Is it time to take 'more of a gamble' to scale nutrition interventions?

WASHINGTON — With 10 years left to meet the Sustainable Development Goals, the world is not on track to meet Goal 2 of ending hunger and improving nutrition.

The international community is mobilizing to try to meet the goal, but different groups working on the issue do not always have the same approach. Some focus most intently on nutrition-specific interventions, while others believe a multisectoral and nutrition-sensitive approach is the best way to achieve scale for improved nutrition.

Is one approach more effective?

An exact measure of the efficacy of nutrition-specific versus nutrition-sensitive programming is extremely difficult to come by, which makes it challenging to say one is better than the other for achieving scale, said Lawrence Haddad, executive director of the Global Alliance for Improved Nutrition. His organization works to have a balance of both nutrition-specific and nutrition-sensitive programming, Haddad said, because investing in large-scale food fortification is as important as investing in market-based interventions that make food more available and affordable around the world.

Haddad said more evidence is needed on the benefits of nutrition-sensitive interventions to determine whether the cost of scaling such programs is worth adding a nutrition component to other programs — something he called “quite a tall order analytically.”

“For nutrition specific — direct — programs we know the benefits and the costs. For nutrition sensitive programs — indirect —  we know the costs of inserting nutrition and we can get the overall costs, but we do not have much evidence yet on the value add to nutrition of making, say, an agricultural program a nutrition sensitive agricultural program,” Haddad wrote in an email. “The benefit to cost ratio would [be] the extra impact on nutrition of making something nutrition sensitive divided by the extra cost of doing so.”

The distinction is important, because nutrition-specific interventions are only able to address a relatively small part of the problem, he said, citing estimates that only 20% of existing stunting is helped by the scaling up of nutrition-specific programs. Nutrition-sensitive interventions are “more of a gamble” with regard to impact, but “if we can get impact, the potential for scale is much bigger,” Haddad said.

Bringing sectors together

The Scaling Up Nutrition Movement began in 2010 as the global community recognized a failure to address malnutrition challenges on the appropriate scale. Its model is based on the premise that accelerating progress on reducing all forms of malnutrition will happen only when a diverse coalition is brought together with real incentives for progress. The movement embraces a country-led, multisectoral approach and works to unite governments, civil society, donors, and the United Nations all around the goal of attacking nutrition challenges at scale.

SUN Movement countries all have a “country focal point” — a person who must already be in the government, who is tasked with coordinating its strategy to improve nutrition. Debora Di Dio, policy specialist at the SUN Movement, said allowing countries to drive multisectoral programming increases the likelihood of their scaling success. SUN has seen improvements in stunting in countries such as Bangladesh, Peru, and Mali.

“You can really make an impact on stunting, which means you can really make an impact on the long-term sustainable development growth of the child and of the community,” Di Dio said.

She said that the first two phases of their work have focused on helping countries embrace the multistakeholder and multisectoral approach by identifying prospective countries, producing evidence, and making sure participants have the tools in place to succeed with this approach. Countries must produce multistakeholder plans that are costed, which facilitates the ability to mobilize donor funds. Di Dio said bringing everyone together is the only way to appropriately fight malnutrition in all its forms.

“If we continue to invest only on nutrition-specific interventions, only vitamin A supplementation, only folic acid supplementation — yes, they are super important and in some cases they are lifesaving. But that will not create the long-term sustainable impact that only a multisectoral approach can give you,” Di Dio said.

“If your child receives Vitamin A supplementation but then falls sick of diarrhea because his immune system is compromised because he’s malnourished, there is no way that just vitamin A, just nutrition-specific intervention can work. So you really need nutrition-specific and nutrition-sensitive interventions.”

Moving forward, SUN will shift from piloting interventions in only one or two areas of a country to scaling successful approaches at a subnational level by ensuring appropriate plans are in place to support the multistakeholder approach.

‘Their countries, their money, their decision’

Nutrition programs have grown in scale and significance at the World Bank as the institution has recognized how intertwined nutrition is with achieving other development benchmarks, said Meera Shekar, the bank’s global lead for health, nutrition, and population.

“We try as much as possible to focus on where we can get impact for the money that we spend, so under the Nutrition for Growth [platform] we are pushing on two fronts: more money for nutrition in order to be able to scale up, but also more nutrition for the money so that we can improve the efficiency of the spending,” Shekar said.

The bank focuses on evidence to decide where its investments are best placed to have maximum impact for scale, Shekar said. Part of that analysis comes from the Optima Nutrition tool, developed in partnership with the Bill & Melinda Gates Foundation. It is designed to examine how a set amount of money should be used — on which interventions and on what scale — to best reduce malnutrition in a particular context.

“The evidence base is heavier on ... what is referred to as the nutrition-specific set of interventions, so as you look at the tools you’ll see that there’s much more focus on the nutrition-specific side and less on the nutrition-sensitive side, which is essentially nutrition-sensitive agriculture, or nutrition-sensitive social protection,” Shekar said.

Similar to the SUN approach, Shekar acknowledged that achieving scale does require involvement of a diverse set of government actors who see the wholesale benefits to improve nutrition for a country and its economy, including a more educated population and higher GDP growth. The World Bank’s focus on human capital has meant many more sectors are now involved with nutrition programs, she said.

The bank works to co-locate nutrition programs along with other projects to maximize the impact, while allowing each sector to control its budgets. This is a large barrier to the multisectoral approach on nutrition, Shekar said, because ministries such as agriculture or education may not want to cede their funds to nutrition interventions, even if the evidence shows that such an approach would maximize impact.

“Multisectoral projects where you have three or four ministries are much harder to implement. Co-located projects where it’s clear which ministry is delivering what and what time frame and with what money and who is accountable for what — those are easier to track and easier to implement. You get to the same outcome because co-location happens at the village level or the community level, but each ministry comes in to do what they know best how to do,” Shekar said. “Their countries, their money, their decision.”

The need for more data

The Gates Foundation, which focuses on proven strategies to reduce malnutrition, particularly in the 1,000 day window, works closely with the World Bank on its nutrition work.

Ellen Piwoz, a senior program officer in the nutrition division at Gates, said it can be a challenge to help governments design and implement programs at scale, particularly in contexts where officials believe the problem will solve itself as a country’s average income rises. Other barriers include human resources, finances, knowledge and awareness, and political commitment, she said.

“People talk about nutrition-specific interventions and … there’s an assumption that all of those interventions have to be delivered in one system,” Piwoz said. “But they can come from different systems, with food fortification being a great example. That’s a nutrition-specific intervention, putting nutrients into food, staple foods, but comes not through the health system but through industrial fortification and other means.”

While Gates is focused on getting more resources directed toward nutrition, Piwoz said there’s also recognition that current resources aren’t being used as effectively as they could be. The Optima Nutrition tool is designed to solve this problem by doing allocative efficiency modeling, but more work needs to be done to gather relevant data so the analysis can be as helpful as possible.

“For all the sectors that are working in nutrition, the idea of having evidence for how to achieve the impacts at scale is really critical,” Piwoz said. “Optima, those tools, are only as good as the information we have to feed into them. That means we need better information on what things cost in order to know how to optimize the resources and then we need better information on what impact we could expect them to have to make informed decisions.”

This reporting made possible by a grant from the Eleanor Crook Foundation. Contents of the article are editorially independent without influence by external organizations or parties.

Take a closer look at what it takes to achieve scale in the nutrition sector.