What drives political commitment for nutrition? A review and framework synthesis to inform the United Nations Decade of Action on Nutrition

Actors

Irrespective of country-context, effective nutrition actor networks (NANs) (factor 1) generated commitment through inter alia advocacy and awareness-raising, framing nutrition problems and solutions (ie, norm promotion), generating data and evidence, coordinating policy development, implementation and monitoring activities, building capacities and mobilising resources.24–47 Such networks varied widely in structure (formal vs informal), maturity (nascent vs highly evolved) and membership composition including parliamentarians, bureaucrats, academics, international agencies and civil society representatives.24–47 Their effectiveness was enhanced in the context of high cohesion among members,29 30 32 40–47 strong leadership44–46 and when possessing strategic and organisational capacities.25 29 37 43 48–50 Conflict and fragmentation within NANs was, however, frequently reported resulting from many topics of disagreement.12 25 28 33 34 36 40 51

Nutrition leaders (factor 2), including those within and outside of government enabled commitment in many studies through establishing, unifying and mobilising NANs, championing policy ideas and engaging with decision-makers.15 24 29 32 36 41 44–46 52–59 They included advocates promoting external attention to nutrition, policy entrepreneurs (eg, who softened-up technical communities to political realities, built consensus and advocated policy ideas) and high-level political champions.12 24 26 27 40 41 43 44 46–49 54–57 59–64 Their leadership was enhanced when possessing certain strategic capacities (eg, emotional intelligence, management, communication, negotiation and conflict management skills),24 26 31 36 41 43 45 46 54 55 they had the support of high-level political champions26 54 55 and when elected or appointed into positions of authority (eg, as legislators or high-level bureaucrats).24 36 41 43 45 46 53 57 65

The mobilisation of civil society groups (factor 3), including a diversity of international and national non-governmental organisations and social movements (eg, health-orientated, disease-specific, faith-based, consumer-focused), was often integral to NAN formation, development and impact. Groups varied in their expertise, available resources and functional roles.26 27 29–32 45 46 52 53 62 66–69 Their activities included advocacy, awareness-raising and coalition-building, acting as an accountability mechanism (eg, by monitoring and reporting on government and other stakeholder activities), giving voice to the politically marginalised, delivering on-the-ground services and informing policy development, monitoring and calibration.26 27 29–32 45 46 52 53 62 66–69 Civil society impact was enhanced when supported by the media27 55 and international actors,29 53 70 and when inclusive governance arrangements linked policy-makers with civil society groups and policy beneficiaries.30 42 45 48 52 53 64 71

In several LIC and MIC studies, supportive international actors (factor 4) enabled commitment by mobilising resources for policy, programming and capacity-building,29 48 52 55 61 63 72 providing technical assistance and legitimacy to policy initiatives,12 26 43 44 60 and by advocating to governments.25 43 44 48 53 They included multilateral organisations (eg, World Health Organization, Unicef, World Bank), donor agencies (eg, United States Agency for International Development, United Kingdom’s Department for International Development) and global nutrition initiatives (eg, Scaling Up Nutrition).15 39 42–44 53 55 57 61 63 67 In some cases, policy and programming was almost entirely donor-driven.61 63 72 The role of international actors was weakened when their actions were misaligned with government priorities,24 25 31 52 when the absence of coherent government policies, coordinating structures and accountability mechanisms encouraged donors to ‘go it alone’38 70 and when recipient governments became overdependent on donor financing.39 40 63

In many MIC and HIC studies, private sector interference (factor 5) impeded commitment for food regulations targeting obesity prevention by inter alia undermining policy debates (eg, by emphasising individual or parental responsibility, disputing evidence, intervention as ‘nanny-statist’), pre-emptively adopting self-regulation (ie, policy substitution) and direct lobbying of policy-makers.28 35 36 73–80 This was enhanced in the context of a neoliberal ideology28 35 73 81–83 including a shift towards hybrid (ie, public-private) governance arrangements that expanded private-interest influence in public policy,28 35 73 79 82 84 the food industry’s ‘productivist power’ as suppliers of jobs and tax revenue28 35 53 and greater international capital mobility (ie, via trade liberalisation) allowing transnational corporations to punish or reward governments for their policy decisions.56 79 In some LIC and MIC studies, agricultural subsidies, tax concessions and ‘pork-barrelling’ may have created powerful private-interest constituencies resisting nutrition-sensitive agriculture and food distribution policy change.27 52 61 70 85

