Enabling environments for nutrition

Understanding the role of leadership, capacity and accountability.

Liben, Somali region in Ethiopia.|Save the Children
Edited by Tracy Zussman

At the core of the Transform Nutrition consortium is the argument that enabling environments are fundamental to transforming thinking and action on undernutrition, and reversing decades of neglect. Research by the programme reviewed and systematically investigated wider policy and political processes which underpin nutrition’s basic determinants and which affect the capacity to act at basic, underlying and immediate levels.

Foundational reviews published in The Lancet and World Development have been accompanied by innovative new research reviewing the role of governance amongst other predictors of nutrition outcomes, and the role of leadership and capacity in determining how countries perform. Further foundational work has contributed to the development of new methods of assessing country-wide or sub-national levels of commitment such as real time monitoring of nutrition outcomes via mobile phones and social and community accountability in health and nutrition.

This is the first of three guides that summarise the research of the consortium from 2012-2017 around its three main themes.

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Transform Nutrition’s research has summarised the wider institutional, governance and political factors behind successful nutrition-relvant action which together constitute 'an enabling environment for nutrition'.   A paper which formed part of the Lancet Series on nutrition concluded that governance and policy process studies broadly concur on three factors that shape enabling environments: a) framing, knowledge and evidence, b) politics and governance and c) capacity and resources. A further paper widened such considerations to themes common in critical development studies including power, social accountability and the role of political narrative. Complementary work at a country level has shown how such factors operate in context at both national and community levels.

Another study built on econometric analysis of nutrition and Demographic and Health Survey (DHS) data sets to identify where governance variables drive nutrition outcomes. It found that safe water and sanitation, women’s education and empowerment, and the quantity and quality of food available in countries have been key drivers of past reductions in stunting. Uniquely the research shows how income growth and governance both played essential facilitating roles.


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.
Reducing child undernutrition: past drivers and priorities for the post-MDG era
World Development, 2017
Reducing child undernutrition is gaining high priority on the international development agenda in the post-MDG agenda, both as a maker and marker of development. In this paper, the authors use data from 1970 to 2012 for 116 countries, finding that safe water access, sanitation, women’s education, gender equality, and the quantity and quality of food available in countries have been key drivers of past reductions in stunting. Income growth and governance played essential facilitating roles.
Why worry about the politics of childhood undernutrition?
World Development, 2014
Undernutrition affects over 2 billion people; but most of the global policy focus has been on technical solutions rather than an understanding of nutrition politics. This paper reviews existing literature on nutrition politics and policy. The authors identify a number of recurring themes surrounding knowledge; politics, and capacities.

Identifying and supporting nutrition leadership

Leadership has been identified as a critical factor in countries or programmes which have successfully tackled undernutrition. However, until recently there were very few studies of what leadership actually meant in practice.  Transform Nutrition carried out a study of 89 individuals or representatives of organisations who had been identified as national level leaders within the field of nutrition in four countries: India, Bangladesh, Kenya and Ethiopia. Leaders here came from diverse backgrounds but were able to adapt strategically to the political landscape, span boundaries between sectors and disciplines and bring others along as their understanding of nutrition’s multi-sectoral nature developed. The findings place less stress on character traits and formal positions and more on the actual practice of leadership – where this is adaptive and responsive, where it helps translate between the technical and the political – then others will follow.

As what leaders do is more important than who leaders are, the research suggested a number of way in which leadership can be supported and nurtured. A more structured effort is called for to build up a cadre of leaders to the challenge of working effectively to tackle undernutrition as a pressing global issue. Important initiatives such as the African Nutrition Leadership Programme need to be supported and replicated elsewhere. The Transform Nutrition consortium has also experimented with further ways to support nutrition leadership, from highlighting the work of nutrition champions, to building a network of leaders trained in the latest research and evidence.


