Nine key ingredients for transforming nutrition delivery
Lessons from a series of country-level case studies.
Nutrition-specific interventions target the immediate causes of undernutrition, namely inadequate dietary intake and ill-health. In 2013 the Lancet Series on Maternal and Child Nutrition recommended ten direct interventions that could reduce stunting by 20% for countries with high rates of undernutrition.
Against this backdrop and the impetus generated by the Scaling Up Nutrition (SUN) movement, we know with reasonable certainty what nutrition-specific interventions works. However, we also know that this is not enough. Large-scale impact requires the right intervention(s) delivered to the right people at the right time in the right context. This ‘right mix’ is essential for successful translation of policies and programmes and underpins efficient allocation of limited resources in developing countries.
In order to gather evidence on the critical ingredients of this mix Transform Nutrition conducted an evidence review which explored the necessary ingredients for scaling up effective interventions in particular contexts and identified nine essential elements.
These nine ingredients subsequently formed the basis of a framework for a series of follow up studies which allowed us to distil lessons from a series of country-level case studies that we have called “Stories of change”. This Guide walks you through some of what we found.
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Transform Nutrition is supported by the UK Department for International Development
Scaling up impact on nutrition
The reduction of undernutrition has been a key issue in several global developmental agendas and discourses. Better nutrition is in everyone’s best interests but nobody’s responsibility. The massive scale of the nutrition challenge hinges on the cooperation and collaboration of diverse stakeholders. Although there is consensus on key interventions and a growing momentum to scale these up, less is known about how to operationalize the right mix of actions (nutrition-specific and nutrition-sensitive) equitably, at scale. Our evidence review explored a large literature base on scaling-up and 4 case studies of large-scale nutrition programmes to synthesize critical elements for impact at scale. The review identified nine essential elements:
- having a clear vision or goal for impact
- intervention characteristics (what exactly is to be scaled up –whether a technology, a process, project, innovation, and/or methodology)
- an enabling organizational context for scaling up
- establishing drivers such as catalysts, champions, system wide ownership, and incentives
- choosing contextually relevant strategies and pathways for scaling up
- building operational and strategic capacities
- ensuring adequacy, stability, and flexibility of financing
- ensuring adequate governance structures and systems
- embedding mechanisms for monitoring, learning, and accountability
One potential area of collaboration is with the private sector; that is the development of strong public-private partnerships (PPP). While there has been great momentum with the SUN movement, the 2015 Independent Comprehensive Evaluation (ICE) suggests the process “has not solved the multiple COI [conflict of interest] challenges facing the movement” and there is also a lack of consensus on the best way to proceed with PPP engagements.
Within this context, our paper: brings structure to the discussion of private-sector engagement in nutrition; summarizes the evidence base; and outline some potential ways forward.
First, we find that while there appears to be a large body of evidence on this topic, closer examination shows that there are few independent, rigorous assessments of the impact of commercial-sector engagement in nutrition.
Second, progress in this area requires that the private sector recognize that past and current actions by some firms have created an environment of mistrust. It also requires that the public sector accept that sustainable PPPs are those that permit private firms to generate profits.Addressing these concerns takes time. We found no examples of successful PPPs that took less than two years to establish.
Third, PPPs are best placed to operate where the benefits (to nutrition) are highest and where public-sector solutions are not readily available, effective, or sustainable. We see significant scope for the use of the private sector in driving innovations that could reduce undernutrition and the potential for the private sector to provide finance. Underpinning all these efforts must lie open discussions of the objectives, roles, and expectations of all parties along with potential conflicts of interest; an open platform where challenges can be discussed and addressed; strong, transparent, and well-enforced monitoring processes; and serious, independent evaluations of these activities.
Another approach is to drive change through reform of government policy and practice. In 2011, the Government of Bangladesh, in an effort to optimise nation-wide nutritional outcomes, integrated key nutrition-specific interventions in their existing health system delivery platform – the National Nutrition Service (NNS).
Two years after this roll-out, we supported an evaluation commissioned by the World Bank to identify what was being done right but, perhaps more importantly, where mainstreaming fell short. Apart from being overwhelmed by the myriad nutrition-specific interventions, NNS was hampered by frequent changes in leadership, weak coordination and capacity gaps at all levels - national and sub-national. The evaluation also found that the NNS started with too many interventions for its existing implementation capacity, and there were critical mismatches in choice of platforms to deliver the preventive interventions.