Institutions

Tackling malnutrition requires coordinated action and commitment within and across multiple sectors (horizontal coordination) and levels (vertical coordination) of governance. The complex institutional arrangements involved, the absence of institutional ownership for nutrition, and institutional failure often impeded this.15 24 26 27 40 45 48 52 60 61 67 The establishment of empowered coordinating agencies and institutional systems with a mandate to address malnutrition (factor 6) was important in overcoming these challenges through inter alia providing structures for convening stakeholders, coordinating multisector/multilevel policy development, implementation and monitoring activities and mobilising human, technical and financial resources.25 27 30 40 43 44 52 55 60 This often centrally involved the health and agricultural sectors, but also inter alia education, gender, labour, finance, economic development, industry, water and sanitation, social protection and trade.24 30 44 50 52 59–61 67 69 86–88

Coordinating agencies were typically located within suprasectoral agencies (eg, office of the prime minister) or line agencies (eg, ministry of health, agriculture),27 43 44 53 and embedded within wider multisector/multilevel institutional systems with delineated roles and responsibilities.24 30 43 45 53 Agencies were more often effective when positioned suprasectorally and possessing sufficient capacities, resources and leadership,12 24 53 55 67 69 and when institutional systems had strong multisector/multilevel cooperation incentives (eg, enabling legislation, policies and plans, shared and sector-specific goals, performance measures and performance and/or results-based budgeting systems).43 53 61 67 71 Institutional failure resulted from inter alia insufficient authority, capacities and resources (often when located within politically weak line ministries),27 39 43 52 53 61 69 70 an overfocus on technical or implementation activities to the neglect of advocacy24 53 60 and interorganisational competition.24 39 60

Vertical coordination presented a significant challenge given the many actors involved in policy and programming activities within and across levels of governance.12 24 25 28 29 39 52 61 63 69 72 76 86 89 90 Effective vertical coordination (factor 7) was important for incentivising actions, building ownership and driving coordinated action along national to subnational ‘implementation pathways’.29 52 53 63 71 86 89 This was enhanced through strong cooperation incentives (eg, legislation requiring multilevel cooperation, resource transfers and performance and/or results-based budgeting),52 53 71 and subnational institutional structures with sufficient capacities and resources.29 52 53 63 Decentralisation processes underway in many countries increased the power of subnational stakeholders, making their involvement in centralised policy processes critical,25 49 52 53 60 63 and their exclusion detrimental.38 52 61 63 67 In some cases, decentralisation also undermined the authority of centralised coordinating agencies.25 39 43 49 60 63

The development and adoption of national nutrition policies, operational plans and enabling legislation (factor 8) enabled commitment by demonstrating commitments to which governments could be held accountable, enabling beliefs on the need for coordinated action within government, and by providing a framework for action.15 46 53 61 63 67 69 71 Commitment was further enhanced when nutrition was positioned within broader national development plans, social welfare reforms and/or poverty reduction strategies,24 29 45 53 56 66 when global-level policies and/or commitments compelled national governments to initiate responses42 43 52 57 63 91 and when policies had clear numerical commitments that enhanced accountability.52 61 92 It was diminished when nutrition was excluded or marginalised from broader policy agendas,60 61 93 and when there was limited capacity to achieve consensus among stakeholders during policy processes.15 31 37 64

Political and societal contexts

Political administrations, including the executive, legislative and administrative branches of government were often the primary power structures shaping nutrition responses at all levels. Supportive political administrations (factor 9) enabled commitment by articulating policy debates, championing policy initiatives, facilitating inclusive policy processes (eg, public consultations), drafting policy and legislation, providing institutional memory and enhancing accountability through oversight of policy initiatives, agencies and expenditures.12 29 30 45 52 This was more likely with the election or electoral continuity of governments with strong social welfare and antipoverty agendas,12 24 27 38 42 45 52 53 55 56 71 when actions were taken to build non-partisan (ie, multiparty or multifaction) coalitions for nutrition and when parliamentarians were actively involved in policy processes.30 43 52

Unsupportive political administrations were frequently reported.25 29 38 45 52 55 61 69 83 93 In several cases, rhetorical commitments by members of the executive branch were not converted into directives for legislative and administrative enactment.15 24 52 53 70 This was more likely in the context of weak electoral demand and/or civil society pressure (ie, reducing the political costs of inaction),25 38 45 52 55 61 69 93 the low-level visibility of nutrition and poor nutritional literacy among parliamentarians, administrators and citizens,15 38 39 49 63 66 when attention to nutrition was eclipsed by more tangible ‘vote-winning’ issues24 38 40 42 43 49 60 61 63 67 and in highly partisan, fragmented or unstable political environments.38 90 In some HIC studies, commitment for food regulations targeting obesity prevention was undermined by the election of, or congressional control by, more right-wing (eg, liberal-conservative) governments.28 35 36 58

