(see more information on indicators in Annex 3)
Community participation in governance processes, and accountability mechanisms between the government and its citizens, are key to underpin governance programmes linked to nutrition.
2.10 Improving nutrition through human rights
There is a body of international human rights law made up of individual instruments. States have ratified some or all of these instruments and thus have the primary duty to respect, protect and fulfil the rights of their citizens. The willingness of the state to prioritise this duty is crucial to being able to realise rights.
Non-state actors may also be significant duty-bearers, especially in situations where they hold territorial control and become the de facto government. However, even in such circumstances, their duties are not clear-cut, especially where territorial control is partial and/or shifting.
All states have a responsibility not to take actions that may lead to increased levels of hunger, food insecurity and undernutrition. Furthermore, it can be argued that states have also committed, to the maximum of available resources, to invest in the eradication of hunger. Governments must also protect citizens from the actions of others that might violate their human rights. Furthermore, states have acknowledged the essential role of international cooperation and assistance.
Contributions to this aspect of undernutrition include56:
Right to food:57The right to food is, above all, the right to be able to feed oneself in dignity;58
Employment rights: Non-discrimination and fair pay in employment legislation and practices;
Children’s rights: Includes the right to adequate food, health and shelter;
Non-discrimination in the context of the right to food or access to health and nutrition services;
Refugee and humanitarian law in protracted crises;
Land rights regarding marginalised groups and women in particular;
Water rights, with a specific focus on poor households and women;
Human rights monitoring/reporting to the treaty bodies. Reports may reveal discrimination against groups failures by duty-bearers;
Support to human rights office within government.
Box 10: Key indicators for nutrition benefits through human rights
(see more information on indicators in Annex 3)
Human rights discourse tends to emphasise social and political rights but in fact basic needs are also enshrined in international law and affect the living conditions of the world’s poorest populations. Those rights must also be emphasised.
Sources of Further Information
Publications on Infant and Young Child Feeding: t/nutrition/publications/infantfeeding/en/index.html
Publications on breastfeeding:
Publications on severe acute malnutrition: t/nutrition/topics/malnutrition/en/index.html
Publications on the reduction of micronutrient malnutrition: t/vmnis/publications/en/
The Lancet Series /series/maternal-and-child-undernutrition#
Scaling Up Nutrition – What will it cost?, 2010 Scaling Up Nutrition – A framework for Action, 2010 /HEALTHNUTRITIONANDPOPULATION/Resources/Peer-Reviewed-Publications/ScalingUpNutrition.pdf
Can Conditional Cash Transfer Programs Play a Greater Role in Reducing Child Undernutrition?, World Bank, 2008: /SOCIALPROTECTION/Resources/SP-Discussion-papers/Safety-Nets-DP/0835.pdf
Lasting benefits – The role of cash transfers in tackling mortality, Save the Children, 2009 .uk/en/docs/Lasting_Benefits_low_res_comp_revd.pdf
‘From Agriculture to Nutrition – Pathways, Synergies, and Outcomes’, World Bank, 2007 /INTARD/825826-1111134598204/21608903/January2008Final.pdf
Publications on water, sanitation and hygiene: t/water_sanitation_health/en/
Right to food: /righttofood/publi_02_en.htm
CHAPTER 3: INTEGRATING NUTRITION IN THE PROGRAMMING PHASES
Strategies to combat undernutrition have been established as priorities in order to confront major global challenges 59
Chapter 1 underscores the multiple avenues that can cause undernutrition, and Chapter 2 highlights the specific contribution that different sectors or thematic areas can make to combating it. Undernutrition needs to be understood, therefore, as a multi-sectoral concern that requires a multi-sectoral response. But, such breadth means that it is not always clear how nutrition should be overseen and managed by government as there is no consistent institutional ‘home’ for it. Coherence therefore is built through strong and senior government leadership (see Section 3.1.2), which can oversee and coordinate the work of individual line ministries and departments. Donor support is undoubtedly critical to the success of such efforts.
3.1 Analysing and understanding undernutrition in context
This section provides guidance on assessing the causes of undernutrition in a specific context so that programmes can be designed or enhanced to address them specifically. The focus is on approaches to address undernutrition within a country. However, it could also be appropriate to consider approaches that cut across national borders (see Sahel case study – the added value of a sub-regional approach to nutrition, food security and public policies - in separate file) to demonstrate the added value of taking a regional approach.
