«Jomo Kwame Sundaram Vikas Rawal Michael T. Clark Tulika Books Published by Food and Agriculture Organization of the United Nations (FAO) Viale delle ...»
Recent studies, including from the World Bank, doubt that behavioural changes alone can bring about the requisite increase in the use of improved Access to Safe Water and Sanitation 83 sanitation. The 2015 World Development Report argued that “a program to change social norms about sanitation in these two countries was important but not sufficient to end open defecation” (World Bank, 2015). It took the position that programmes aiming for behavioural change “can complement, but perhaps not substitute for, programmes that provide resources for building toilets” (World Bank, 2015).
Assessing sanitation programmes in Bangladesh, often cited by proponents of CLTS, Black and Fawcett (2008) point out that progress in Bangladesh is not merely because of CLTS, but has much to do with sustained political commitment at the highest level, sustained efforts of the Department of Public Health Engineering and NGOs, and various specific socio-economic and ecological conditions. A comparative assessment of sanitation outcomes in CLTS and non-CLTS villages in Bangladesh by Hanchett et al. (2011) showed a substantial increase in the adoption of improved sanitation in all areas, and no significant difference between CLTS and non-CLTS villages. The study concluded that “the government’s commitment may have been the cornerstone for influencing the social norms in favor of improved sanitation behaviors and facilities, regardless of the specific approach”. Black and Fawcett (2008) strongly argue against using CLTS as a magic bullet to deal with the problem of sanitation regardless of national contexts.
Given that the inability to have or use toilets fundamentally reflects a failure of entitlements, the ethical underpinnings of using humiliation, policing, punishments, and coercion rather than focusing on provision of sanitation facilities along with education, literacy, and sustained awarenessbuilding are questionable. A detailed study of CLTS programmes in Indonesia found that “it is primarily the poor who are the ‘targets’ of this intervention and that they are, in effect, punished for their poverty and local practices” (Engel and Susilo, 2014). Engel and Susilo (2014) conclude that “CLTS is clearly a very intrusive process involving facilitators from outside the village inspecting individual households and shaming predominantly poor individuals and households for their circumstances and local practices.” Experiences from countries that have made significant advances in access to safe water and improved sanitation suggest that political commitment at the highest level, involvement of all levels of government, sustained fiscal support for the development of common infrastructure and household-level facilities, and a major thrust in awareness-building programmes hold the key to success in the area. Community participation in raising awareness and building a social commitment to sanitation has always been crucial.
It is important to design solutions keeping in mind the local context, including both constraints and resources, rather than imposing one-size-fitsall technical or economic solutions. Improvement in the area of sanitation often goes hand in hand with improvement in access to water on the household premises. This is particularly important for rural areas, where 84 Ending Malnutrition the gap in access to water supply on household premises is substantial in many countries. In such countries, programmes for development of domestic water supply and sanitation in rural areas should be planned and implemented together.
Box 5.2 ICN2 Framework for Action: Recommended actions on water, sanitation and hygiene
• Recommendation 50: Implement policies and programmes using participatory approaches to improve water management in agriculture and food production.a
• Recommendation 51: Invest in and commit to achieve universal access to safe drinking water, with the participation of civil society and the support of international partners, as appropriate.
• Recommendation 52: Implement policies and strategies using participatory approaches to ensure universal access to adequate sanitationb and to promote safe hygiene practices, including hand washing with soap.
a Including by reducing water wastage in irrigation, strategies for multiple use of water (including waste water), and better use of appropriate technology.
b Including by implementing effective risk assessment and management practices on safe waste water use and sanitation.
Governance: Accelerating and Sustaining Momentum Much has changed in recent years, bringing nutrition to the forefront of the global development agenda. In 2008, the worst food-price spike in a generation compelled political leaders across the globe to rethink assumptions and received wisdom about the capacity of economic growth alone to address food access and malnutrition problems. A series of articles published at the same time in The Lancet provided new evidence demonstrating the high human and economic costs of malnutrition, and issued a clarion call for reform of what the authors of a paper on international action against undernutrition described as the “fragmented and dysfunctional” “international nutrition system” (Morris, Cogill, and Uauy, 2008).
Soon afterward, in 2010, the Scaling Up Nutrition (SUN) movement was born, a new type of multi-stakeholder and multisectoral partnership initiative launched under the administrative aegis of the UN SecretaryGeneral (United Nations, 2012), but with a decidedly open and flexible governance structure that allows it to be called a movement rather than a UN initiative or programme. In a relatively short period of time, SUN has also garnered the active involvement of major donors and more than 100 major organizations organized into four networks: donors, civil society, the private sector, and UN system agencies, funds, and programmes. The SUN movement seeks to organize itself around the priorities of countries that have subscribed as members of the movement. By June 2015, SUN had attracted 55 countries to its ranks.¹
Owing in part to the well-organized advocacy of SUN and bolstered by a second series of Lancet articles published in 2013, a variety of complementary initiatives have been launched, including the June 2013 Nutrition for Growth Summit, which focused attention on nutrition and mobilized more than US$4.15 billion in public investment commitments, along with US$19 billion in nutrition-sensitive investments, between 2013 and 2020;² the launch of the Global Panel on Agriculture and Food Systems for Nutrition at the same time; and the commitment to publish the Global Nutrition Report, first published in November 2014 and produced under the editorial aegis of the International Food Policy Research Institute (IFPRI) with contributions from across the global nutrition community.