Long-term changes in societal conditions and short-term focusing events (factor 11) presented opportunities or challenges for generating commitment by influencing many aspects of government policy agendas and by focusing public and political attention directly onto or away from nutrition and/or closely related issues.27 31 32 64 Examples of these are given in table 4. Some focusing events (eg, famines) were detrimental when they focused attention onto and institutionalised food production and distribution responses at the expense of broader (ie, nutrition-sensitive) and longer-term responses to undernutrition.31 Changing societal conditions and focusing events were more likely to advance commitment when NANs had sufficient foresight, leadership and capacities to take advantage of emerging opportunities or mitigate threats.31 64

Certain belief systems (factor 12) entrenched within political systems, policy-making institutions and/or in society-at-large were found to narrow or skew perceptions about the scale, scope and nature of nutrition problems, thereby impeding commitment for more balanced policy responses addressing the wider determinants of malnutrition.15 25 28 48 82 94 Three were most evident as described in table 5. In primarily HIC studies, a ‘neoliberal ideology’ was found to skew overweight/obesity responses towards behavioural-lifestyle and market-driven (ie, industry-led) approaches with a limited role for government and legislative intervention.28 32 35 56 73 81–83 In several LIC and MICs, a ‘food-centric’ belief system was found to orientate policy responses towards agricultural production, food distribution and hunger reduction to the exclusion of nutrition.13 15 27 31 49 53 55 61 63 68 69 93 A ‘nutricentric’ belief system skewed undernutrition responses towards nutrition-specific and/or curative/biomedical interventions to the neglect of nutrition-sensitive ones.38 44 52 53 61 63

Knowledge, evidence and framing

Irrespective of issue or country-context, the availability of credible indicators and data systems (factor 12) was critical to enabling commitment by informing problem identification (ie, demonstrating the changing prevalence and distribution of malnutrition), policy development, monitoring and calibration activities, the development of internal frame alignment (ie, a shared discourse) within NANs, and as a foundation for effective financing and accountability systems.12 15 26–31 40 43 44 52–55 57 59 66 68 75 76 90 Data demonstrating ‘policy success’ enabled successful advocacy efforts for sustaining long-term commitment.24 40 44 49 90 Insufficient data and weak data systems were, however, reported in many studies,26 27 31 33 37 38 40 60 61 63 83 84 86 92 often resulting from the limited capacities, resources and incentives of nutrition actors to collect, analyse and disseminate data.40 42 52 61 69 72 93

Evidence demonstrating the causes and consequences of malnutrition and the efficacy and cost-effectiveness of interventions (factor 13) helped to support effective advocacy and policy activities when available, clearly communicated and accepted.30 32 43 44 47 53 62 66 71 This was more likely when evidence was communicated via ‘knowledge-brokers’26 42 56 69 95 in language policy-makers understand,61 69 95 by using communicative devices (eg, country profiles, short briefs, nutrition maps)53 69 and when authoritative bodies were commissioned to gather, integrate and report evidence.33 47 71 The perception that evidence was lacking, inconsistent or unconvincing was frequently reported.12 27 28 33 37 40 56 61 63 69 75 76 80 81 84 95 Although in some studies a strong international evidence-base supported country-level activities,26 33 40 42 43 66 many reported an absence of locally relevant evidence and/or the perception that international/national evidence was inapplicable to national/subnational contexts.26 27 31 33 37 40 63 83 84 86 Higher evidential requirements were needed to inform policy decisions when issues were strongly contested, as in the case of food regulations targeting obesity prevention.28 35 75 84

