Wednesday, 25 September 2013

How can we maximise the impact of nutrition interventions when evidence is limited?

By Stephen Spratt

The Scaling Up Nutrition (SUN) Movement has been holding its Global Gathering in New York over the past two days. Rather than the ‘high-level’ expert meetings of previous years, this event brought a range of stakeholders from different countries – 42 countries are now signatories to the SUN Framework – together to share experiences about what works and under what conditions.

This is essential. The profile of nutrition has risen rapidly up the development agenda over the past few years. If the opportunity this creates is to be realised, however, we need to move from the abstractions of the drawing board to the messy realities of the real-world.

Finding sustainable solutions to undernutrition is difficult. A wide range of factors influence outcomes at different levels. Ensuring an adequate dietary intake and good health are the most immediate determinants, but underpinning these factors are issues like food security, the care of children and women, and access to good quality health services.

To date, most attention has focused on the most immediate drivers. There is a large body of evidence on the most effective ‘nutrition-specific’ interventions – the fortification of food and treatment for acute malnutrition, for example. It is universally accepted, however, that any gains made through these types of interventions will not be sustained unless progress is also made on the underlying factors described above.

Little existing evidence about nutrition-sensitive interventions that work

The problem is that we know far less about the types of ‘nutrition-sensitive’ interventions that are likely to work best than we do about nutrition-specific options. What should be done under these conditions?

One option would be to do nothing until we have a more complete body of evidence. This is problematic for three reasons.
  • First, we know that the impact of nutrition-specific interventions will be greater if they are complemented by nutrition-sensitive interventions. 
  • Second, for the gains made by the scaling up of nutrition-specific interventions to be sustained, it is imperative that the underlying determinants are also addressed.
  • Finally, even if the full scale-up of nutrition-specific interventions could be achieved, this would only partially resolve the problem. 
In their costing work, Horton et al (2010) estimate that implementing the full package of nutrition-specific interventions would reduce the incidence of stunting by 20%, severe acute malnutrition by 50% and underweight by 20-30% ("Scaling up nutrition - what would it cost?" (PDF)). While these would be huge achievements, it cannot be acceptable to stop there, as many millions of children would still be afflicted by these conditions. To address this problem properly nutrition-specific and sensitive interventions need to be working in unison.

Another option would be to muddle through, prioritising areas where it is easiest to raise money, or which appeal most to different donors or national governments for their own particular reasons. While this is likely to yield positive results, it is very unlikely that these results will be the maximum that could be achieved with limited resources.

Action Against Hunger and IDS propose a 'four-step' diagnostic framework

In a recently published report with Action Against Hunger UK (ACF International), we sketch out a third option. In the report we develop a diagnostic framework to help prioritise nutrition-sensitive interventions in a situation where evidence is both limited and unevenly distributed. As well as potentially helping different stakeholders to enhance the effectiveness of their interventions, the approach performs another important function – by making the best use of the evidence that does exist, it clearly identifies the gaps in this evidence base.

There are four steps, with a set of criteria in each case. The criteria are flexible enough to accommodate the fact that different actors will have different priorities: 
  • Step 1 is the initial choice of location for the intervention, which is determined by factors such as the burden of undernutrition and the presence of conditions that are likely to amplify impact. 
  • Step 2 is the choice of sector, where criteria combine importance for nutrition outcomes with the greatest potential for impact. 
  • Step 3 entails the choice of ‘pathways’ within each sector. When considering interventions in agriculture, for example, there are a number of ways that agriculture affects nutrition outcomes. Here the criteria combine importance for nutrition in that particular context (e.g. the relative importance of subsistence versus cash crop farming), with potential for the greatest impact by focusing on groups that could benefit the most. 
  • In Step 4, specific interventions are chosen based on evidence of their effectiveness.
This is very much a starting point of what should be an ongoing combined research effort.

In the coming years, more evidence will accumulate on which interventions are most effective, for which groups and under what conditions. Already we know that country context is extremely important: interventions that appear to work well in some environments do less well in others. Improving understanding of what the crucial factors are in each case is essential, and this can only be done with a deep and rich understanding of local conditions.

Sharing practical experiences, as in the SUN Global Gathering, is an important part of this. Generating robust evidence in a variety of forms is also key. If we are to achieve the greatest possible impacts, however, it is essential that we develop mechanisms to translate this growing body of evidence into the most effective interventions on the ground. While better tools than the one proposed here will no doubt emerge in the future, it is hoped that this will serve as a useful starting point. 

Stephen Spratt is a Fellow at the Institute of Development Studies. His research interests relate to development finance, financial sector development, and the ‘green transformation’.

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