Nine key ingredients for transforming nutrition delivery

Lessons from a series of country-level case studies.

Health worker Durgesh addresses a meeting on malnutrition in  Jahangir Puri, New Delhi, India|Save the Children
Edited by Alan Stanley
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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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Shams El Arifeen 

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  1. 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: 

  1. having a clear vision or goal for impact
  2. intervention characteristics (what exactly is to be scaled up –whether a technology, a process, project, innovation, and/or methodology)
  3. an enabling organizational context for scaling up
  4. establishing drivers such as catalysts, champions, system wide ownership, and incentives
  5. choosing contextually relevant strategies and pathways for scaling up
  6. building operational and strategic capacities
  7. ensuring adequacy, stability, and flexibility of financing
  8. ensuring adequate governance structures and systems
  9. 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.



Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition?
The Lancet, 2013
Acceleration of progress in nutrition will require effective, large-scale nutrition-sensitive programmes that address key underlying determinants of nutrition and enhance the coverage and effectiveness of nutrition-specific interventions. The authors of this article in the 2013 Lancet Series on Maternal and Child Nutrition reviewed evidence of nutritional effects of programmes in four sectors - agriculture, social safety nets, early child development, and schooling.
Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost?
The Lancet, 2013
Maternal undernutrition contributes to 800,000 neonatal deaths annually; stunting, wasting, and micronutrient deficiencies are estimated to underlie nearly 3.1 million child deaths annually. Progress has been made with many interventions implemented at scale and the evidence for effectiveness of nutrition interventions and delivery strategies has grown since The Lancet Series on Maternal and Child Undernutrition in 2008.
Maternal and child undernutrition and overweight in low-income and middle-income countries
The Lancet, 2013
Maternal and child undernutrition, including stunting, wasting, and deficiencies of essential vitamins and minerals, was the subject of a Series in The Lancet in 2008, which quantified their prevalence, short-term and long-term consequences, and potential for reduction through high and equitable coverage of proven nutrition interventions. The Series identified the need to focus on the crucial period of pregnancy and the first 2 years of life - the 1000 days from conception to a child’s second birthday during which good nutrition and healthy growth have lasting benefi ts throughout life.
The politics of reducing malnutrition: building commitment and accelerating progress
The Lancet, 2013
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.
Scaling Up Impact on Nutrition: What Will It Take?
Advances in Nutrition, 2017
Despite consensus on actions to improve nutrition globally, less is known about how to operationalize the right mix of actions—nutrition-specific and nutrition-sensitive—equitably, at scale, in different contexts. This review draws on a large scaling-up literature search and 4 case studies of large-scale nutrition programs with proven impact to synthesize critical elements for impact at scale.
Global Nutrition Report 2015: Actions and accountability to advance nutrition and sustainable development
International Food Policy Research Institute, 2015
Tackling, reducing, and even eliminating malnutrition in all of its forms should be considered an achievable priority for the world. This is a sentiment expressed in the Sustainable Development Goals (SDGs), at the 2015 Nutrition for Growth (N4G) summit, and in this 2015 Global Nutrition Report. A vast number of authors and researchers from multiple institutes and organisations contributed to make this report the most comprehensive and authoritative study on the state of global nutrition.
Public-private partnerships and the reduction of undernutrition in developing countries
International Food Policy Research Institute, 2015
This paper brings structure to the discussion of private-sector engagement in nutrition by clarifying different models of engagement, reviews the evidence base on public-private partnerships (PPPs) for the reduction of undernutrition, and outlines some potential ways forward. The paper finds that there are few independent, rigorous assessments of the impact of commercial-sector engagement in nutrition.
Bangladesh national nutrition services: assessment of implementation status
World Bank, 2015
This report presents the findings of an operations research study conducted to assess the implementation of the Government of Bangladesh’s National Nutrition Services Program (NNS) and to identify the achievements, determine the bottlenecks that adversely impact these achievements, and highlight potential solutions to ensure smooth delivery of the program.
Scaling Up Impact on Nutrition: What Will It Take?
Transform Nutrition, 2015
Over the last five years or so, a broad-based consensus on the “what” questions in nutrition has solidified. We know a lot more about what is driving malnutrition and we know more about the type of interventions that are needed to respond. And yet, we continue to struggle with the “how” questions. We simply do not know enough about how to operationalize an appropriate mix of actions - nutrition-specific and nutritionsensitive – equitably, at scale, in different contexts.The concept of “scaling up nutrition” is now so routinely espoused within the nutrition community, it has become a mantra.
Public-private partnership for reducing undernutrition
International Food Policy Research Institute, 2015
Discussions surrounding public-private partnerships (PPPs) in undernutrition are characterized by optimism by some, mistrust by many, and confusion by all. Optimism, because the private sector is seen as a potential source of expertise, technical resources, and new funding for nutrition. Mistrust because many civil society and government actors have experienced private-sector behavior that undermines public policy.
Public-Private Partnerships and Undernutrition: Examples and Future Prospects
, 2016
In this chapter, we clarify what is meant by public-private partnerships (PPPs), provide examples of both successful and less successful PPPs and describe some broad lessons. We see scope for PPPs that would reduce aspects of undernutrition. However, this optimism comes with significant caveats. First, while there would appear 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.

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.


Predictors of Essential Health and Nutrition Service Delivery in Bihar, India: Results From Household and Frontline Worker Surveys
Global Health Science and Practice, 2017
 In Bihar, India, coverage of essential health and nutrition interventions is low. These interventions are provided by 2 national programs—the Integrated Child Development Services (ICDS) and Health/National Rural Health Mission (NRHM)—through Anganwadi workers (AWWs) and Accredited Social Health Activists (ASHAs), respectively. Little is known, however, about factors that predict effective service delivery by these frontline workers (FLWs) or receipt of services by households.
Quality of nutrition services in primary health care facilities: Implications for integrating nutrition into the health system in Bangladesh
PLoS ONE, 2017
In 2011, the Bangladesh Government introduced the National Nutrition Services (NNS) by leveraging the existing health infrastructure to deliver nutrition services to pregnant woman and children. This study examined the quality of nutrition services provided during antenatal care (ANC) and management of sick children younger than five years.MethodsService delivery quality was assessed across three dimensions; structural readiness, process and outcome.

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.

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Stories of Change in Nutrition Country Brief: Odisha, India, September 2016
Transform Nutrition, 2017
The Stories of Change (SoC) research project aims to capture experiential learning from policy makers and implementers in countries with high burdens of malnutrition to understand how changes in nutrition outcomes were achieved in particular contexts. In India, due to inter-state variability in development outcomes (including nutrition), as well as differences in the political and policy environment, SoC focused on one state, Odisha.
25 Years of Scaling Up: Nutrition and health interventions in Odisha, India | IFPRI
International Food Policy Research Institute, 2016
ODISHA, A STATE of 42 million people in eastern India, is one of the poorest in the country. It has faced many development challenges over the years, including insurgent movements, large pockets of extreme deprivation among scheduled tribe communities, social disparities, and natural disasters, as well as a relatively late fiscal turnaround (in 2004–2005) in comparison with other states. Yet Odisha has made significant progress in reducing child undernutrition—less than India as a whole, but more than many other richer states. How has it achieved this progress?