Partnerships are essential for ending malnutrition
Malnutrition in all its forms has a detrimental affect on society and not all forms are on the decline.
Malnutrition affects nearly every country on the planet. As the recently published Global Nutrition Report notes, almost half the world’s population suffers from at least one of the following: stunted growth, low weight, micronutrient deficiency or overweight and obesity. The consequences are staggering. Undernourished children will learn less in school, earn less in the labour market, be more likely to live in poverty as adults and have a greater propensity to diseases such as diabetes, hypertension and heart disease. Being overweight or obese is a risk factor for non-communicable diseases and premature mortality.
All forms of malnutrition constitute a heavy economic burden for society – at the national level estimates are that more than 10% of GDP is lost due to this avoidable condition (from GNR Table 2.1, drawn from Horton and Steckel 2013). And while some forms of malnutrition are (slowly) decreasing (e.g. under 5 stunting rates – low height for age), some are static (e.g. under 5 wasting – low weight for height, women’s anemia) and some are increasing (e.g. under 5 overweight, adult obesity).
Combining efforts to combat nutrition
What will it take to address this trend? The “what” is quite well articulated by the evidence, a combination of: (1) interventions designed explicitly to address malnutrition – so-called “nutrition specific” interventions, such as interventions to improve complementary feeding practices for children after exclusive breastfeeding; (2) interventions designed to make policies and interventions in sectors related to nutrition more “nutrition sensitive”, such as social protection that focuses on the first 1000 days post-conception or interventions designed to improve dietary diversity; and (3) actions, policies and legislation to improve the enabling environment for malnutrition reduction, such as labelling, legislation on the marketing of breast milk substitutes and the publication of indices and data to improve the transparency of financial and policy commitments made to end malnutrition.
The “how” behind the “what” is less well articulated. Combatting malnutrition requires the involvement and coming together of many sectors, disciplines and stakeholders, as malnutrition is rooted in the interaction of multiple causes, such as poor diets, infection and physical inactivity. Underlying these immediate causes are unhealthy food environments, poor care practices for infants, children and adults, weak health systems and unclean water, poor hygiene and inadequate sanitation services. Income increases alone cannot address malnutrition and can actually contribute to some forms, such as obesity.
Levels of interventions
Coherent action across a range of fronts is needed. Coherence runs from coordination through to deep integration. There are no easy recipes and blueprints for “how”. Such action will be context specific, varying with regard to the nature of particular malnutrition problems, the existing capacity of nutrition champions and their allies, and the political opportunities that emerge. At the nutrition specific level, nutrition programmes need to draw on health services and child development services in a synergistic rather than competitive way, for example by using vaccination days to provide vitamin A supplementation to children under five and by providing pregnant women with the antenatal care, knowledge about feeding practices, and sufficient iron folate supplements they need to ensure their babies have the best possible start in life.
At the underlying level, the agricultural sector needs to find overlaps between profit and health by, for instance, investing in R&D to make fruits and vegetables more affordable to consumers and worthwhile for farmers to produce. Cash transfers could be predicated on health and education related conditionalities such as attendance at prenatal care sessions and keeping girls in school longer. Health systems need to place a greater emphasis on prevention of malnutrition and on early childhood nutrition. Water and sanitation programmes need to pay more attention to practices that prevent babies and infants from coming into contact with human and animal faeces.
At the enabling environment level, ministers of finance and planning need to understand the economic case for investing in nutrition – the median benefit cost ratios of 16:1 are larger than many infrastructure investments (Figure 2.1 in GNR, original source Hoddinott et. al. 2013). Civil society needs to be prepared and able to hold governments to account and businesses must make their structures, conduct and performance as they relate to nutrition much more transparent. Researchers need to keep pushing for more and better data on nutrition, analysing it and publishing it publicly, drawing out actionable implications for the wide range of stakeholders to use. Researchers should work closely with the media to help it report responsibly on the evidence regarding nutrition- related matters.
Partnerships are key
How do we support the emergence of the network of coherence that these actions rely on? In short, alliances, relationships and partnerships have to develop and flourish. This requires cultivating and incentivising leaders who can bridge the cultural, administrative and disciplinary boundaries between sectors and administrative levels. Bureaucratic systems must be enablers not barriers to collaboration. More resources need to be pooled and institutional flag waving tendencies reined in. Presidents, prime ministers and state and district leaders need to cut across fiefdoms and bring people together by forging a common vision for all to work towards and by giving bureaucracies the incentives to work with rather than against each other. Experiences from Maharashtra (India) and Peru show what can be done to reduce malnutrition through establishing explicit high-level political commitment. In Maharashtra this was achieved through a state “Nutrition Mission” – a public declaration of intent by the highest political leader, the Chief Minister, to lead a collective and sustained programme of action to reduce malnutrition (Haddad et al. 2014). In Peru, high-level commitment was driven by a civil society campaign in 2005 to get presidential candidates to sign up to a nutrition charter (Mejia Acosta and Haddad 2014).
I often hear the term “partnerships are overrated”, and it is true that partnerships for partnerships’ sake are more trouble than they are worth. But partnerships that have a clear common purpose and bring together complementary skills with strong, sustained and accountable leadership are likely to succeed. Let’s be clear: malnutrition will not be reduced without them.
About the author
This article was published in GREAT insights Volume 4, Issue 2 (February/March 2015).