But the study did highlight potential solutions to achieve sustained improvement in the quality of nutrition services.
Over-ambition, so common in early phases of many rolled-out programmes, needs to be tempered with the practical reality of what can be achieved and how.
Collaborations with existing NGOs can increase coverage of preventive nutrition interventions through community platforms, optimize workload and also benefit from the years of experience in community engagement.
Strategic investments in ensuring capacity development, transparency, monitoring and accountability mechanisms are key to sustainability.
Constraints in delivering programmes at the community level
Among the factors identified in our review of scaling up, issues of barriers and capacity directly relate to delivery of nutrition-specific interventions as scale and achieving high coverage. Translating upstream policies to downstream health and nutrition services effectively requires understanding how various grass-root level factors might influence uptake at the population level. Embedding the interventions into appropriate platforms; maintaining uninterrupted supply of quality service and promoting community demand for use of the services are critical.
The delivery and uptake of health and nutritional services, both product-oriented (e.g – immunisation) and information-based (e.g – counselling) are influenced by a number of factors. At the community level the success of health and nutrition programmes can be affected by much more practical constraints related to the performance of front-line health workers (FLW) and/or the characteristics of recipient households. The influence of these factors is highly contextual and so requires study at a fairly granular level.
In India for example, despite specific programme guidelines for FLWs, the coverage of information-based services has generally been low in rural areas. Our study, conducted in one district of the state of Bihar, found that beneficiaries like pregnant women are more likely to receive counselling if the FLWs maintain a registry of recipients and have a lower work load in terms of the number of pregnant women in their catchment areas requiring a visit.
In Bangladesh, delivery of nutrition specific interventions were mainstreamed into the health systems with the introduction of the third health sector programme in 2011. Routine health systems platforms including antenatal care (ANC), post-natal care (PNC) and management of childhood illnesses at health facilities were chosen as the key contact opportunities for offering nutrition services. After more than two years of introduction, while the quality of nutrition counselling during ANC services had improved, this was not the same for the sick child management contacts. Poor training of frontline health workers impeded service delivery at the community and outreach level. In addition, lack of systematic supervision and oversight, combined with weak accountability processes, had stymied the delivery of quality nutrition services.
The Bihar study confirmed that incentives for FLWs were important for service delivery and that incentives for product-oriented services like immunization had a spill-over effect on the delivery of information-based ones like general nutrition counselling.
On the demand-side, household education and socioeconomic status disproportionately influenced receipt of certain services that should be universal. We found that educated household heads were more likely to be aware of and receive immunisation services than their less educated counterparts suggesting that, in the short term at least, outreach efforts could prioritise less educated households to raise awareness of available services like immunisation.
Analyzing the drivers and pathways of progress
One of the best ways to achieve positive change is to learn from and adapt what has worked before. However, this requires an in-depth understanding of the context of what has worked. Through a series of structured case studies, our Stories of Change in Nutrition series explores how changes in nutrition outcomes were achieved in 6 countries in fairly diverse contexts: Bangladesh, Nepal, Odisha (India), Ethiopia, Senegal and Zambia.
The case of Odisha is an interesting one. In recent years it has outpaced richer states in India in terms of delivering health services and improving nutrition outcomes. The overarching story of change in nutrition has highlighted how scale-up of nutrition programmes can be achieved by integration with health service delivery platforms. Odisha achieved this because of high-level support for programme innovations, the use of diverse pathways for scaling up, leadership at all levels, adequate financing through multiple sources, and important collaborations with committed development partners.
Despite this progress, challenges persist in sustaining the progress and achieving further improvements in nutrition outcomes. First, capacity constraints could challenge the quality of nutrition-specific delivery across the board and significant coverage gaps remain for some key interventions. Secondly, actions are needed to improve underlying drivers of nutrition, especially sanitation, female education and early marriage, as improving nutritional outcomes will be an almost impossible challenge if these are not addressed. Last but not the least, poverty, inequality and the issue of land rights are seen as impediments to any further progress.
The Odisha nutrition story is a success story waiting to burst out of the straightjacket imposed on it by less than stellar improvements in underlying and basic determinants. Our analysis has highlighted that these underlying and contextual areas are absolutely imperative for Odisha’s policy and programme community to invest in.