding • Weak capacity & credibility of nutrition units • Competition & rivalry • Avoidance and weak accountability • Decentralization etc. • Food programs • Targeting • Micronutrient strategies • GMP • Stunting vs underweight • RUTF for moderate malnutrition • U2 vs U5 • School feeding • Vertical vs integrated • Long vs short routes etc. Strategies and Tactics policy makers at the International Conference on Nutrition in 1992, re-estimating malnutrition prevalence based on international standards in Vietnam), and have been used successfully in many countries to advance the nutrition agenda. However, they may not command the same level or duration of attention as the broader factors included under societal conditions. While societal conditions and catalytic events both have presented opportunities for the nutrition agenda, they have also sometimes resulted in serious challenges. The most common example is when a drought, complex emergency, economic downturn, war, right-to-food movement, or other event stimulates food distribution by the government and/or its partners. In many cases this has led to the institutionalization of food distribution (often encouraged by food aid donors and NGOs), the delegation of responsibility for nutrition to a Ministry of Agriculture, and/or the tendency for policy makers to associate malnutrition with lack of food. All of these outcomes tend to orient the nutrition policy agenda towards food distribution, food access, and agriculture. Although this can be useful for enhancing food and economic security in countries where these are important causes of malnutrition, it makes it difficult to create a more balanced agenda that addresses the care, feeding and health status of infants and young children. Such dynamics have been evident in Bolivia, Chile, Guatemala, Mexico, Peru, Senegal, Tanzania, Ethiopia, Vietnam and many other countries not included in this study. “As happened to quite a few other countries, nutrition appeared on the political agenda of (country) following a series of natural disasters that brought about a looming nutrition crisis.” (Country nutrition actor) “Every time, the country tried to put a feeding program into project documents and we had to erase it.” (Donor agency) “We know the fact that the food supplementation takes so much time to actually execute for the frontline work on nutrition. The community nutrition workers, do not have the time to counsel the women. And they’re feeding women in groups so they don’t have individual follow-up.” (International NGO) Other examples of challenges created by societal conditions and catalytic events include the narrowing of the nutrition agenda by the international micronutrient focus, the erosion of support for successful nutrition programs due to health sector reform, struggles over the institutional home for nutrition due to party politics, or simply the neglect of nutrition due to more pressing priorities. Points of contention One of the most prominent themes in these countries relates to disagreements and conflicts over strategies and interventions, complicated by politics among mid-level actors. Such points of contention were evident in almost all nineteen countries. They can arise over virtually the entire range of potential interventions and strategies, depending on which are under consideration in a given country (Table 1). A striking feature of these disagreements is that they take place primarily among mid-level actors in the national nutrition system, rather than among politicians or at high administrative levels. They occur in countries with both back to contents SCN NEWS # 36
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