3.1.1 Is there a problem of undernutrition?
The various causes of undernutrition can work at individual, household, community and environmental levels (see Figure 5). In each context, the relative importance of these causes needs to be clearly understood, including the chain of cause-and-effects that leads to undernutrition. This requires pooling information from different sectors and stakeholders to consider how different causal routes conspire to produce undernutrition – whether chronic or acute – in young children and their mothers. In all likelihood, reaching a shared understanding will require a process of discussion; the stronger the information base that feeds into these discussions, the clearer the parameters will be for agreeing on the causal chain behind undernutrition.
A preliminary judgement on whether a full nutrition situation analysis is necessary can be made using existing information as well as discussions with key stakeholders. Health and food security information systems are likely to be important sources of information, together with any existing nutrition-specific data.
Qualitative information may also provide insights into behavioural or poverty-related factors that contribute to undernutrition, such as anthropological studies, food economy analyses or socio-economic assessments. Where feasible, understanding the perspective of community groups can provide valuable insights into the constraints faced by families on a day-to-day basis that may have an impact on nutrition. Local civil society groups or women’s organisations may be helpful in this.
Furthermore, changes over time can reveal links between deteriorating nutrition and possible causal factors such as production failures, ecosystem degradation, price rises, changes in water supply management, disease outbreaks (whether seasonal or not) or significant changes in the local economy (such as employment opportunities or savings schemes). A rapid deterioration could point to an emerging humanitarian crisis; a slower, endemic, problem could require longer-term redress.
These different information sources will reveal different aspects of the undernutrition problem and caseload. A profile of undernutrition can be built by compiling them and considering them as a collective (including structured discussions with key stakeholders to arrive at a shared analysis). Operational priorities can then be set, together with an understanding of possible contributions to address undernutrition through various sectors, as outlined in Chapter 2.
Where such information is limited (e.g. in sectoral breadth and/or geographical coverage), a profile to understand the causes of undernutrition cannot be built. It then becomes necessary to fill the information gaps. There are various analytical tools that can be used for this. Annex 6 provides model terms of reference for undertaking a nutrition situation analysis.
(See again the Laos Case Study on the value of analysis in separate file)
3.1.2 Analysing and understanding governments’ response to undernutrition
Experience from around the world highlights several key characteristics of government that shows a national commitment to nutrition:60
Government leadership, often at senior level such as the President’s or Prime Minister’s office;
Strategic capacity in government;
Strong local governance, decentralisation and community participation (as in Bolivia);
Legal frameworks to secure nutrition commitments, even with changes in government or personnel (as in Madagascar);
Strong mechanisms for cross-sectoral and cross-ministerial coordination (as in Peru);
Accountability, monitoring and the ability to track progress;
Countries are ready to use multiple contributions for nutrition:
in Brazil, the food security agenda was a primary entry point,
in Peru, poverty was the entry point,
in Laos, nutrition was linked to the economic growth agenda.
Funding through national budgets (as in Bolivia, which pursued efforts to implement programmes to scale rather than through pilots). Donor flexibility was also seen as essential;
Evidence-based decision making where strategic priorities are informed by research on integrating nutrition in the national development plan (as in China).
The importance of government leadership and strategic capacity is worth underscoring. These are essential to ensuring that nutrition is meaningfully included in the national agenda. For this reason, the government’s position needs to be understood so that donor investments can be aligned with it.
These characteristics may be of strategic use to donors when considering how to approach nutrition. For it could be that strategies that aim to build such government characteristics are essential pre-conditions to effective programming, helping, as it were, to create a conducive environment where nutrition-focused investments can be effective (see Section 3.3). The Case Study from Brazil (see separate file) offers some insights into how such government characteristics can generate real political momentum behind nutrition, both nationally and internationally.
Annex 3 sets out key indicators that can be used to assess a government’s commitment and capacity to combat undernutrition. An assessment of some governments’ commitment to addressing undernutrition has already been made (see Annex 2).
3.1.3 Analysing and understanding other stakeholders’ responses to undernutrition
The activities and plans of other stakeholders, (such as the UN, NGOs, civil society groups and the private sector) need to be included in any contextual analysis.
Understanding the positions and capacities of existing stakeholders provides an indication of what is feasible in a given context.
3.2 Raising the national profile of nutrition
The first requirement is to make nutrition a priority for the national government. From this basis, a donor can then develop their own strategy to support the government, in line with other stakeholders. In emergency situations, there may be resistance from a government to prioritise nutrition, since the emergence of undernutrition may be seen as failure of the State’s services. The government may also wish to avoid an influx of new agencies and international media that a ‘nutritional emergency’ can inspire. In such cases, strong evidence of the need for humanitarian action is a critical component to the advocacy that may be required.
