Elsevier

The Lancet

Volume 371, Issue 9612, 16–22 February 2008, Pages 608-621
The Lancet

Series
Effective international action against undernutrition: why has it proven so difficult and what can be done to accelerate progress?

https://doi.org/10.1016/S0140-6736(07)61695-XGet rights and content

Summary

Many transnational organisations work to support efforts to eliminate maternal and child undernutrition in high-burden countries. Financial, intellectual, and personal linkages bind these organisations loosely together as components of an international nutrition system. In this paper, we argue that such a system should deliver in four functional areas: stewardship, mobilisation of financial resources, direct provision of nutrition services at times of natural disaster or conflict, and human and institutional resource strengthening. We review quantitative and qualitative data from various sources to assess the performance of the system in each of these areas, and find substantial shortcomings. Fragmentation, lack of an evidence base for prioritised action, institutional inertia, and failure to join up with promising developments in parallel sectors are recurrent themes. Many of these weaknesses can be attributed to systemic problems affecting most organisations working in the field; these are analysed using a problem tree approach. We also make recommendations to overcome some of the most important problems, and we propose five priority actions for the development of a new international architecture.

Introduction

Undernutrition kills or disables millions of children every year, and prevents millions more from reaching their full intellectual and productive potential.1, 2 Although the causes of maternal and child undernutrition are multiple and inextricably linked to poverty, the third paper in this Series showed that effective policy and programmatic interventions are available.3 Such interventions could avert, in 36 high-burden countries, the loss of 25% or 63 million disability-adjusted life-years associated with stunting, intrauterine growth restriction, and micronutrient deficiencies. The fourth paper in this Series showed that these interventions are not reaching those in need, and many of the worst affected countries lack the human resources and institutional capacity to plan and implement effective responses.4

This paper starts from the observation that there are many people and many organisations based outside these worst affected countries that are also working to reduce the global burden of undernutrition. They are to be found in: agencies and programmes of the UN (at least 14); international and regional development banks (five); regional cooperation organisations such as the African Union (at least five major); bilateral (or country-to-country) aid agencies (over 20), charitable foundations (at least five major), and the implementing agencies they create (at least 15); international non-governmental organisations (over 30); major universities and research centres (at least 20 with international scope, plus the 15 centres of the Consultative Group on International Agricultural Research); academic journals (several hundred) and the non-specialist media; and multinational commercial food and nutrition companies (at least 12 major). At best, these international actors are able to mobilise financial, intellectual, and political resources that support country-level initiatives. Although they make up a disparate group, with different objectives, products, and ways of working, we contend that they do nonetheless comprise a system; they are interlinked, financially, intellectually, and personally, and they also share a common target group—the malnourished populations that are their beneficiaries and clients. Although there is great potential for complementary and mutually reinforcing actions, the various organisations often behave adversarially and compete for attention from the same few interlocutors at country level. At worst, they can siphon off scarce human resources and promote poorly designed solutions to problems they cannot solve independently.

Key messages

  • The international nutrition system—made up of international and donor organisations, academia, civil society, and the private sector—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-income and middle-income countries

  • 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 (including the evolving epidemiology of nutrition)

  • The funding provided by international donors to combat undernutrition is grossly insufficient and poorly targeted, and 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-income and middle-income countries

  • The problems of the international nutrition system are long-standing and deeply embedded in organisational structures and norms. The international community needs to identify and establish a new global governance structure that can provide greater accountability and participation for civil society and the private sector

  • 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

We aim to explain why the international nutrition system has not been able to do more of its best and less of its worst. We limit our analysis to those actions which consciously set out to improve or preserve nutritional outcomes. Adapting the language of the 2000 World Health Report on health systems,5 we refer to such activities as nutrition actions. We recognise that some actions and processes which have a huge effect on nutritional outcomes—such as the sudden imposition of comprehensive economic sanctions on pariah regimes for example,6 or climate change7—are not nutrition actions, and are determined by actors outside the international nutrition system. For such actions we ask not “why have these processes evolved?” but “why has the international nutrition system not done a better job analysing their implications, advocating for the protection of the vulnerable and proposing mitigating interventions?” Other nutrition-relevant actions, such as the education of girls and the empowering of women, have a strong positive effect on nutrition outcomes8 even though these actions are usually implemented for other reasons. In these cases, the challenge is to ensure that these actions are actively supported by the nutrition community, and that opportunities for synergies with direct nutrition actions are fully exploited.