What drives and constrains effective leadership in tackling child undernutrition? Findings from Bangladesh, Ethiopia, India and Kenya
Food Policy, 2015
Strong leadership has been highlighted as a common element of success within countries that have made rapid progress in tackling child and maternal undernutrition.
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.
Championing nutrition: effective leadership for action
International Food Policy Research Institute, 2016
The calls for strong leadership in the fight against global and national malnutrition have multiplied during the past decade. The role of nutrition champions in advocating for nutrition, formulating policies, and coordinating and implementing action in nutrition have increasingly been recognized in such countries as Peru, Brazil, Thailand, and the Indian states of Tamil Nadu and Maharashtra.

Assessing key nutrition-relevant capacity

Capacity in nutrition goes well beyond individual leadership to encompass both organisational and systemic level needs. As part of its research programme, Transform Nutrition undertook a range of reviews on the state of public health nutrition education and capacity in India and South Asia. This included quantitative work and a situation analysis mapping the state of public health nutrition in South Asia, curriculum analysis, and qualitative work. In addition, to assess the capacity/potential for nutrition impact through existing programmes, Transform Nutrition completed a review of Government of India programmes for women and children, and assessed their implications for nutrition during the 1000 day period.

The research found that a significant constraint for colleges in South Asia is the lack of access to journals. Another challenge is the lack of accreditation for students seeking a career in nutrition. Accreditation signals that a profession is valued and useful, and its lack may deter ambitious students from following this as a career path. Accreditation might also encourage government and other employers to prefer students qualified in public health nutrition, rather than generalists.

In addition to this research on capacity, Transform Nutrition and partners PHFI, CCDC and POSHAN also contributed to building capacity in the region, adapting a short course to the Indian context and holding national and state level courses in Delhi and Bihar.


Postgraduate education in nutrition in south Asia: a huge mismatch between investments and needs
BMC Medicine, 2014
Despite decades of nutrition advocacy and programming, the nutrition situation in South Asian countries is alarming. We assume that modern training in nutrition at the post graduate level is an important contributor to building the capacity of individuals to think and act effectively when combating undernutrition.
A review of government programmes for women and children in India: implications for nutrition during the Thousand Day Period
The Indian Journal of Nutrition and Dietetics, 2014
The current Maternal and Child Health Nutrition (MCHN) statistics from India reflect poorly on the existing Government schemes. Experts recognize the conception of two year period (the first 1000 days) as a critical window of opportunity for influencing the poor MCHN status.
Mapping of nutrition teaching and training initiatives in India: the need for Public Health Nutrition
Public Health Nutrition, 2012
This paper is a situational analysis of Public Health Nutrition (PHN) across India, mapping teaching and training initiatives. The analysis was conducted using a combination of Internet search, telephone calls as well as interviews with experts. Information collected was pooled and tabulated using a snowball approach.Currently, there are nearly 190 institutes in India that offer one or more nutrition courses, with the majority offering full-time courses. Of these, PHN was offered in less than five institutes across India and opportunities were confined to specialisation options/modules.
Strengthening public health nutrition education in India
Transform Nutrition, 2014
Malnutrition remains a major challenge for public health and for human and economic development in India. A lack of adequately trained public health professionals and nutritionists means that this challenge is not being met. Due to resource constraints, the most realistic way of improving this situation is to optimise the use of existing infrastructure.
Educating and training a workforce for nutrition in a post-2015 world
Advances in Nutrition, 2015
Nearly all countries in the world today are burdened with malnutrition, manifesting as undernutrition, micronutrient deficiencies, and/or overweight and obesity. Despite some progress, efforts to alleviate malnutrition are hampered by a shortage in number, skills, and geographic coverage, of a workforce for nutrition.Here, the authors report the findings of the Castel Gandolfo workshop, a convening of experts from diverse fields in March 2014 to consider how to develop the capacity of a global cadre of nutrition professionals for the post-2015 development era.