Donors can help governments establish nutrition as a development priority through on-going political dialogue. Key factors in building national commitment to nutrition include:-
Champion(s) of nutrition - people able to access policy makers and to carry out evidence-based advocacy – to build partnerships of individuals and institutions to influence politicians and implementing agencies. Key to this is convincing others that improving nutrition is essential to achieving their own goals (whether political stability, national security, developing education, industry or agriculture, or international competitiveness).
Effective communication is the key to building commitment. Different communication strategies are needed to win the support of different stakeholders.
Building informal constituencies in the civil service and in civil society, as well as with industry where appropriate. Efforts to organize civil society in support of nutrition are particularly critical as they can exert public pressure to keep government or donor commitments on track.61
Any cooperation strategy in the field of maternal and child undernutrition must take into account the nature of the problem, the commitment of the government, the strengths and weaknesses of the different sectoral or thematic interventions of the government and the strategies of other stakeholders. A basic starting point is having nutrition-sensitive national policies that encourage a multi-sectoral approach to addressing chronic and acute undernutrition. One key point of leverage is the inclusion of nutrition in the national strategic framework (Box 11).
Having nutrition in a national plan or strategy provides the legitimacy and feasibility that enables donors to channel support. The type of support will depend on the outcomes of the various analyses described earlier (see again Figure 6 for an overview of the likely possibilities).
Box 11: Introducing nutrition objectives into a national strategic framework62
Step 1: Determine whether the country has a nutrition problem of public health significance:
• Yes – if listed in Annex 2 as one of the 68 high-burden countries
• If yes, a strong rationale for including nutrition issues in the national strategic framework exists.
• If no, develop a case for prioritising nutrition in the country national strategic framework.
Step 2: If nutrition issues are important:
• Review the size and nature of the nutrition problem
• Using estimated levels of undernutrition, calculate estimated productivity losses attributable to undernutrition, and analyse the costs-benefits of addressing undernutrition.
Step 3: Identify the (possible) causes of undernutrition:
• This information may be available in the country.
• If not, commission some analytical work—Demographic Household Survey (DHS)63 data are usually a good source for these analyses; also check for other data sets such as Multiple Indicator Cluster Surveys (MICS)64 and Living Standards Measurement Surveys.65
Step 4: Identify what is already being done:
• Assess political commitment of government to tackle undernutrition
• Review government policies, strategies, programmes, institutional arrangements and capacity
• Review other national and international involvement in nutrition
Step 5: Design intervention strategy:
• Identify objectives and priorities for nutrition in the country.
• Select strategies and actions that will respond to the size and nature of the nutrition problem.
• Prioritise action to match the epidemiology of the problem and the country’s capacity.
• Ensure appropriate institutional arrangements to support implementation of nutrition activities across sectors.
• Identify monitoring and evaluation arrangements and capacity development plans.
Step 6: Allocate reasonable funds and resource them through subsequent strategies:
• Support implementation.
• Strengthen capacity and implementation through a learning-by-doing approach.
3.3 Shaping a donor response to undernutrition
The process of incorporating specific nutrition objectives (and therefore results and indicators) in programmes can be spread over several programming phases. These are summarised in Box 12.
Box 12: Incorporating nutrition objectives in programming
Analysis and scoping
Implementation and Monitoring
Nutrition situation analysis – at country or regional level (see Annex 6)
Negotiation of sector priorities, both focal and non-focal sectors
(Government, member states, EU Delegation, other stakeholders)
Inclusion of nutrition issues in donor Country Strategy Paper (see Table 3)
Nutrition included in National or Regional Programme:
Nutrition included in TOR for annual programme design missions
Focal sectors have objectives and outcomes linked to reduction/prevention of undernutrition66
Mid-term review; Nutrition included in monitoring missions
Nutrition objectives/indicators included in
Section 3.3.1 focuses primarily on donors’ engagement in stable contexts where close alignment with the country’s priorities is likely to be possible. Section 3.3.2 considers specific issues that may emerge in situations of emergency, fragility and transition. There are a number of potential contributions to the donor’s country/regional strategy where information on the nutrition situation (needs and actors) can be integrated. These are summarised below.
3.3.1 Setting priorities
The 2005 Paris Declaration on Aid Effectiveness and the 2008 Accra Agenda for Action67 are fundamental underpinnings to the donor approach.
