2014: the year we defeat child hunger?
2013 was a golden year for nutrition, with ramped up political attention and massive financial pledges. But 2014 has to be the year when this momentum is translated into measurable impact and child stunting dramatically reduces across the world.
There has been much recent discourse on 'scaling up' in nutrition, but what do we mean by it? In response to the sobering words of the first Lancet Nutrition Series in 2008, which described the international nutrition system as "fragmented and dysfunctional," the Scaling Up Nutrition (Sun) movement is now driving the global momentum.
Forty five countries (which include nearly 60% of the world's stunted children) have now signed up to the Sun movement – the glaring exception is India, home to over one third of the world's stunted children. In London last June, the Nutrition for Growth summit made history by generating over $23bn (£14bn) in pledges to tackle undernutrition (over $4bn for nutrition-specific and $19bn for nutrition-sensitive interventions).
The Sun movement and Nutrition for Growth have both made progress on the issue, but if 2014 is to be the year when significant numbers of children receive better nutrition then we need to understand how to reach more children. We need clear strategies, to learn from the past, and assess capacity.
While most focus on quantitative aspects of scaling, we cannot forget quality. In the late 1990s, India rushed to universalise its main nutrition programme, the integrated child development scheme, to cover all its districts – and yet there was little change in malnutrition levels in the years that followed. Boxes may have been ticked, but many villages didn't have the means to implement the scheme.
The state of Maharashtra (which recently joined Sun, despite India's decision not to) has since shown what is possible. Responding to reports of a wave of child deaths from starvation in marginalised tribal districts despite a state-wide economic boom, a nutrition mission was launched. The mission focused on strengthening implementation of existing programmes. Ensuring that existing vacancies were filled and frontline workers were supported by systems of training, supervision and monitoring (aimed at motivating, not policing) paid huge dividends. The frequency and quality of interaction between community workers and mothers improved enormously, and the rate of stunting decline between 2005 and 2012 was more than quadruple that of 1999 to 2005.
A generation before, a similar approach in Thailand underpinned its great leap forward, when child undernutrition rates plummeted during the 1980s. The breakthrough here came with the use of basic minimum needs indicators for community and district planning by teams of community leaders, nutrition and health professionals, mid-level government officials, representatives from NGOs and district chiefs of various sectors. Based on the problems revealed by these indicators, a 'menu' of nutrition-relevant actions was developed and implemented. A key factor in the project's success was a manageable ratio of community-level mobilisers and district-level facilitators. Wider collaboration between health, agriculture, education and rural development sectors supported these community initiatives. Lessons from successful projects like this are relevant today.
Too many strategy discussions start by asking how we expand the intervention. Instead, the starting point should be a vision of what success looks like, and what constitutes impact. Achieving that vision may require different routes. In an influential paper in 2000 Peter Uvin delineated four key pathways to reach large-scale impact (in this case of NGO activities):
a) Quantitative ( or 'scaling out') in which the coverage of an intervention increases.
b) Functional, in which horizontal (cross-sectoral) or vertical (national to local) linkages are made.
c) Organisational, in which capacities of organisations are strengthened.
d) Political, which reflects a move towards progressive empowerment of communities to make demands and national leaders' being held accountable for public action.
Due to its multi-sectoral nature, most of these pathways will need to be pursued to achieve wider impact on nutrition.
We now know that 10 nutrition-specific interventions reaching 90% coverage in 34 high burden countries will avert 20% of the global burden of stunting. We also know there is huge potential for enhancing the nutrition sensitivity in agriculture, health, social protection, water and sanitation sectors – though we need more and better evaluations. And we have already seen political progress in creating a better environment for nutrition.
But there are no simple solutions. With a new set of international development goals on the horizon, we should look back on this year as the watershed for nutrition – when the grand words and pledges of past high-level summits get turned into large-scale action, millions of children get healthy fulfilling lives.