What is an enabling environment for nutrition and how can it be built? Lawrence Haddad, IFPRI...
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Transcript of What is an enabling environment for nutrition and how can it be built? Lawrence Haddad, IFPRI...
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
24
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
25
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
27
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
28
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.
30
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
32
Identi
fy and
analy
se nu
trition
pro..
.
Design
effec
tive pr
ogram
mes an
d p...
imple
mentin
g and
man
aging
pro..
.
Monito
ring a
nd as
sessi
ng pr
ogr...
Advoc
acy, n
egoti
ation
and m
obilis
ati...
Resou
rce ge
nerat
ion an
d mob
ilis...
Conve
ning a
nd fa
cilitat
ing ef
fective
dial.
..
Effectiv
ely ov
ersee
ing th
e ove
rall n
ut...
High qu
ality t
rainin
g opp
ortun
ities a
vaila
bl...
Opport
unitie
s ava
ilable
(inclu
ding f
undin
g) fo.
..
Opport
unitie
s (Inc
lduing
fund
ing) fo
r goo
d a...
11
37
47 4742
53
26
4753
7984
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.
33
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
34
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