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. We know with reasonable certainty what nutrition-specific interventions work- 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 - However, we also know that the interventions alone are not enough. To have large-scale impact, the right interventions need to be delivered to the right people, at the right time and in the right context. Efficient allocation of resources and successful translation of policies and programmes both depend on a good understanding of these precise contextual conditions.
Transform Nutrition conducted an evidence review which explored the necessary ingredients for scaling up effective interventions in particular contexts, and 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 organisational 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
These nine ingredients subsequently formed the basis of a framework for a series of follow-up studies which allowed us to distil lessons, or “stories of change” from a number of country-level case studies. This Guide explains some of our findings.
The reduction of undernutrition has been a key component in international development agendas and discourses. Better nutrition is in everyone’s best interests but it is seemingly nobody’s responsibility. The massive scale of the nutrition challenge hinges on the cooperation and collaboration of diverse stakeholders.
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Scaling up impact on nutrition
One potential area of collaboration is with the private sector for 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.
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. What is apparent is that progress in this area depends on the private sector recognising the environment of mistrust caused by the behaviour of some firms. To make progress, the public sector will need to accept that sustainable PPPs permit private firms to generate profits. Addressing these concerns takes time. We have found no examples of successful PPPs that took less than two years to establish.
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. There is 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. But for this to work initiatives must be underpinned firstly by an open platform where objectives, expectations and challenges of all parties can be discussed and secondly by strong, transparent, and well-enforced monitoring and independent evaluation of 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 of 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 longer term sustainability.
Constraints in delivering programmes at the community level
Translating upstream policies into downstream health and nutrition services effectively requires understanding how various grassroots-level factors might influence uptake at the population level.
The delivery and uptake of health and nutritional services, both product-oriented (for example, immunisation) and information-based (for example, counselling) are influenced by a number of factors. At the community level, the success of health and nutrition programmes can be affected by practical constraints at a fairly granular level related to the performance of front-line health workers (FLW) as well as the characteristics of recipient households.
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 a 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 lower numbers of pregnant women in their catchment areas to visit.
In Bangladesh, nutrition specific interventions were mainstreamed into 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 hindered the delivery of quality nutrition services.
The Bihar study confirms that incentives for FLWs are important for service delivery and that incentives for product-oriented services like immunisation 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. This suggests 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 successes. However, this requires an in-depth understanding of the context of these successes. Through a collection 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.
Odisha makes an interesting case, as 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 nutrition programmes can be successfully scaled up by integration with health service delivery platforms. Odisha succeeded because of high-level support for programme innovations, the use of diverse pathways for scaling up, strong leadership at all levels, adequate financing through multiple sources, and important collaborations with committed development partners.
Despite this progress, challenges persist in sustaining 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 challenges in these areas are not addressed. Last but not 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 in waiting, held back by less than stellar improvements in underlying and basic determinants. Our analysis emphasises that creating the right context for nutrition-sensitive interventions is absolutely imperative for the success of Odisha’s policies and programmes.