An individual donor’s response to undernutrition will necessarily be guided by the plans/priorities of the government and the plans/responses of other stakeholders. There will therefore be a process of negotiation with the government and other donors on which sectors to prioritise and invest in. It is at this stage, therefore, that critical decisions will need to be taken.
As outlined above, an analysis of the nutrition situation, including the chain of cause-and-effects that lead to undernutrition, provides the evidence base required to make informed judgements. Figures 5 and 6 can be used to steer the negotiations and help rationalise the choice of sector priorities and the contribution of each stakeholder.
In developing a donor country strategy paper, there are a number of avenues where nutrition (needs, objectives, actions and indicators) can be incorporated. Table 3 provides a summary of these.
Table 3: Nutrition in the donor country strategy paper
Possible contributions to CSP
Nutrition is featured as a policy objective.
Situation analysis (economic, political, social and environmental)
Main nutrition challenges are defined, together with social and economic factors that could affect progress.
This section could include, for example:
- major pressures and impacts resulting from social, economic and political trends.
- options for addressing undernutrition that are likely to be economically attractive: i.e. impact on GDP of stunted children between age 0 to 24months.
Quantify payoffs from investing in nutrition for productivity (direct), schooling (indirect productivity impacts), and health (mortality, morbidity, disability; DALYs). Identify links between poverty alleviation and women’s health benefits.
Policy agenda of the beneficiary country
National, regional and continental nutrition policies could be mentioned. Nutrition may also be an indicator in the national poverty reduction framework.
Outline of EU/MS assistance
This would be based on the results of the nutrition situation analysis, including any lessons from previous nutrition interventions, and would also take account of action by other stakeholders to address undernutrition.
This would identify measures to address nutrition concerns, including challenges, risks and constraints. The strategy would highlight ways to optimise the positive changes brought about through the donor’s intervention, such as:
1) Selection of focal sectors;
2) Objectives, approaches and strategies for focal sectors;
3) Selection of non-focal sectors and type of actions to be supported
4) Work programme and budget
5) Policy dialogue
3.3.2 Specific approaches for humanitarian response, transition situations and fragile states
In populations affected by emergencies, the priority focus is on acute undernutrition (wasting, and more rarely, kwashiorkor), which is associated with a higher risk of mortality and morbidity. Around 55 million (10 %) of the world’s under-five children are wasted, 19 million severely so. Wasting contributes to nearly 15 % of worldwide deaths of under-five children.
A third of the world’s stunted children live in fragile states.
The donor approach in such situations is likely to be guided by the Principles of Good Humanitarian Donorship68 and the OECD Principles for Engagement in Fragile States.69
There are specific challenges associated with programming in emergencies, fragile states and transition situations. One important challenge is the need to build coherent approaches and meaningful links to relief, rehabilitation and development (LRRD). This should ensure that the short-term objective of saving lives does not, as far as possible, undermine prospects to properly manage the burden of undernutrition on a more sustained basis. Likewise, it should ensure that building longer term capacities to manage undernutrition include, rather than compromise, capacity to respond to nutritional shocks and crises. Although there is general acceptance of the need for such coherence, making it happen can be more difficult. One of the core dilemmas of LRRD in emergencies, fragile states and protracted crises concerns the relationship between donors, humanitarian actors and the state. There may be scepticism or unwillingness to support the building of national capacity and long-term systems in contexts where the state’s role or legitimacy are in question or where close relationships could compromise humanitarian principles.
There are also several practical constraints, such as funding timeframes, choice of sector priorities or the aid modalities and partners used (see the Mali case study – Challenges in building coherent programmes in situations of transition in separate file).
The importance of coherence across emergency, fragile and transition situations is underscored in the OECD/DAC principles to guide international engagement in fragile states (Box 13). These emphasise the need for close cooperation between economic, development, diplomatic, humanitarian and security actors. Although the principles are generic, and specific to fragile states as opposed to humanitarian contexts, many are nevertheless valuable reminders of approaches that can inform donors’ engagement concerning undernutrition in a variety of contexts, especially since cooperation across the aid/development/security spheres is increasingly important to the EU and many Member States.
Box 13: Principles of good international engagement in fragile states70
1. Take the context as the starting point: requiring a sound political analysis to recognise the different constraints of capacity, political will and legitimacy.
2. Do no harm: avoid creating societal divisions and worsening corruption and abuse by undertaking strong conflict and governance analysis. Transparency is key to avoiding corruption.
