‘The persistence of malnutrition, especially among children and mothers, in this world of plenty, is immoral.’ This was an opening statement of a report published in 2000. The report was produced by the Commission on the Nutrition Challenges of the 21st Century and was presented to the UN System Standing Committee on Nutrition (UN SCN). Its title was Ending Malnutrition by 2020 (1). We know now that undernutrition – the new name for an old outrage – is liable to persist indefinitely. Why?
Some reasons are given in the Lancet series on maternal and child undernutrition, published earlier this year. The fifth and final paper in this series(Reference Morris, Cogill and Uauy2) asks why all the efforts to alleviate undernutrition are so ineffective and proposes some ways forward. The paper, in common with the others in the series, is the product of the work of a large study group from all continents including senior people from relevant UN agencies, whose judgements have been informed by testimony from many other sources. The work was supported by the World Bank and the Gates Foundation, and was focused in a Bellagio workshop. So what follows is a concerted view.
This commentary summarises some of the main points made in the paper. Its purpose is to involve the readers of this journal in the problems and – it is hoped – the solutions.
The system is broken
The UN SCN is – or should be – the focal point of the international nutrition system. The whole system is made up from the nineteen UN agencies with an interest in food and nutrition policy, together with bilateral government and other donor organisations, and academia, civil society organisations and the private sector. This system is fragmented and dysfunctional. Reform is needed so that it can perform key stewardship functions, mobilise resources, provide services in emergencies, and strengthen capacity in low- and middle-income countries.
The fundamental issue is what the UN system and the bilateral agencies should do in order to fulfil their mission. The desire to alleviate undernutrition is certainly there. The SCN 35th session in Hanoi this March had as its theme ‘Accelerating Reduction of Maternal and Child Undernutrition’. The theme of the 33rd meeting in Geneva in 2006 was ‘Working Together to Achieve Freedom from Child Hunger and Undernutrition’. This title is revealing. The UN agencies do indeed have problems working together. Their activities in addressing nutrition problems provide in most cases a poor example for coordinated and effective actions at the national or regional level.
Processes are ineffective
The UN system is slow to respond to change. Current processes for producing normative guidance are laborious and duplicative, and fail to produce guidance that is prioritised, succinct and evidence-based. Programme evaluation is weak, and insufficient resources are devoted to analysing and responding to major global challenges.
Stewardship means managing assets without owning them, anticipating future trends and making plans to address problems as they arise. The complexity of the multiple micronutrient-focused organisations is presented and discussed in the Lancet paper. It highlights the need for all to work together to produce a single set of succinct, up-to-date, evidence-based position papers on different options for effective interventions based on different local contexts. Instead, we have competing initiatives. These confuse country-level nutrition practitioners and often exhaust the capacity of the limited human technical resources that must deal with them.
Starved of good money
The funding provided by international donors to combat undernutrition is grossly insufficient and poorly targeted. Also, it is inappropriately dominated by food aid and supply-led technical assistance. Much more investment is needed in human and institutional capacity for nutrition in low- and middle-income countries. Total donor investment in basic nutrition in low- and middle-income countries has been estimated at a maximum of $US 250–300 million a year for the 2000–2005 period, during which time food aid allocations exceeded $US 2 billion per year(Reference Morris, Cogill and Uauy2).
These small sums of official aid allocated to basic nutrition by donors signal their lack of commitment to the issue. The most resource-constrained countries with high rates of stunting need to be assisted to establish effective interventions with high coverage. This implies at least a doubling or even a tripling of dedicated aid flows. In view of the lack of government commitment in strengthening local capacity to implement, monitor and evaluate nutrition interventions in the worst-affected countries, donor expenditures on building or strengthening country-level capacity for effective action are badly needed. The international community devotes few resources to nutrition-relevant organisational development in low- and middle-income countries.
Research: babble and babel
The problems of the international nutrition system are long-standing and deeply embedded in organisational structures and norms. All those involved in the international nutrition system need to identify and establish a new global governance structure that can provide both greater accountability and greater participation for civil society organisations and the private sector.
