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.


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.


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.


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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