Q&A: What does it take to create a nutrition program with lasting impact?

Malnutrition is a global health crisis of a staggering magnitude: Nearly 1.9 billion adults are overweight or obese, while another 462 million are underweight, according to the World Health Organization. And malnutrition is one of the leading causes of death for children under the age of 5, globally.

Effectively addressing malnutrition in all its forms will require interventions that maximize both impact and scale. Unfortunately, scaling high-impact nutrition interventions is more easily said than done — which is why stakeholders serious about reducing malnutrition need to think strategically and carefully about ease of implementation and delivery systems well before the implementation phase, according to Richard Kohl, president and lead strategy consultant at Strategy and Scale.

“Sometimes the best is the enemy of the good: it’s my experience that there are a lot of innovations with average impact out there that are a lot easier to implement than things that are high impact,” he said in an interview with Devex.

“If I could get one million people to successfully adopt an impact that’s only a five on a 1-10 impact scale, versus 100 people who adopt an innovation that’s a 10 on the impact scale — you tell me which makes the most sense?”

This conversation has been edited for length and clarity.

What are some of the pitfalls that stakeholders who are trying to implement high-impact nutrition programs might fall into?

There’s a tendency in people trying to solve problems in developing countries to find solutions or innovations or technologies or programs that have a high impact, and I think that this is fundamentally misguided and putting the cart before the horse.

To use a mathematical metaphor, I believe that the potential impact of an innovation, of a program, can be calculated by multiplying the potential impact by the ease of implementation, by the actual scale of implementation and by the quality of implementation.

You might have noticed that three of the four categories have to do with implementation, and not potential impact. That’s because so many researchers come up with potentially high-impact programs that look great on paper, but are extremely difficult to implement or don’t have any existing delivery mechanisms — and without a delivery mechanism, a program with high impact potential is not going to be delivered with much impact or scale.

How should stakeholders be thinking about delivery and implementation to avoid this potential pitfall?

They need to ask themselves, “what is the distribution system for this program or intervention or technology, and why would people want to adopt this?” One of the mistakes made again and again with the ease of implementation is that we seem to confuse need with demand.

With a lot of things related to nutrition, there’s an extraordinary need, but that doesn’t necessarily translate to demand. For example, if I talk to a head of a household in a rural community in a low-income country, and ask them to tell me their top five priorities, they might say a good harvest, feeding my family, I need to pay school fees, and my mother in law is sick, and I have to take her to the hospital. Very rarely will someone talk about nutrition in their top five priorities.

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.

Another aspect of ease of implementation that affects the success of scaling is aligning the implementation requirements of a program or innovation with the capabilities of existing delivery mechanisms or systems. One of the analogies I sometimes use when talking about this is to look at what happened with the Apollo 13 lunar mission. You have these astronauts that are 99 million miles away, and when the oxygen recycling system breaks down and they have to fix it, they don’t get to fix it with what is available in Houston, or specifically Mission Control, they have to fix it with what is available on the lunar module. It’s the same for nutrition programs.

You have to look at what already exists to implement and deliver the solution on the ground for the particular population. We need to develop solutions that are aligned with delivery capacity and capabilities of existing delivery systems and financial resources.

Similarly, incentives are quite key, beginning with why policymakers and government should adopt and fund a nutrition model at a large scale. Incentives are especially key for front line service providers or those who are delivering a program to those who are being asked to adopt it or change their behavior.

So we need to ask ourselves, why should anyone who is distributing, selling, or producing want to do this? And why should people on the receiving or buying end want to take it or adopt the new model or behaviors?

Could you highlight any strategies that can improve a program’s likelihood to scale and make a big impact in the nutrition space?

You need to get the marketing strategy right — and behavior change communication is key if you want to scale. Most BCC approaches think in terms of knowledge – attitudes – behaviors. Knowledge or information is necessary but usually insufficient to change behavior, we need to look at motivation, another way of saying incentives. For example, I was in a conference in Indonesia that was focused on trying push for exclusive breastfeeding for the first 6-12 months. And for years they had these outreach and campaigns about how wonderful breastfeeding is, and about this benefit and that, and it got a certain level of uptick and then plateaued.

And then they brought in a company that uses private marketing approaches and applies them to international development, especially health and nutrition. Their advice was that the way a good marketing person basically “sells” things is on the basis of aspirations, social pressure, shame, or sex — and that’s much more successful than informational campaigns, which is what most public health and nutrition campaigns tend to use.

When was the last time you saw a car advertisement ad talking about how this car gets better mileage? Most car ads are aspirational — if it’s a big fat truck, you’re a macho man, you’re a hunky dude who can drive through the tundra.

Similarly, we need to know what the primary things are that motivate people about nutrition and health. And in many developing countries, unlike the U.S., it’s a collective society, organized collectively, where social pressure and social shame and social norms are very important for peoples’ behavior.

So to improve breastfeeding rates, they started a TV ad in which a woman is walking through a market in Jakarta with her baby, and all the women in the market, “ooh and aah” about the baby. Then someone says, what are you feeding it? And she answers, “I’m feeding it formula.” And all the market women, their faces drop, pain and anguish written all over their expressions. And the subtext is what kind of mother are you that feeds your child formula?

The commercial didn’t go into specifics of why breastfeeding is good. It used social pressure to get the message across — and it was much more successful than all the information campaigns that came before it.

In cases where the private sector is involved in production, distribution or sales of nutritional products or marketing, it is important to think about bundling with other products or services. We have to ensure that there is a business case for nutrition — how do I make this profitable? It’s difficult for someone to make a living delivering nutrition supplements. However, you can bundle it with other high-profit services.

Think about it looking at what other existing delivery systems are already out there, so we can piggyback or blend with them — that’s the idea behind fortifying basic commodities. This also applies in some sense to public sector delivery in terms of lowering costs or leveraging what is already there. You have to ask yourself what delivery systems already exist, and work with what’s already there.

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