Fragmentation was found to be a common and persistent theme in the analysis conducted. There are reams of uncoordinated normative guidance from multiple and often competing projects and agencies with almost indistinguishable acronyms. There are more than 400 journals publishing so-called new research on undernutrition. This fragmentation makes it difficult for any one organisation to muster sufficient resources to act at scale and prevents a shared understanding of the range of interventions that are currently being deployed. Linkages with national-level processes need to be significantly enhanced, so that priorities that are felt at country level are better reflected in international normative guidance, donor funding, research and advanced training.
What then is to be done?
The Lancet paper proposes an action-oriented critical issues research agenda that includes the following:
1. Research into the accountability and responses of governments to their nutrition-relevant commitments under international conventions such as the UN Convention on the Rights of the Child and the Convention on the Elimination of all forms of Discrimination against Women, as well as on the effectiveness of alternative mechanisms to strengthen these instruments.
2. Rigorous analysis of the linkages between nutrition outcomes and global change processes such as climate change, trade liberalisation, international migration and remittances, and long-term trends in energy prices. There is also a need to assess the effect on nutritional status outcomes of changes in agricultural technologies and policy.
3. Research into the quantity and effectiveness of international aid for improved nutrition, including modalities such as country-level technical assistance, budget support (sector and general) and humanitarian intervention, as well as investment in nutritional global public goods. This research would include rigorous assessment of the effect of public–private partnerships in nutrition.
4. Evaluation and prioritisation of interventions to ensure timely and relevant emergency responses, including improved problem analysis, more efficient sampling methods for the estimation of the prevalence of severe acute malnutrition and targeting of interventions, and cost-effectiveness studies of different food commodities and therapeutic foods.
5. Research on the gap between current and required manpower, training capacity and training resources, at national, regional and global levels, as well as research on best practices for designing and delivering the pre-service training, continuing education and knowledge management systems that practitioners need to address undernutrition effectively.
6. Meaningful self-assessment and peer-assessment of the effectiveness of individual organisations involved in designing and delivering goods, services and ideas relevant to the elimination of maternal and child undernutrition.
Action this year
Finally the paper calls for specific actions, as follows.
A new global governance structure
All those interested in working to eliminate maternal and child undernutrition need to come together to review the current international architecture for nutrition. Such a meeting should agree options for a structure that will more effectively represent supranational organisations, civil society organisations and the private sector, as well as facilitating dialogue with national actors from high-burden countries. Once specific options have been laid out, they could be evaluated against the problem tree (see http://www.globalnutritionseries.org/web_appendices)to establish whether they have potential to alleviate the most pressing problems.
Such a review is now being considered by the UN SCN, and independently by other relevant actors including major donor agencies and also the civil society sector of the SCN.
A more effective UN organisation
In the short term, the UN SCN needs to become a forum that makes individual UN agencies accountable for results. Well in advance of the 2009 annual session, all UN member agencies should publicly state that they want the UN SCN Committee to exercise this function. The UN SCN Chair and Secretary should explain how they will manage working groups more effectively in support of the necessary international and country-level actions.
Fewer parallel organisations and fewer mandate gaps
Donors should immediately clarify how they plan to contribute to the simplification of the current system, ending duplications and overlap between the multiple programmes that coexist, especially those addressing micronutrient deficiencies. More investment is needed in capacity strengthening in high-burden countries.
New funding should be committed in 2008, representing an appropriate balance between needs-based training for talented individuals, budget support for key organisations and flexible, demand-led technical assistance for sectoral or cross-sectoral institutional reform. Strengthening of regional and sub-regional networks should be treated as a priority. These networks have the potential to reach a larger number of beneficiary countries.
Research leadership in areas that matter
Editors of academic journals with an interest in maternal and child undernutrition should meet in 2008 and report to the 2009 International Congress of Nutrition in Bangkok, to develop a strategy to increase the profile and programmatic relevance of the topic and to reduce fragmentation. Major donors should immediately clarify how their funding will reduce the imbalances noted in the comparison between published work and the research base needed to support policy and programme design, implementation, monitoring and evaluation. Research and training groups in high-income countries should review how they can contribute new theoretical and practical knowledge in the process of scaling up successful nutrition projects, programmes and policy initiatives.
