Q&A: Why most nutrition programming is not scalable

Malnutrition imposes staggering costs on a global scale. According to the European Commission, it is estimated to kill more than 3.5 million children each year, accounting for more than one-third of all deaths of children under the age of 5.

Additionally, malnutrition is believed to cost the global economy more than $3.5 trillion per year — roughly $500 per person — in the estimated loss of individual earnings and unnecessary health care costs. The current scale of malnutrition globally also presents a major challenge to achieving the targets set by Sustainable Development Goal 2 — ending global hunger and malnutrition by 2030.

But despite decades of work by development stakeholders, very few international nutrition programs are going to scale, according to Jeremy Shoham, director of the Emergency Nutrition Network.

“One of the key failings of the Scaling Up Nutrition movement has been an inability to look critically at its successes or lack of success,” Shoham said. “If we truly want nutrition programs to achieve scale, we need to develop a culture of admitting when the money wasn’t well-spent, so we can learn from our failures.”

In an interview with Devex, Shoham discussed why scaling nutrition programs can be so challenging, as well as some key strategies that stakeholders can harness moving forward.

The following excerpts from the conversation have been edited for length and clarity.

Why are so few nutrition programs reaching scale?

There are multiple reasons. One of the key reasons is that a lot of pilot innovative programs are being implemented by NGOs and U.N. agencies with very little consideration on how feasible it is for governments to fund the scale-up. It’s very easy for an NGO to implement a program that shows great results and impact, but very little thought is generally given to whether the treasury in the government would actually fund the whole thing being scaled up to a national level — even if it is a very effective program.

There is no better example than the treatment of acute malnutrition. Many years ago, a product was developed called Plumpy’Nut to address this issue. It was in the form of a paste, which made it possible to give out to kids, as their mums would be able to come to a health center and take this magic product home, and it would cure their acute or severe malnutrition. The coverage of the programming went up from less than 2% in some countries to more than 50% — but the problem was the product isn’t cheap. It’s patented by a company in France, and the ingredients are expensive, so very few governments could afford it.

What about the SUN movement? Why hasn’t this been an effective model in scaling nutrition programs?

The Scaling Up Nutrition movement aims to promote multisector nutrition programming and then have that scaled up. SUN, in its wisdom, focused on the first five years of building an enabling environment — you develop a national multisector nutrition plan, and in the plan you have sectors working together with a common understanding of causes of malnutrition and collective outputs and outcomes. The thinking was that once you have the plan, the next stage is getting resources from the external partners, and increasingly the government would come on board and put more and more money towards that plan.

But the problem with this model is that it’s very difficult to get sectors to work together in government — each sector has its own demands and outputs that it prioritizes. And it’s very difficult to get everyone on board unless the goals also align with their core priorities. Also, SUN has focused a lot on the national level — but that doesn’t always translate well to the subnational level, where the programming actually takes place.

What are some of the key strategies that international stakeholders and NGOs should adopt to improve the scalability of nutrition programs?

From an external development partner point of view, we should work to deploy our resources and overseas development aid to encourage, support, and nurture governments to spend more on nutrition. One of the key challenges is that, if you look at humanitarian aid, 95% goes through development partners and not through local governments. That means that not only is it cost-inefficient, but also you’re not creating channels within government — like budget lines for nutrition. You want the money to be used to build something beyond the short-term emergencies.

Also, from a donor perspective, there’s been a huge amount of funding and work going into pilot programs. But so often, those pilots can’t be scaled up. Any agency applying for money to conduct a pilot program should be required to analyze the scalability from a financial point of view. NGOs often don’t have the capacity to do that, so the responsibility falls on donors to do an analysis of the government health systems, involving modeling budgets and having a realistic appraisal of whether a program that they are being approached to finance as a pilot could actually be funded by government and, if not, where the longer-term funding is going to come from. It’s a responsibility both for the implementers and the donors, working along with the government.

Additionally, pilot programs that are being tried in a country need to align with government policies, plans, and strategies. Most countries have a nutrition policy, a framework for common results, and a multisectoral plan — and a lot of these policies and plans are coherent with one another. But if you have an agency coming into a country that wants to try out a new type of program to deal with malnutrition in a particular way, it has to align with those policies, or it won’t work in the long run.

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