The rest of this paper is divided into six sections, the first four of which discuss the current performance of the international system in four functional areas. Again, we have built on the conceptual framework laid out in the 2000 World Health Report5 to put some structure around the functions that we believe an adequate international nutrition system should perform. These functions should directly support national actors in high-burden countries, as well as producing so-called global public goods, which can be taken advantage of by interested parties anywhere. They include: regulating, setting standards, and identifying priorities—a crucial function that has been referred to as stewardship;9 mobilising, pooling, and distributing financial resources for nutrition, and, where desirable, procuring programme inputs to take advantage of economies of scale; providing food and nutrition services directly where national actors are unable or unwilling to do so themselves; and strengthening human and institutional resources for nutrition by training, capacity building, and research and development;

The final sections of the paper ask what needs to change now to improve the performance of the international nutrition system, focusing on features of the entire system. The analyses presented throughout this paper draw on a large number of new and existing reviews (some in the public domain and others held by individual institutions), as well as primary data collected through interviews with key informants, surveys, and statistical analysis of publicly accessible data sources. Detailed information on sources and methods is presented in the search strategy.

We should acknowledge that the analyses and recommendations in this paper necessarily reflect the organisational experience and disciplinary biases of the authors, and others analysts might have emphasised differently the various strands of data that we present. Many different voices will need to be listened to in order to generate the inclusive discourse that the nutrition profession so desperately needs.

Section snippets

Stewardship

Stewardship embodies notions of “manag[ing] assets without owning them, anticipat[ing] future trends and devis[ing] grand plans”.9 Grand plans are certainly familiar to the international nutrition community, which set out one major and seven other supporting nutrition-related goals in the World Summit for Children in 1990,32 made 28 references to nutrition in the 1996 World Food Summit Plan of Action,33 and included the halving of the prevalence of childhood underweight as one of 48 millennium

Financing

Every year, the international community invests large amounts of money in improving nutritional outcomes in poor countries. Exactly how much is not clear, because of the difficulty in isolating a discrete set of nutrition investments and because each donor's financial management information system is different, with few routinely reporting on maternal and child nutrition as a distinct budget line.

One imperfect but accessible source of information is the aid database of the Development

Direct service provision by international organisations

Most service provision is, and should be, the purview of national actors. But natural disasters and armed conflict often preclude effective action against undernutrition by national governments, and in these circumstances the international system can assist with both situation assessment and humanitarian response. Nutrition assessment includes information generated by early warning systems and surveys. Early warning systems are largely focused on tracking food availability and access using a

Strengthening human and institutional resources

Although strengthening human resources for tackling undernutrition must ultimately take place at country-level, international actors also play a major part: at least 20 major universities in high-income countries offer postgraduate training in international nutrition, public (health) nutrition, or human nutrition with a focus on low-income and middle-income countries, and international donors provide much of their support for nutrition in the form of technical assistance. Yet the shortage of

Overall performance of organisations

We have shown that there remain significant deficits in the international nutrition system. If the challenge of reducing global undernutrition is to be met, then all organisations that are part of this system need to re-examine their strategies, resources, and internal incentives; this will require frank dialogue best undertaken in a forum where different kinds of organisations are present and can give feedback to each other about what they perceive as the barriers to effective collaborative

Towards a new international architecture for nutrition

Fragmentation has been a persistent theme of this paper, from reams of uncoordinated normative guidance, through multiple projects and agencies with almost indistinguishable names, to the 417 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. Worst of all, as each

Search strategy and selection criteria

Multiple methods were used to generate and analyse the material presented in this paper:

  • Systematic reviews. First, we reviewed all research included in the CABI nutrition and food sciences database (CABI, Wallingford, UK) in the second half of 2005. The research was categorised by nutritional problem and disciplinary knowledge area with slightly modified versions of the definitions set out by Llanos et al.10 One reviewer classified all 6023 abstracts. Second, we reviewed all

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