What is an enabling environment for nutrition and how can it be

built?

Lawrence Haddad, IFPRI

University of Zambia September 23, 2014

Enabling Environments Make it Easier for Everyone to Contribute to Nutrition

Improvement

Framing, knowledge

and evidence

Politics and governance

Capacity and

financial resources

Impact

1. Building Awareness2. Making Commitments3. Governance arrangements4. Mobilising Resources5. Holding Stakeholders to Account6. Capacity and Data to support 1-5

3

1. Building awareness of the problem and its consequences

4

Thompson, R. A., & Nelson, C. A. (2001). Developmental science and the media: Early brain development. American Psychologist, 56(1), 5-15.

Human Brain Development

5Bloom, D. and D. Canning. January 2011. Demographics and Development Policy. PGDA Working Paper No. 66. Harvard University

The Demographic Dividend will only be fully realised at low levels of undernutrition

6

Effective framing of how little attention nutrition gets in aid spending

7

2. Making Commitments

8

Reasons for Weak Commitment to Nutrition

Adapted from Heaver, Richard. 2005. Strengthening Country Commitment to Human Development: Lessons from Nutrition. Washington, DC : World Bank. https://openknowledge.worldbank.org/handle/10986/7310

1. Malnutrition is usually invisible to malnourished families and communities.

2. Families and governments do not recognise the human and economic costs of malnutrition.

3. Governments may not know there are faster interventions for combating malnutrition than economic growth and poverty reduction or that nutrition programmes are affordable.

4. Because there are multiple organisational stakeholders in nutrition, it can fall between the cracks.

5. Malnourished people have little voice.

6. Governments sometimes claim that they are investing in improving nutrition when the programmes they are financing have little effect on it

9www.hancindex.org

IndicatorsThemesSub-indicesIndex

HANCI

Hunger Reduction

Commitment

Legal frameworks 4

Policies & programmes 4

Public expenditures 2

Nutrition Commitment

Legal frameworks 1

Policies & programmes 10

Public expenditures 1

Civil Society, Galvanising Commitment: Hunger and Nutrition Commitment Index (HANCI)

<1000 1000-1499

1500-1999

2000-3499

>=3500

High commitment

Malawi Guatemala

Madagascar

Brazil

PeruPhilippine

sIndonesia

Moderate commitment

Mozambique

Burkina Faso

Tanzania Vietnam

Rwanda GambiaMali Ghana

Zambia Bangladesh

Low commitment

Niger Ethiopia Benin Cambodia India

Sierra Leone

Nepal Cote d’Ivoire

Nigeria China

Uganda Senegal Pakistan South Africa

Very low commitment

Congo,DR Togo Kenya Lesotho Angola

Liberia Afghanistan

Sudan

Burundi Guinea B YemenCameroonMauritania

HANCI political commitment groupings by Gross National Income per capita

Commitment to Nutrition is Not the Same as a Commitment to Hunger Reduction

13

14

Locking in CommitmentNutrition and the post 2015

Development Goals

15

3. Governance Arrangements

16

Need for a more in depth and political analysis of nutrition governance

17

Doing the right things in the right orderPrioritising and sequencing

Source: Doing Growth Diagnostics in Practice: A ‘Mindbook’ Ricardo Hausmann, Bailey Klinger, Rodrigo Wagner CID Working Paper No. 177 September 2008. Harvard University.

Multistakeholder action—how coordinated does it have to be?

As coordinated as it needs to be

• Broad based action• Political shift in national identity, e.g. Brazil• Perfect storm: Good things happening for nutrition in a number of areas, some planned,

some not e.g. Maharashtra

• “Think intersectorally, act sectorally”• Convergence, e.g. India, open defecation• Coordination, e.g. SUN national plans of action

• Integrated action• Embedded components, e.g. DFID in Bangladesh• New interventions, e.g. HKI in Burkina Faso

4. Mobilising Resources

20Planning and costing for the acceleration of actions for nutrition: experiences of countries in the Movement

for Scaling Up Nutrition. SUN. May 2014. www.scalingupnutrition.org

Composition of costed country nutrition plans, SUN members

21

How much money is needed for nutrition specific interventions? $4bn additional

donor funding pledged at Nutrition 4

Growth Summit

7 years 2013-2020

$10bn extra

spendingrequired/

year

Domestic $50bn

Donor $20bn

Total $70bn

Donor scale up $10bn

Resources for Nutrition: Look everywhere but be guided by a plan, with checks and

balancesCountry type

High burden

countries

Create budget lines, Increase

commitments,Find nutrition

sensitive opportunities

Fortification,Logistics,

Local innovationMarket purchases

Mobile phones

Donor

countries

ODA: Increase commitments,

Create incentives that leverage high burden

resources

Nutrition Bonds(payment to private sector on delivery of

impact)

Ethical trading

Public-only Private-public networks

Private-only

Resources for Nutrition

Nutrition specific

Underlying

Basic

Nutrition Sensitive

Different Spending

Categories for Nutrition

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The Private Sector and nutrition: why bother?