Building commitment and accountability

Getting governments and others to step up to the challenges of undernutrition requires concerted efforts to build commitment, responsiveness and accountability for progress. For the past six years Transform Nutrition has been at the forefront of research on commitment, accountability and nutrition. The programme was catalytic in the development of the Hunger and Nutrition Commitment Index (HANCI), which measures commitment in terms of government expenditure, programmes and legal frameworks in areas directly targeting improved nutrition. It has been published as an annual global index and as a special African Index in 2016. Accompanying research has consideried broader drivers of commitment to both nutrition and hunger in a five country comparison, which found that hunger and nutrition commitment do not necessarily go hand in hand.

Undernutrition tends to be invisible until the need to act becomes a political necessity, but this often occurs too late to be effective for those most at risk.

Severe Acute Malnutrition (SAM) is responsible for between 1-2 million preventable deaths every year and affects around 17 million children under five. Supported by Transform Nutrition, a mobile health (mHealth) application was developed and piloted in five countries by World Vision, Dimagi, Save the Children and International Medical Corps (IMC) to help health workers follow treatment protocols for Community Management of Acute Malnutrition (CMAM) and generate accurate and timely data to respond to changes in caseloads. The experience documented by the project reveals some of the challenges faced in adapting the mobile app and rolling it out in some of the most remote, hard to reach health facilities in the world. Further work by Transform Nutrition on nutrition surveillance systems and real time monitoring supports the need to find innovative ways to monitor nutritional status in vulnerable communities.

Social accountability initiatives (SAIs) have been trialled successfully in many public sectors including education and health, but there is still little evidence on their use directly benefiting nutrition.  Research published by Transform Nutrition in collaboration with the Making All Voices Count Programme has reviewed the evidence in South Asia and pointed to a number of innovative ways in which social accountability tools are now being applied to health, nutrition and related sectors.

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Equate and conflate: political commitment to hunger and undernutrition reduction in five high-burden countries
World Development, 2015
As political commitment is an essential ingredient for elevating food and nutrition security onto policy agendas, commitment metrics have proliferated. Many conflate government commitment to fight hunger with combating undernutrition. Here the authors test the hypothesis that commitment to hunger reduction is empirically different from commitment to reducing undernutrition through expert surveys in five high-burden countries: Bangladesh, Malawi, Nepal, Tanzania, and Zambia. Findings confirm the hypothesis.
Using mobile phones for nutrition surveillance: a review of evidence
Institute of Development Studies UK, 2013
Nutrition surveillance - or the systematic and periodic collection of information on nutrition - is vital to the capacity of governments and other agencies to track their progress towards reducing undernutrition, to promoting the accountability of their actions and to improving their ability to respond promptly to rapid changes in nutrition status brought about by food price volatility and other shocks. However, nutrition surveillance is expensive and logistically laborious and therefore often non-existent in resource-low countries.
Nutrition surveillance systems: their use and value
Save the Children Fund, 2017
The detrimental consequences of child undernutrition are well documented. The fact that the effects of undernutrition early in life are largely irreversible means that quick and effective action is crucial. Large-scale surveys that take place every few years are useful for mapping national and global trends, but their infrequency and the time lag before obtaining findings, and their aggregated nature, mean other sources of data are needed for policy and programme decisions which need to be taken quickly.
Social accountabilty initatives in health and nutrition: lessons from India, Pakistan and Bangladesh
Institute of Development Studies UK, 2017
South Asia is home to nearly a quarter of the world’s population and is a region of dynamic economic growth, yet it performs relatively poorly on health and nutrition indicators.
A mobile health application to manage acute malnutrition: lessons from developing and piloting the app in five countries
World Vision, 2017
Malnutrition is the world’s most serious health problem and the single biggest contributor to child mortality and the global burden of disease. Community based Management of Acute Malnutrition (CMAM) is a proven high-impact and cost-effective approach in the treatment of acute malnutrition in developing countries.
A perspective on the development and sustainability of nutrition surveillance in low-income countries
BMC Nutrition, 2016
Many varied activities are encompassed by the term 'nutrition(al) surveillance'. Several national surveillance systems were initiated soon after the World Food Conference in 1974, but few have lasted. Most were complex, expensive, slow to produce findings, and were eventually stopped.