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 Awareness
2. Making Commitments
3. Governance arrangements
4. Mobilising Resources
5. Holding Stakeholders to Account
6. Capacity and Data to support 1-5

3
1. Building awareness of the
problem and its
consequences Human brain development
Original: Thompson, 2001; taken from Grantham-McGregor, 2007
Thompson, R. A., & Nelson, C. A. (2001). Developmental science and the media: Early brain development.
American Psychologist, 56(1), 5-15.
Human Brain Development
4
5
Bloom, 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
Effective framing of how little attention
nutrition gets in aid spending
6
7
2. Making Commitments
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
8
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
9
www.hancindex.org



Indicators



Themes



Sub-indices



Index
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
Peru
Philippines
Indonesia
Moderate
commitment
Mozambique Burkina Faso Tanzania Vietnam
Rwanda Gambia
Mali Ghana
Zambia Bangladesh
Low
commitment
Niger Ethiopia Benin Cambodia India
Sierra Leone Nepal Cote
dIvoire
Nigeria China
Uganda Senegal Pakistan South Africa
Very low
commitment
Congo,DR Togo Kenya Lesotho Angola
Liberia Afghanistan Sudan
Burundi Guinea B Yemen
Cameroon
Mauritania
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 Commitment
Nutrition and the post 2015 Development
Goals
15
3. Governance Arrangements
Need for a more in depth and political
analysis of nutrition governance
16
Doing the right things in the right order
Prioritising 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.
17
Multistakeholder actionhow 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
20
Planning 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
How much money is needed for nutrition specific
interventions?
21
$4bn additional
donor funding
pledged at
Nutrition 4
Growth Summit
7 years 2013-2020
$10bn
extra
spending
required
/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 balances
C
o
u
n
t
r
y

t
y
p
e

H
i
g
h

b
u
r
d
e
n

c
o
u
n
t
r
i
e
s

Create budget lines,
Increase
commitments,
Find nutrition
sensitive
opportunities

Fortification,
Logistics,
Local innovation


Market purchases
Mobile phones
D
o
n
o
r

c
o
u
n
t
r
i
e
s

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
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 countrys 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
24
The Private Sector:
Improving the nutrition status of the poorest while
making a profitcan it be done?
Improving nutrition
outcomes for the
poorest

Strengthening the
enabling
environment for
nutrition
Making a profit
When does
this overlap
exist?
25
5. Holding stakeholders to account
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
27
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.


Bjrkman, 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 73569
28
Cumulative donor spending commitments on
nutrition specific and sensitive programmes : 12
major donors
29
SUN Donor Network. June 2014.
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).
30
See Picanyol, C. and P. Fracassi (2014). Tracking Investments at Country Level, draft, 16
th
of June. SUN Secretariat .
6. Capacity and data gaps that make an
environment less enabling
32
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 20052006. 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
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/
34
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 audience
2. Making Commitments identify them, make public
3. Governance arrangements dont get stuck on a model of horizontal
coordination, dont forget about vertical coordination
4. Mobilising Resourcesmake sure they are driven by a plan
5. Holding Stakeholders to Account transparency and civil society are
key
6. Capacity and Data to support 1-5 transparency and holding to
account requires data

Thank You