Presentation from Institute of Development Studies Nutrition Group and Transform Nutrition seminar on 19 February - 'Effective Governance and Policies to Improve Nutrition Outcomes: A Cross Comparison of Nine Country Cases'

1. Effective Governance and Policies to Improve
Nutrition Outcomes:
A cross comparison of nine country cases
Andrés Mejía Acosta (IDS)
a.mejia@ids.ac.uk
Jessica Fanzo (Columbia University)
jfanzo@gmail.com
Institute of Development Studies
Brighton, 19 February 2013

2. The Nutrition Paradoxes
 Nutrition and GDP growth
 economic growth does not lead to
improved nutrition
 India vs Brasil vs Peru
 Nutrition and food security
 policies designed to boost food
production are not sufficient to reduce under
nutrition
 The Maradi Paradox
 Pakistan, Niger

3. A political economy approach
 Analysing policy change…
 Number of stakeholders involved
 Ideological differences
 Winset = space for policy change
 PEA of Nutrition
 Why some countries that are strongly committed to reducing
malnutrition can effectively deliver on nutrition outcomes while others
make insufficient or no progress at all?
 Why and when do government officials become accountable to the
needs of the most vulnerable?
 How are advocacy coalitions formed around a single narrative to
reduce under nutrition?

4. Stunting levels across nine countries
65
Bangladesh
60
Ethiopia
55
India
50 Kenya
Niger
Rate of Stunting
45
Pakistan
40 Peru
35 Zambia
30
25
20
1990-92 93-95 1997-99 00-02 2003-05 2006-08 2009-11
Source: WHO Global Database on Child Growth and Malnutrition

5. Roadmap
 Analysing Nutrition Governance
 We are not the first ones but…
 Building a dashboard of indicators
 Intersectoral cooperation
 Vertical articulation
 Sustainable funding
 Looking at and measuring the comparative
evidence

6. What is perceived as good
Nutrition Governance?
 According to the WHO, Strong 'nutrition
governance' countries are those
 where governments are committed to having a
national nutrition plan,
 which is also part of the national development
strategy,
 they have set up inter-sectoral coordinating
committees,
 maintain regular surveys and data collections,
and
 allocate budget lines for nutrition strategies and
plans, among other criteria

7. How do we measure governance?
 Governance Indicators (World Bank)
 Governance scores on the
commitment and willingness (WHO
Landscape)
 How do we measure accountability
and incentives?
 Performance budgeting
 Institutional and capacity building

8. Translating Governance Analysis
to effective interventions and
Scaling Up
 Multisectoral nutrition
planning (1970s)
 WHO Landscape Analysis
(2009)
 World Bank (2002-2011)
 Scaling Up Nutrition
movement
 Undernutrition: What Works?
Action Against Hunger (2010)  REACH country process
 Mainstreaming Nutrition
Initiative (Pelletier et al 2011)

9. Analysing Nutrition Governance
–our framework-

10. The fieldwork
 Nine countries, since 2010
 A dozen researchers
 Nearly 230 interviews
 Four languages
 Similar questionnaire adjusted to country
specific concerns
 Working papers, research reports and policy
briefings posted at
http://www.ids.ac.uk/nutritiongovernance

11. ANG: Intersectoral cooperation
 How (-and why-) do government actors,
donors and other stakeholders cooperate
with one another?
 Are there any formal or informal cooperation
instances/coordinating bodies?
 Is there direct involvement of the Executive?
 Is nutrition part of the national development
and poverty reduction agenda?

12. In Peru: Initiative Against Child Malnutrition (CNI)

13. Multisectoral coordination in Ethiopia
FMOH
Nat. Nutrition
technical
committee Agenda-
(experts) setting
National Nutrition Individual
Coordinating Body donors
Coordination/ (line ministries chaired by
implementation MoH) NDPG
forum
Nutrition
working group Food
(DPs and MoH) Security
Program
PSNP Emergency
nutrition
Source: Taylor 2012

14. Min of Food
ISC in Bangladesh Min of and Disaster
Min of Min of Finance Management Min of Local
Livestock Government
Educ.
Min of Min of Health Min of
Women & Min of Min of
Child Affairs Ag and Family Sanitation and
Planning
Welfare Water
Food
National Nutrition policy
Programme
management
committee
IPHN
National Nutrition
Programme BNN
1) Coordinating cttee C
(NGO implementers)
2) Monitoring group
(NGO mgrs & NNP
monitors)
Community level interventions

15. What makes ISC work?
 H1: improved ISC will contribute to (the
formulation of) improved nutrition
governance
 H1a: “policy dictators” can make swift policy
changes but are not sustainable over long run
(Niger)
 H1b: broad and inclusive “nutrition coalitions”
(…) are likely to make nutrition policies more
sustainable (Brazil)

16. ANG: Vertical articulation
 Why would local elites want to implement
national level policies?
 Are there decentralised structures (regional
and local) that facilitate local implementation
and coordination?
 Are local elites motivated to comply with and
influence national level policies (upwards)?
 Are they accountable to demands of voters
(downwards)?

17. Vertical Coordination in Brazil

18. Vertical coordination in Ethiopia
Ministry of Heatlh EPRDF (party) Ministry of Agriculture
Regional health bureau Regional agriculture office
Woreda development
Woreda health committee Regional agriculture
officials officials
Kebele development
Ag.
Health committee
Ext.
ext.
worker
worker
6x
Ag
Dev.
Dev. Dev. Dev. Army
Dev. Dev. Dev.
Army Army Army Army Army Army

19. What makes vertical articulation
work?
 H2: effective Vertical coordination is likely
to contribute to improved nutrition
governance (implementation)
 H2a: when it builds on existing decentralized
structures
 H2b: when it generates greater local
ownership
 H2c: when it reproduces intersectoral
cooperation at the national or subnational
level

20. ANG: Sustainable Funding
 How do funding mechanisms facilitate
inter sectoral and vertical cooperation?
 Are there centralised (pooled) or coordinated
funding schemes or funding sources are
fragmented?
 Are there independent monitoring and
oversight mechanisms that promote efficient
use of revenues?
 Are there additional, unexplored sources of
revenue? private sector funding; taxation;
natural resource revenues?

21. Pooled funding in Niger
 Several types of pooled funds:
 Bilateral Funds – discretionary
 Programmatic – coordinated
 Emergency - OCHA
 New embedded funding line in the budget
 How to make long term use of emergency funds?

22. Siloed funding in Bangladesh
 Fragmented funding encourages isolation
and duplication
 Multiple recipients: “Anyone can get funded”
 Funding is source of political influence
 It can privilege relations with MPs or local goverments

23. What makes funding work?
 H3. Sustainable Funding is likely to
contribute to (financing) improved nutrition
governance
 H3a: greater government ownership – greater
government share in nutrition funding - into
state budgets and political process (ie.
Nutrition line?)
 H3b: when funding allocations are at least
coordinated to avoid corruption or overlap
 H3c: when there are institutional provisions
(earmark, taxes, multiyear budgets) that
ensure long term funding

24. How does it all add up?
 Intersectoral coordination
 inclusive, partially inclusive, not inclusive
 Vertical Articulation
 Effective, partially fragmented, fragmented
 Funding
 Pooled, coordinated, uncoordinated

25. Towards a comparative analysis
of nutrition governance
Country studies Inter Sectoral Vertical coordination Funding Outcome
cooperation (or path
process)
Brazil Inclusive Effective Coordinated O
Peru Inclusive Partly fragmented Coordinated O
Kenya Partially inclusive Partly fragmented Coordinated O
Niger Inclusive fragmented Coordinated and --
Pooled
Bangladesh Not inclusive Effective Uncoordinated --
Ethiopia Partially inclusive Effective Uncoordinated --
Zambia Inclusive Partly fragmented Uncoordinated --
India Not inclusive Fragmented Uncoordinated X
Pakistan Not inclusive Fragmented Uncoordinated X

26. Advantages of a process driven
nutrition governance approach
 Unpacks the notion of “political will” to look
into specific mechanisms of political
commitment around nutrition
 Focuses on the formation and
sustainability of nutrition coalitions
 Seeks to measure and extract practical
policy advice for scaling up nutrition efforts