Opinion: The tension in global nutrition that no one is talking about

These days, it seems like every speech and event in the global health and development space includes a call to break down silos and a push for new approaches that are inclusive, universal, and multisectoral.

This was particularly apparent during the United Nations General Assembly this past September under the theme “Galvanizing Multilateral Efforts for Poverty Eradication, Quality Education, Climate Action, and Inclusion.” The list of accompanying side events was full of vague, all-encompassing titles, many of which could have been retitled: “A General Discussion on the Topic of Everything.” We seem to be having a lot of those these days.

In the global nutrition sector, this focus on interconnectedness is omnipresent. Our sector is captivated by the idea of multisectoral approaches. We know that malnutrition is caused by a complex array of factors, and so naturally, we posit that a multisectoral package of solutions is required to address the problem. But has this approach really worked in practice, at scale?

How far have we really come?

In order to inform future investments, our team at the Eleanor Crook Foundation has spent considerable time looking back on the past 15 years in global nutrition to identify what has demonstrably changed at scale on the ground. It turns out the list is pretty short, despite hundreds of millions of dollars spent on research into improved solutions over the same time period. This is a troubling paradigm.

If we want to end malnutrition by 2030, we are going to have to develop and scale radically improved solutions to address malnutrition at a much faster pace than we have historically seen. We don’t expect that business as usual is going to yield dramatically better results.

There are many reasons why so few innovations have gone to scale in nutrition in recent years. First, it has only been in the last several decades that nutrition has become a sector in its own right. And — despite the fact that malnutrition is a global crisis limiting the cognitive and physical development of 1 in 3 people on Earth, and is responsible for nearly half of childhood deaths globally — funding and public awareness of malnutrition remain frighteningly low.

While our community continues to work to make global malnutrition a policy and funding priority, the magnitude of the problem also demands a critical look at past and current programmatic approaches. In particular, the tension between multisectoral approaches on the one hand and established best practice for designing for scale on the other demands further exploration.

Often, our ever-broadening quest to attack malnutrition in every form and from every angle has led to a “Christmas tree-decorating” approach to nutrition program design. We hang an array of different ornaments — such as nutrition counseling; micronutrient distribution; water, sanitation, and hygiene interventions; and village savings and loan associations — with the hope that this process of layering interventions in the same place, within the same program, will deliver a synergistic effect and, ultimately, add up to a whole greater than the sum of its parts.

In reality, analysis of what has successfully gone to scale across global development sectors highlights that scaling is more often a process of subtraction.

Indeed, working in low- and middle-income countries means that we are trying to integrate improved solutions into some of the weakest and most challenging systems on Earth. So, if a solution has any hope of working sustainably and at scale within these systems, it typically needs to be very simple.

As a result, successful scaling typically requires that we ask not what we can add on, but rather what we can subtract in order to be simpler and more cost-effective: “OK, we’ve done this new thing well in the pilot phase and we see promising results. But now, can we do this with one hand behind our back? What about two hands? Can we do this with both hands behind our back, while standing on one leg?”

A critical gap

The global nutrition sector needs to critically examine its collective approach to scaling. For example, if we can’t sustainably scale vitamin A supplementation by itself, why should we expect that it will be easier to efficiently scale up a multisectoral program that includes vitamin A supplementation among five, six, even 10 other very different interventions, often with very different delivery mechanisms and entirely separate government and policy stakeholders?

We’ve seen scaling analysis as a critical gap among our partners — one that is affecting the success of our investments. We’ve also seen the muddled narratives that can emerge from trying to generate attention on an issue that is presented as so multisectoral that it frequently becomes indigestible by the audiences our partners seek to engage.

Our team does not claim to have the answers about what exactly is best practice for sustainability and scalability in global nutrition. But we do feel confident that the tension between multisectoral approaches and scalability requires urgent additional focus and a fair amount of healthy debate.

Much has been accomplished by the global nutrition sector in recent decades, and the push to conceptualize nutrition as an issue affecting many sectors and outcomes has no doubt been necessary and positive. But we can’t lose our focus. We can’t do everything, everywhere, all the time.

We are hopeful that by further investigating these tensions around nutrition and scaling, we can focus on the highest impact opportunities and radically transform the pace at which we scale the next generation of improved nutrition solutions. We are hopeful that, for nutrition, this next decade will look very different from the last.

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