Despite decades of work and billions of dollars of investment, malnutrition continues to plague every country in the world and, globally, it remains the leading cause of deaths for children under the age of 5. Today, a staggering 149 million children worldwide are stunted and wasting affects nearly 50 million children around the world, estimated to kill a child every 11 seconds. Moreover, obesity affects more than 1.9 billion people globally and 462 million are underweight. Although all stakeholders agree that meeting global nutrition goals will require scalable, high-impact solutions, past progress shows that few nutrition programs have managed to achieve scale.
More from the Scaling Nutrition series
One of the key debates is on the best approach to scale. The drivers of malnutrition are inherently multisectoral, so most nutrition interventions have tended to take a multisectoral approach. However, these complex approaches often stand in direct conflict with basic principles of scalability, where simplicity reigns supreme. Some believe this tension may be slowing the international community’s progress on the World Health Assembly’s global nutrition targets, among others.
While stakeholders have different opinions about why we’re falling short of our goals, they agree one on point: To see major improvements on a global scale, people working in the sector first need to understand where the movement is failing and learn from their mistakes.
“The end of malnutrition will only be reached if the global community is able to scale improved solutions for nutrition relatively quickly and sustainably,” said William H. Moore, executive director at The Eleanor Crook Foundation. “This will require significant financial investments. It will also require a relentless focus on what is working — and what is not — across our sector.”
Throughout the Scaling Nutrition series, Devex asked experts working in nutrition and related fields to weigh in on what they see as the biggest mistakes that are being made in the sector so that we can learn from these and chart a more effective path in the years to come.
Here’s what we’ve learned:
The best can be the enemy of the good
Most strategies for combating malnutrition have intuitively used a multisectoral approach. However, by attempting to address all of the complex, multifaceted, and interlocking drivers of malnutrition simultaneously, a project can quickly become overly complicated, expensive, and resource-intensive.
This might not be such a big issue at the pilot phase, when projects tend to be small and are seeking proof of concept. However, trying to scale up a project that includes too many features can quickly become unwieldy, according to Larry Cooley, president emeritus and senior adviser at Management Systems International.
“Most people’s ability to conceptualize complexity far exceeds our ability to manage that complexity,” he said in a Devex video about why “scaling by subtraction” makes sense for development. “Even small system changes ... usually involve a vast number of moving parts.”
That’s why ensuring the scaling potential of a project often requires taking a hard look at the project goals and focusing on how to simplify rather than add additional features.
“The process of successful scaling is best seen as a game of subtraction, not a game of addition,” Cooley said.
The goal of this approach is to create a project that continues to be realistic, affordable, and implementable even as it grows.
“It’s critical to have that sense of realism right from the start and to invest the time in identifying problems that could arise, rather than being surprised,” Marie McGrath, technical director of the charity Emergency Nutrition Network, told Devex. “We wanted a project that is good enough to scale, rather than something that is perfect on paper but isn’t practical in a real-world environment.”
The importance of planning for scale from day one
While the success of a small-scale pilot project rarely hinges on engaging with national governments, local infrastructure, or markets, failing to do so from the get-go can create real barriers to growth. This might explain why only 1 in 20 interventions that are judged to have been successful at the pilot phase reach national scale, according to Cooley.
Additionally, because most nutrition programs tend to be donor-driven, they run the risk of drying up after the initial funding ends — and in the event that the government and implementing partners are not properly engaged from the beginning, such an outcome is almost guaranteed.
“Because of the pervasive inclination of new managers to do things differently from their predecessor, it is difficult to maintain a scaling focus in institutions,” said Johannes F. Linn, an economist who researches development and scalability, in an op-ed for Devex.
To ensure that promising nutrition projects have the opportunity to grow, it’s vital to plan for scale from day one. Some of the questions that merit careful consideration include: How will the intervention be financed after the initial project is funded? Who will implement and deliver it, and what is their incentive for doing so? How will this project integrate into existing markets?
“Where objective need doesn’t actually translate into felt need or demand, a critical part of any scaling effort is to create demand before we deliver any education, training, or services,” said Richard Kohl, president and lead strategy consultant at Strategy and Scale, in a Q&A on the subject.
Critically, any nutrition project that achieves scale will require the buy-in and support of local governments and implementing partners. To secure these at the planning phase, it’s vital that stakeholders understand how a nutrition intervention aligns with a government’s core policies, plans, and strategies. This makes it more likely that the government’s different departments will prioritize and fund the intervention after the pilot phase ends. It can also be helpful to identify potential “champions” — both within and outside of government — who can act as advocates.
Similarly, interventions should consider the core goals and priorities of implementing partners and other stakeholders. This ensures that all partners involved with the intervention are truly invested in its success — and reduces the likelihood that the project will die after donor funding runs out.
“You want to make sure that the local partners are always carried along in the process, so that they are intimately involved in everything for developing the project and fully understand all the roles that are required to play to sustain and scale the initiative,” said Peter Goldstein, head of strategic communications at HarvestPlus, a research program that aims to develop and scale up biofortified crops. “You need to make sure that they are always there side by side throughout the process.”
To make nutrition an ongoing priority, continue elevating the issue
By its very nature, the field of nutrition cuts across many different sectors, such as agriculture, health, early childhood development, and humanitarian response, to name only a few. Many of these sectors have competing goals and demands — and it’s easy for nutrition to get lost amid other priorities.
For nutrition interventions to scale, the various stakeholders need to see the issue of nutrition as a priority — which requires making it more visible and giving it a certain urgency.
“A consistent, focused advocacy narrative structured around the specific interventions that we know work is our best hope for re-energizing global investments in nutrition,” wrote Emma Feutl Kent, manager of global policy and advocacy at the nonprofit 1,000 Days, in a Devex op-ed. “For me the answer to why governments should invest in nutrition instead of other sectors is simple. Not only are nutrition-specific interventions some of the most cost-effective development investments — with every $1 invested in nutrition yielding up to $35 in economic returns — but the nutrition sector also has a suite of ready-to-scale interventions that have proven effective in challenging, real-world settings.”
To that end, it’s vital that all stakeholders working in the nutrition space continue to collaborate and discuss the most effective ways of achieving scale.
One way to continue this conversation is through the Nutrition Scaling Working Group — part of the Scaling Up Community of Practice, created by Linn and Cooley — which brings together professionals interested in scaling up development impact.
According to Chytanya Kompala, nutrition program officer at The Eleanor Crook Foundation, the working group was “designed to radically shift the focus within the nutrition sector toward finding truly scalable solutions to malnutrition.”
The nutrition sector “has achieved tremendous progress in the fight against malnutrition over recent decades,” The Eleanor Crook Foundation’s Moore said. “Building on this progress, I’m convinced that the end of global malnutrition can be reached — but our current trajectory won’t take us there.”
For this goal to be achievable, stakeholders working in the sector will need to “go one step further” beyond sustainability to include plans for scalability in the design and implementation of every program, according to Sarah Bauler, senior adviser in design, evaluation, and research in nutrition at World Vision International.
“If we fail to do this, we are only ‘tolerating’ or sustaining a program, without planning and promoting that effective interventions are fully embraced and brought to scale for those in desperate need of them,” she told Devex via email.
Take a closer look at what it takes to achieve scale in the nutrition sector.