NANs that were unified around a common problem definition, causal interpretation and set of proposed solutions (factor 14) were more likely to overcome ideological differences, appease powerful ‘veto players’ and undertake effective collective action.15 25 29–31 40 43 46 55 59 69 71 This was more likely when NANs had established structures (eg, governance bodies, conferences, workshops, informal networking events) for sharing information, recruiting and socialising new members, building consensus and managing conflicts,25 29 37 43 48–50 52 55 71 leadership,37 44 52 strategic capacities (ie, soft skills) for building consensus and managing conflicts31 37 40 44 and credible data, evidence and/or a shared causal framework (eg, Unicef nutrition framework) to support a unifying discourse.37 44 52 The failure to achieve this ‘internal frame alignment’ was reported in many cases12 27 28 36–39 44 49 53 56 61 68 70 83–85 96 and resulted more often from normative conflicts (eg, divergent interests, organisational mandates, administrative systems or professional cultures) rather than technical ones.24 25 27 31 37 49 64 Although there were many topics of disagreement within NANs,31 37 52 distrust and disagreement regarding the private sector’s role in nutrition policy was most common.12 26 27 32 37 40 78 96

Certain public portrayals (ie, frames) used by nutrition actors to attribute causality, responsibility, severity, tractability and benefit to an issue were found to resonate strongly with external audiences and thus enable commitment.14 20 28 86 Common frames identified are described in table 6. This ‘external frame resonance’ (factor 14) was more likely when messages were aligned with the underlying values and beliefs of policy decision-makers7 28 43 48 77 including their perceptions of technical and political feasibility,12 24 27 48 when NANs argued behind closed doors and spoke with a common voice31 43 52 and when messages were strategically tailored to align with the priorities, interests and needs of target audiences.7 50 77 83 95 ‘Hooking’ nutrition onto high priority non-nutrition issues (ie, frame expansion) was also found to successfully enable ‘nutrition success without nutrition commitment’ by sensitising broader policy agendas (eg, national development agendas, poverty reduction initiatives, school feeding programmes) to nutrition objectives.30 31 49 52 53 59

Capacities and resources

NANs possessing strategic capacities (factor 16), described as ‘a body of craft knowledge with considerable practical utility'31 ^pS63 were more capable of building cohesive NANs, responding to opportunities and countering threats, and managing complex political and policy processes.15 24 31 43 44 46 47 55 57 90 At the individual level, this included certain attributes of nutrition leaders (see factor 2) and at the institutional level the capacity for building consensus, managing conflicts and developing competencies,25 29 31 37 43 44 48–50 establishing and maintaining strategic multistakeholder partnerships (ie, coalition-building)40 44 46 48 52 53 62 and undertaking strategic communication. The latter included the capacity to negotiate, compromise and tailor messages to different audiences,7 24 31 36 48 52 55 57 advocate for incremental/realistic changes aligned with decision-maker priorities25 30 43 49 53 77 83 and to use champions with direct access to policy-makers.41 43 46 49 52 In several studies, weak strategic capacities were reported as problematic.12 24 27 28 36 61

Limited organisational capacities (factor 17) frequently undermined commitment by constraining the effective management of nutrition policy responses and increasing the likelihood of policy failure (thus trapping nutrition within a low-priority cycle). This was most evident in cases where competent nutrition professionals and administrative staff were lacking, especially at the local level,24 40 42 43 46 52 61 63 67 70 72 86 91 93 when there was a high turnover of ministers or administrative staff and/or disruptive administrative restructuring,12 24 42 44 61 69 limited technical capacities particularly for multisectoral/multilevel data collection, management and analysis,40 42 52 61 69 72 93 when high administrative loads were placed on weak coordinating agencies and other relevant institutions38 48 52 55 63 68 70 72 and when absent or weak budgeting, record-keeping and accounting capacities undermined financial planning, programming efficiency and accountability.48 52 63 68 70 72

The expansion of nutrition budgetary commitments and effective financing systems (factor 18) enabled commitment by empowering coordinating agencies and institutional systems, enabling effective policy implementation, and by creating entitlements among parliamentarians, bureaucrats and citizens.27 52 53 66 67 71 Performance and/or results-based budgeting was effective at incentivising multisector/multilevel cooperation, improving the transparency and accountability of institutional systems and enhancing the efficiency of programming activities.27 29 52 53 66 More generally, accountability was enhanced when there were transparent financing and accounting systems for tracking disbursements.38 48 52 61 72 93 In many cases, inadequate financial resources or the failure to effectively use existing resources led to poor implementation outcomes and policy failure.24 38–40 43 46 48 49 52 61–63 67 68 70 72 90 91 93 Financing activities were undermined by a limited capacity of subnational implementation partners to use or reciprocate funding from central government,12 52 62 the absence of nutrition line items in government budgets or the nesting of nutrition within budgets for non-mandated departments or issues63 67 72 and when siloed financing arrangements encouraged interagency competition and disincentivised cooperation.24 38 40 48 60 93