3. Focus on state building as the central objective: address governance and basic services.
4. Prioritise prevention: reduce future risks; address root causes and avoid quick-fix solutions.
5. Recognise the links between political, security and development objectives: improve the coherence of international interventions.
6. Promote non-discrimination as a basis for inclusive and stable societies: gender equity, social inclusion and human rights.
7. Align with local priorities in different ways in different contexts: seek to build on existing systems rather than creating parallel ones.
8. Agree on practical coordination mechanisms between international actors: through shared analysis; joint assessments; common strategies; and coordinated political engagement.
9. Act fast, but stay engaged long enough to give long-term success a chance: assistance must be flexible enough to take advantage of windows of opportunity and respond to changing conditions on the ground; avoid volatility in funding.
10. Avoid pockets of exclusion (address ‘aid orphans’): where there are no significant political barriers to engagement yet few international actors are engaged, and aid volumes are low.
Consistency in the overall response, the presence of adequate, experienced and well coordinated human resources and sustained funding are of fundamental importance. Relief, crisis management, reconstruction assistance and long-term development cooperation must be properly linked as part of an integrated approach built on the principle of sustainable development.71
This vision of an integrated and coordinated approach has, in practice, been hard to implement in nutrition programmes. This is partly because of a potential divide, in principles and objectives, between humanitarian and development action72; partly because of the (political) willingness to make this approach work and partly because of the bureaucracy that makes it difficult to do so. See Nepal case study – Approaching nutrition in a transitional context - in separate file.
Ultimately, the challenge of tackling undernutrition coherently across changing operational contexts is less to do with technical know-how and more to do with priority-setting and with overcoming the administrative and bureaucratic hurdles that the aid system has created. This is true in terms of nutrition rarely featuring as a priority sector for donor (development) support, but it is also true in terms of the different priorities and funding criteria that prevail during ‘emergencies’ compared to ‘development’ contexts. Thus, the transition from development to humanitarian aid, and from humanitarian to development, requires careful consideration of how the context is changing – in terms of the situation and needs (including use of early warning systems, surveillance information and assessments); the coordination systems and actors involved (including capacity); as well as the funding opportunities, time-frames and funding priorities.
Nevertheless, there are positive experiences too, which highlight the increasing linkages across shifting operational contexts. For example, there is greater focus on disaster risk management and risk reduction within development cooperation, whilst humanitarian efforts are increasingly including policy-level investments that link to longer-term considerations. Reliable information and committed working practices, for instance in the form of joint assessments, joint situation analyses and monitoring, and joint programming efforts, can be a powerful bridge between humanitarian and development actors, across changing operational contexts.
Constant vigilance and analysis are required to ensure that the resources available are used to best effect. The best aid instruments to meet the priority nutrition needs are likely to change as the context shifts (and thereby the operational opportunities). See Mali case study - the need to overcome the emergency/development divide - in separate file. This is the core challenge of transition situations. All the preceding discussions about the need to take a multi-sectoral approach to undernutrition prevail, with the additional requirement to work in a flexible way that straddles the humanitarian and development aid frameworks.
3.4 Designing monitoring, evaluation and learning
Time and again, experience has shown that monitoring of and learning from programmes is weak; monitoring tends to be an afterthought, ill-planned and poorly executed. This is as true for nutrition as it is for other programming areas. It is a serious flaw that needs to be addressed from the earliest stages of programme planning – where monitoring needs to be considered and negotiated with government counterparts regarding: which indicators to use, the frequency of data collection, the lines of responsibility between various stakeholders, the form of analysis and reporting required, and the skills and competencies needed. The need for such improvements in nutrition monitoring and evaluation systems is even greater given the current international focus on the MDGs, and specifically MDG1.
Monitoring nutrition interventions, whether in emergency or development contexts, is an integral component to ensure effectiveness – be it saving lives or preventing nutritional deterioration. Successful monitoring systems allow for real-time improvements to interventions to achieve the desired progress. Monitoring indicators for nutrition are usually a combination of process, outcome and impact indicators (see Annex 3). Combining quantitative data (such as estimates of the prevalence of undernutrition) and qualitative data (such as feedback from target groups on the appropriateness of nutrition-sensitive social protection programmes) provides a stronger base to better understand the appropriateness of interventions and to assess any unpredicted (positive or negative) changes brought about. In addition, evaluations will use the monitoring data to identify overall learning for future programmes, assess the effectiveness of interventions, and compare the costs of the interventions to their impact. Successful evaluations have four main qualities: