Luc Laviolette and Venkatesh Mannar
Effective interventions aimed at reducing under nutrition need to be implemented at sufficient scale to be able to make an impact. There is now growing recognition in the nutrition field that the challenge ahead is much less about scientific research than it is about the operational and management challenges of a scaling-up process. Two examples of scale-up of nutrition interventions presented here highlight the factors influencing successful upscaling.
Despite economic progress and technological advances across the globe, under nutrition rates (encompassing stunting and micronutrient deficiencies) in most developing countries persist at unacceptably high levels. More than one-third of child deaths and more than 10 percent of the total global disease burden is attributable to maternal and child under nutrition. Although there is much variation in the region, some areas of Asia have among the highest under nutrition rates in the world.
Years of experience in field implementation and evaluation have shown that effective interventions aimed at reducing under nutrition—when implemented at sufficient scale—would reduce deaths and disability adjusted life years (DALY) among children under five years of age globally by ten percent. The main platforms through which nutrition interventions can be scaled up are health systems (where government is usually in the lead and the private sector also has a role) and food systems (where the private sector is most active but government has an important role to play). Two examples of scale-up of nutrition interventions from Indian region are presented briefly, along with a summary of the critical success factors.
Case 1 : A successful Example
Addressing Micronutrient Deficiencies in Children through the Integrated Child Development Services (ICDS) in the State of West Bengal
The Government of India’s Integrated Child Development System (ICDS) aims to reduce under nutrition in children under six years of age and to improve early childhood education and development. The program is implemented by individual states and provides, inter alia, a food supplement either through an on-site lunch or take-home ration. Although there is an overall national framework for the program, states have flexibility in choosing specific modalities for implementation. At the national level, the program has so far had very little impact on child under nutrition rates, which suggests the need for more innovation and quality improvement. However, some states have in recent years experimented with innovations that have shown impact. A number of states, such as West Bengal, have made impressive progress in scaling up these new approaches.
In West Bengal, a multi-micronutrient powder called Vita-Shakti™ was developed to fortify meals at the village level. This innovation has been proven to work and has now been scaled up to the entire state. This program in West Bengal is one of the few interventions in ICDS that has led to an improvement in nutritional status in recent years. In addition to an efficacious product, this scale-up effort owes its success to very high-level political commitment: the chief minister officially launched the initiative with a coordination committee chaired by the chief secretary. This committee enforced strong coordination between the various state ministries involved. A special “West Bengal Micronutrient Society” was established by the Government of West Bengal to ensure proper management and monitoring of the initiative.
Factors for successful scaling up Factors
- Strong coordination between West Bengal’s ministries and high levels of state government leadership
- Stable sources of funding are provided by the Government of West Bengal and other partners
- Leadership Champions within the highest levels of government
- Technical capacity provided by development partners and the private sector
- Strong Monitoring System
- West Bengal Micronutrient Society established to ensure proper management and monitoring
- Well-Designed Program with a clear focus on an intervention that works
Case 2: Example of Persisting Challenges
Iron Folic Acid (IFA) Supplementation during Pregnancy in India
Despite nearly four decades of operation, the National Nutritional Anemia Prophylaxis Program has failed to reduce high levels of iron deficiency anemia in India. The most recent survey (NFHS III 2006) showed that six out of every ten Indian women and eight out of ten young children are anemic. While there is widespread recognition within Indian technical circles that anemia must be addressed, and a strong policy framework has identified IFA supplementation as one of the ways to control anemia in women, the coverage of IFA tablets in the country remains very low and has not increased in recent years. The Indian Clinical Epidemiology Network (INDIAClen) carried out a study in 2002 to assess perceptions among healthcare workers and women who should take the IFA program supplements and made some recommendations. Essentially, it is possible to overcome the barriers that are typically identified when attempting to scale up IFA supplementation programs. So why has this not yet worked in India?
A number of factors may explain why India’s maternal IFA supplementation program is not scaling up.
- Although anemia is recognized as a problem in India by nutrition and medical specialists, as is the issue of nutrition more broadly, it is still not a high political priority and so it is therefore not a high priority of government departments.
- There are a multiplicity of supply channels involving state and central government departments and international agencies. This often creates confusion and results in irregular supplies at the field level.
- In order to be successful, IFA supplementation requires significant behavioral change by individual women, and for that to occur there must be strong training and program implementation.
- Success also requires coordination of health and nutrition workers at the village level, a convergence that does not always exist. Providers often have a passive attitude and lack of clarity on program components such as product management, client identification, and counselling. Because of these factors, conditions are not favorable to implementing the IFA supplementation program at a large scale in India at this time.
How to Make it Work:
Key Determinants of Success
Experiences to date in scaling up nutrition interventions have shown that a number of critical factors must be in place in order to achieve sustainable scale-up. These include:
Government leadership and championship
Strong leadership from government is required for a number of reasons. Nutrition interventions that are implemented through the public sector often fall under the responsibility of several ministries and this often leads to a situation where nutrition is “everybody’s concern but nobody’s baby”. Strong leadership at high levels of government have helped overcome this problem in countries where there has been successful scale-up. Such strong leadership not only helps coordinate the efforts of government ministries, it also establishes norms for the private sector that oblige them to participate in and comply with public programs.
Clear public policy
Strong government leadership must be supported by public policies and programs that are tailored to
reach those who are most in need of nutrition interventions. Public policy is required to provide incentives and penalties to guide the work of the private sector. For example, programs can encourage private-sector initiatives by funding some of the initial research required for product development and reducing initial market risk associated with trying to reach the poor through market mechanisms. There is a continuing need for public programs that directly address the needs of people with incomes in the bottom one or two quintiles. By supporting these groups (including through subsidies that reduce the direct or transaction costs of nutritious foods), governments not only can target their investments in nutrition to those who need it most, but they also can invest strategically in increasing national productivity and generating economic growth that helps people out of poverty.
Focus—Appropriately targeted public programs
A critical success factor for nutrition programs is focus. The examples of successful scale-up outlined in this paper were all sharply focused on a few key interventions, as opposed to “integrated development programs,” which provide a broader range of services to communities but tend to be limited in scale.
Partnerships
The more successful examples of scale-up have been achieved by drawing on the different strengths and perspectives of the public, private, and civic sectors. Each sector brings a unique perspective and usually different skills. Under nutrition is a highly complex problem that requires all these skills and perspectives.
However, it is not easy for these three sectors to work together. In recent years some mechanisms such as national fortification alliances have been initiated in order to bring these sectors together around a common goal. Effective nutrition partnerships between the government, food processors, technical agencies, and consumer groups are currently in the early stages in most countries, and so far the experience has been mixed.
Incentives and penalties
Although the private sector is vibrant in the Asia-Pacific region and can and should provide much of the needed push to address under-nutrition through sustainable business models, there remains an important role for the government to ensure that the right incentives and penalties are in place to protect consumers. As noted above, successful and sustainable scale-up requires that the government send clear signals to the private sector.
Effective advocacy and communications
One of the biggest gaps in countries where nutrition interventions are not scaling up as rapidly as they should be is communications. While it is often important to have government as the messenger in communications and messaging for nutrition (government can be a neutral voice), it is also critical to draw on the expertise of the private sector to develop and implement effective strategies and tools. At the pilot/small-scale level, it is relatively easy for independent bodies such as NGOs to organize and deliver a communications and advocacy program. However, advocacy and communications change and shift as programs scale up, and it is much more important at that stage to have a strong voice from government.
National managerial and technical capacity
Successful scale-up requires national technical capacity in areas such as food technology for product
development and refinement; biochemistry for food testing and impact assessment studies; epidemiology for nutrition surveys that help target interventions; and engineering for technological development (e.g., fortification devices). This capacity is present in some countries of the Asia-Pacific, but its absence is a serious impediment in others. Some countries, like Vietnam, India, and Indonesia, have created national public institutes of nutrition, which contribute to varying degrees. In other countries, such as Pakistan, the private sector and academic institutions are the main sources of technical expertise.
Special attention will need to be given to harnessing this expertise where it exists and developing it where it is weak. Ultimately, however, programs cannot scale up unless countries have “strategic capacity.” In other words, countries need citizens who are skilled at managing their way through political systems to move the nutrition agenda forward at the national and subnational levels. These “nutrition engineers” also need to have strong project/program management skills.
Multi-year resource commitment
Scaling up national nutrition interventions requires a significant investment of finances, administration,
and human capital. Small-scale programs begin with relatively limited resources, which can be provided by development partners, but a different financing mechanism, such as budgetary allocation or recovery from consumers, is needed for carrying small programs to a national scale. While these resources can come from both the public and private sources, and from domestic as well as external sources, it is critical that funds be committed over several years and ideally come from a variety of sources to minimize the risk of cancellation of funding. As with any development intervention, attention also needs to be given to avoiding conflict of interest with regard to financial contributions from the private sector.
Monitoring and feedback mechanisms
Any successful intervention requires regular performance monitoring. The private sector monitors sales and consumer acceptance closely because sales and profitability depend on this feedback. Unfortunately, the incentive to monitor within public programs remains weak, although it is increasing as programs become more driven by results and evidence. The most successful examples of scaled-up nutrition programs have had well-designed and managed monitoring systems.
Monitoring helps programs focus corrective measures on areas of lower performance (either program
components or specific geographic areas). The feedback provided by monitoring is particularly important in nutrition because the experience of scaling up many specific interventions is limited. Thus, in most cases an iterative approach is required where changes in implementation strategy are expected (and made based on the results feedback) when programs are launched. These performance-monitoring systems should be simple and focused on essential performance areas. As such they do not need to be highly complex or expensive. Nevertheless, they do require dedicated resources. Monitoring a smaller scale program requires a different approach than monitoring a large scale program. While the former can often be managed by personal interactions, the latter requires more sophisticated systems and tools, including sampling and independent assessments.
The world could be a remarkably better place for women and children in less than a decade if even only a small number of the most cost-effective nutrition interventions were scaled up. There is now growing recognition in the nutrition field that the challenge ahead is much less about scientific research than it is about the operational and management challenges of a scaling-up process. As this paper has outlined, there are lessons to be learned from initial scale-up successes in nutrition, but the field should also draw from other areas of development work, such as microfinance and HIV/AIDS awareness campaigns. A focus on scaling-up will require much more effective collaboration among the current development partners working in nutrition and a change in the core skill set expected of a typical nutrition worker.
Luc Laviolette, Regional Director, Asia, Micronutrient Initiative. Email: llaviolette@worldbank.org
Venkatesh Mannar, President, Micronutrient Initiative. Email:vmannar@micronutrient.org
A longer version of this article first appeared as Luc Laviolette and Venkatesh Mannar, “Scaling Up and Sustaining Nutrition Interventions: Lessons Learned from Success in the Asia-Pacific Region”, National Bureau of Asian Research (NBR), Center for Health and Aging, 2008, available at http://nbr.org/research/initiative.aspx?id=25