• The private sector already plays a large role in delivering to people in poor countries

• foods, health care, water and sanitation• in India, private health services accounted for 56 percent of health care use in the

poorest households

• Private sector has enormous logistical reach which could serve the poorest• in many developing countries, the private sector owns and manages 40 to 50 percent

or more of the country’s health infrastructure

• Private sector may need the public sector to expand reach the poorest • Subsidies in rural areas• Increase demand through public health campaigns

• Regulation and tax changes could make private sector more pro-nutrition

Adapted from: Partnerships with the Private Sector in Health. What the International Community Can Do to Strengthen Health Systems in Developing Countries. Final Report of the Private Sector Advisory Facility Working Group. April Harding, Chair November 2009

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The Private Sector: Improving the nutrition status of the poorest

while making a profit—can it be done?

Improving nutrition outcomes for the

poorest

Strengthening the enabling

environment for nutrition

Making a profit

When does this overlap

exist?

5. Holding stakeholders to account

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Making Commitment Transparent

• In Speeches (from Jan 2005-end 2006) • DFID: 0/50 • EC: 0/28

• In Press releases (from Jan 2005-end 2006)• DFID: 0/197• EC: 0/239

• In policy documents• 0 in G8 2005 and 2006• 12 in Commission for Africa Report• 0 in DFID Social transfers and chronic poverty• 0 in European Consensus on Development

Source: Sumner, Lindstrom and Haddad 2007. IDS Sussex

Public Commitments: Mentions of Nutrition

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Citizen Feedback: Are nutrition programmes working?

Randomised control trial of community-based monitoring of public primary health care providers in Uganda

• Citizen report cards reduced child mortality by 33 per cent

• The study documents large increases in utilisation and improved health outcomes

• Cost per child death averted was $300, well below the average of $887 for 23 other interventions.

Björkman, M and Svensson, J. (2009) 'Power to the People: Evidence from a Randomized Field Experiment on Community Based Monitoring in Uganda’, The Quarterly Journal of Economics, Vol 124: 2, pp 735–69

29

Cumulative donor spending commitments on nutrition specific and sensitive programmes : 12 major donors

Nutrition Sp

ecific 2

010 Commitments

Nutrition Se

nsitive

2010 Committments

Nutrition Sp

ecific 2

012 Commitments

Nutrition Se

nsitive

2012 Commitments

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

SUN Donor Network. June 2014.

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SUN Review of Nutrition Budget Data Availability

• General budget allocation information was publicly accessible for only 32 of 51 SUN countries

• 28 of the 32 countries had up to date information • 21 of the 28 country budgets had the necessary detail at the programme level

to be able to assign line items in different departments to nutrition• In 10 of 21 countries there was a clear nutrition programme which helps to

make some nutrition spending more visible• Budgetary analyses like this are incomplete because they frequently exclude

recurrent costs such as staff costs• Information on actual expenditure is scarce• Different countries use different methods to track budget allocations and

expenditures on health, including: Public Expenditure Reviews (PER), National Health Accounts (NHA), the Clinton Health Access Initiative (CHAI) Resource Mapping Tool, and Public Expenditure Tracking Surveys (PETS).

See Picanyol, C. and P. Fracassi (2014). “Tracking Investments at Country Level”, draft, 16th of June. SUN Secretariat .

6. Capacity and data gaps that make an environment less enabling

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47 4742

53

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Percent of 19 countries that self assess as having minimal or no capacity to..

System capacity to address malnutrition is

inadequate-- and opportunities

are limited

Maternal and child undernutrition: effective action at national level

Jennifer Bryce, Denise Coitinho, Ian Darnton-Hill, David Pelletier, Per Pinstrup-Andersen, Lancet 2008.

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India: Filling front line vacancies to reduce child stunting in Maharashtra

• Even in Maharashtra, the wealthiest state in India, 39 per cent of children under age 2 were stunted in 2005–2006. But by 2012, according to a statewide nutrition survey, the prevalence of stunting had dropped to 23 per cent

• The State Nutrition Mission began by working to improve the effectiveness of service delivery through the Integrated Child Development Services and the National Rural Health Mission, the national flagship programmes for child nutrition, health and development.

Their focus was on filling vacancies in key personnel, particularly front-line workers and supervisors, and on improving their motivation and skills to deliver timely, high-quality services in communities.

Unicef 2013 Report

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Individual capacity can

make a difference:

Health Centre Workers in India, asked, without

prompting, “what is important for keeping a

child healthy and strong?”

www.hungamaforchange.org/

Evidence Gaps

• Data on current capacity levels• Better tools on how to sequence and prioritize all

nutrition actions• More evidence and impact evaluations on how the

private sector can best add value• Systems that allow governments to track nutrition

spending easily and accurately

Summary

1. Building Awareness – tap into your audience2. Making Commitments – identify them, make public3. Governance arrangements – don’t get stuck on a model of horizontal

coordination, don’t forget about vertical coordination4. Mobilising Resources—make sure they are driven by a plan5. Holding Stakeholders to Account – transparency and civil society are

key6. Capacity and Data to support 1-5 – transparency and holding to

account requires data

Thank You