In July 2014, the UN General Assembly’s Open Working Group on Sustainable Development Goals produced a report calling for 17 new Sustainable Development Goals (SDGs) and 169 targets. That report has been subsequently accepted as the basis, with only minor technical adjustments, for the post-2015 development agenda that will be adopted by the UN member-states at a special summit in September 2015. The new SDGs include at least six headline goals and eighteen targets materially relevant to nutrition, including not only targets that specifically mention nutrition, but also targets such as poverty eradication, improved food systems, women’s empowerment, and improved access to safe water and sanitation – which, when combined, present a comprehensive approach not only to enhance efforts on nutrition, but also to address its underlying causes.
While the process may only endorse one or two indicators of malnutrition, the potential number of nutrition-related indicators may be much larger.
In light of these developments, the Second International Conference on Nutrition (ICN2), which took place in Rome in November 2014, represented a culminating event. Jointly organized by the Food and Agriculture Organization and the World Health Organization, both United Nations specialized agencies, ICN2 was an effort to integrate and unify a broad range of activities within a defined set of intergovernmentally endorsed political commitments, and to provide a flexible and comprehensive framework for action. Achieving broad agreement among the world’s nation-states is always a challenge, and is made even more challenging when the issues are as complex as they are with nutrition. Thus, while ICN2’s two outcomes – the Rome Declaration and Framework for Action – did not break new ground in knowledge or policy, they made a major contribution to nutrition action by forging a new intergovernmental consensus on the needed scale and scope for adequate policy action.
² “Nutrition for Growth Commitments: Executive Summary”. Available at www.gov.uk/ government/uploads/system/uploads/attachment_data/file/207274/nutrition-for-growthcommitments.pdf.
Governance 87 The ICN2 has thus given impetus to efforts to reform and adapt existing institutional arrangements for coordination of collective action at global, regional, and national levels. It has been a timely reassertion of the universal relevance of nutrition issues, and has established an inclusive balance among the broad array of policy and technical emphases extant in the revival of nutrition activity across the globe. The ICN2, in short, was a summing up and ratification by the largest meeting of governments and non-state actors assembled against malnutrition in history. It marks the climax of the agendasetting phase of nutrition activism and heralds the next phase: a concerted collective action to improve nutrition across the world.
Does this mean that all the ‘heavy lifting’ has been completed to build political momentum for a major breakthrough on nutrition? From past experience the answer is no. This is not the first time that the world community, armed with new evidence of the developmental consequences of malnutrition and new policy approaches, has attempted to put nutrition at the forefront of the global development agenda. A real breakthrough is possible but, to realize this potential, further action is necessary to overcome the forces of political inertia that have doomed past global initiatives on malnutrition.
At least twice before, about two decades apart, the world community has rallied around a new or renewed vision of the relevance of nutrition for development. In the early 1970s, the then World Bank President Robert McNamara called for a reorientation in the Bank’s mission, shifting emphasis to poverty reduction. In his annual address to the Bank’s Board of Governors on 27 September 1971, McNamara described malnutrition as “a major barrier to human development” and said to the finance ministers of the world: “the central conclusion I wish to propose to you is that the international development community and the individual governments of the countries concerned must face up to the importance and implications of the nutrition problem” (cited in Herforth and Hoberg, 2014, p. 8). The new emphasis on improved nutrition as essential for development was supported by the scientific finding of the previous decade that malnutrition could lead to lifelong physical and cognitive impairment, and was given additional political impetus by the world food crisis created by the food price spike of 1972–73.
In the event, however, World Bank executives and development specialists were uneasy about the idea of investing in nutrition, and embedded the new nutrition emphasis in work on integrated rural development. The result was a flourishing programmatic emphasis on multisectoral planning in which nutrition targets and monitoring were seldom well-defined (Herforth 88 Ending Malnutrition and Hoberg, 2014, p. 11). By the end of the 1970s and in the early 1980s, both integrated rural development and its handmaiden, multisectoral planning for nutrition, were in crisis for having failed to produce significant results.
Both would soon be abandoned altogether in the face of the developing country debt and financial crises that led to the end of nearly all major forms of development planning and policy interventions; deep cuts in government budgets, staffs, and services; and a growing belief among donors and governments that all economic and social problems, including nutrition, would be solved by market-induced growth.
By the early 1990s, the high food and commodity prices of the early 1970s were long gone, and an era of abundant, low-cost world food supply was expected to lead to progressive alleviation of malnutrition and food insecurity. When this did not happen, efforts were once again renewed to draw world attention to the key developmental importance of addressing malnutrition, including both undernutrition and undernourishment. The 1992 International Conference on Nutrition (ICN) drew attention to the former, and the 1996 World Food Summit (WFS) to the latter.