Malnutrition, especially stunting, is a complex problem, and complex problems require multifaceted responses. UNICEF’s widely accepted conceptual framework suggests that the underlying causes of poor child nutrition are lack of access to a nutritious diet, inadequate preventive and curative health, and inadequate care including feeding, and each of these underlying causes in turn results from multiple factors. Successful elimination and prevention of malnutrition thus requires a multifactorial, multisectoral response.
Multisectoral models have become the overwhelming consensus for modern nutrition programming. Major agencies subscribing to this approach include the U.S. Agency for International Development, the U.K. Department for International Development, the World Bank, UNICEF, GAIN, and others, and multisectoral actions are also the foundation of the global Scaling Up Nutrition Movement.
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And yet, reviews of earlier multisectoral efforts suggest that increased complexity introduces challenges that can interfere with large-scale implementation success. For this reason, some oppose this approach, but implementation of a nonmultisectoral program raises a question as to whether such programs could truly eliminate malnutrition if they do not address all of its causes.
Above all, successful malnutrition elimination at scale will require learning from the mistakes and successes of the past, as well as finding new approaches to deal with the challenges inherent in large and complex — i.e. multisectoral — systems.
Challenges in scaling multisectoral nutrition programs
The challenges of implementing multisectoral nutrition programs, or MSNP, are extensive.
There are several high-level challenges that stand above others, and addressing these may be the highest priority for NGOs to consider when designing a multisectoral nutrition program.
First, multisectoral approaches can suffer due to differing cultures, mandates, and incentives characteristic of different sectors. These factors are barriers to coordination and cooperation, and intersectoral rivalries and turf battles further interfere with integrated action. Ministries may see nutrition as subordinate to their larger mandate such as agriculture, or as the responsibility of a different sector.
Second is the need for increased high-level commitment. Nutrition has been called “the forgotten sector”; it often falls within health, where it is treated as an infection and treatment issue, or with agriculture, where it often is assumed simply to be a product of food unavailability and/or poverty. Unfortunately, nutrition, being multisectoral, does not fall neatly into either of these categories. Planners and implementers of MSNP often assume that high-level political and civil service actors automatically will make nutrition a priority. This simply isn’t the case.
A third important challenge for MSNP is identifying and establishing consensus about the minimum framework of interventions, from multiple sectors, to prioritize. This framework must contain all of the necessary intervention elements that support nutrition but cannot attempt to co-opt every intervention from every sector’s full mandate.
Equally important is technical consensus about how to solve the problem of malnutrition. The international nutrition community long has been plagued by infighting over technical issues and mandates. The technical community needs a unified and cooperative voice when interacting with government agencies.
And finally, capacity to implement is lacking in many low-income countries and varies among sectors. As a result, excellent policies and well-conceived technical approaches at the national level can fall apart at the level of implementation.
Opportunities to support MSNP
Despite past failures in the scaling of multisectoral nutrition programming, successes do exist, and NGOs have made important contributions to them. Here is a look at five of the successes, and advice on how to follow suit:
1. Establish high-level commitment
No easy solutions exist for achieving high-level commitment and a shared vision, but NGOs can have an important role in building it.
For example, Peru’s national success in reducing stunting has become an example for the world, and high-level commitment. Much of Peru’s success in reducing stunting — and in gaining high-level support for improved nutrition — resulted from the efforts of the Child Nutrition Initiative comprising local and international NGOs and United Nations agencies.
According to Andrés Acosta, political scientist and a governance research fellow at the Institute of Development Studies at the University of Sussex, CNI played a key role to “advocate in favour of making nutrition the central component in the government’s fight against poverty,” and to “disseminate and review government efforts in the fight against malnutrition and secure future political commitment from elected politicians.”
2. Unify vision
Decades of research and experience have provided much more clarity than in the past about “what works,” and about appropriate target populations, e.g. the “1,000-day population”, greatly reducing the bickering over technical issues. Furthermore, the global Scaling Up Nutrition Movement has led to most countries adopting multisectoral national nutrition action plans to guide policy and implementation.
Importantly, a technical group such as the CNI needs to decide which sectors, and which interventions within those sectors, are necessary to meet overall objectives. Nonetheless, multisectoral success requires determining which sectors and interventions do not need to be prioritized, and sectors that must be included such as health, agriculture, and food security, social protection, education — especially girls’ education — water and sanitation, environment and climate change, and the private sector.
The appropriate “mix” of sectors depends on the local context, and the local causes of malnutrition.
3. Eliminate clashes between sectors
Formal structures creating horizontal coordination and vertical coordination are essential. Horizontal coordination refers to coordination across actors and sectors at a given level, say at the community level, while vertical coordination to coordination between levels, such as community, district, region, and national.
NGOs can play a critical role in developing these structures. For example, CARE’s Nutrition at the Center project in Bangladesh has been working with the government since 2015 to create multilevel, multisectoral, coordinating committees reaching down to the community level while also strongly linked with higher levels of administration. These structures facilitated “horizontal coordination” as well as “vertical coordination,” allowing plans at higher levels to accommodate outputs from lower levels. The Government of Bangladesh actively contributed to the creation of, kept a close eye on, and participated in these activities. The government, led by the Institute of Public Health Nutrition and the Bangladesh National Nutrition Council, decided to incorporate this model into the second national plan of action on nutrition.
4. Build implementation capacity
The need for capacity development offers a unique opportunity for NGOs and other development agencies. The critical need is in support for actors trying to understand their role in a multisectoral context supporting nutrition. NGOs and other agencies can provide strategic support and guidance that enables local actors to understand and execute their important responsibilities.
One immediate-term approach is documented in the findings of the African Nutrition Security Partnership, which placed staff in Burkina Faso, Mali, Ethiopia, and Uganda to serve as “boundary-spanning actors” with the intention to “enhance the performance of a [complex adaptive system, in this case multisectoral nutrition]”.
The project’s findings highlight three types of support that are most helpful for fostering multisectoral success: 1. creation or reform of coordinating structures, working groups, and alliances; 2. ensuring multisectoral dimensions in preexisting policies, programs and plans; and 3. “soft” support aligning policies/programs/approaches as well as raising multisectoral awareness, commitment, ownership, and capacity.
5. Focus on inputs to support nutritional improvement at scale
While the scaling of MSNP has had mixed results, a logical assessment of the causes of malnutrition suggests that the need to implement across sectors is essential for eliminating malnutrition. A multicausal problem cannot be solved with an approach that does not multiple causes.
The lessons from these successes suggest several areas where NGOs can contribute, most notably through coalition-building to engage high-level political support, establishing technical consensus concerning the sectors and interventions to be promoted, creating, and supporting multilevel coordination mechanisms, and building and supporting implementation capacity.
Take a closer look at what it takes to achieve scale in the nutrition sector.