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Despite the absence of a trigger event such as the 1972–73, or the 2008, 2010–11, and 2012 food-price spikes, these two global conferences of the 1990s did contribute to a broader awareness that the problems of undernutrition and undernourishment could not be solved by the availability of food alone. Special interventions, it was recognized, would be needed to address the economic, social, and environmental causes of malnutrition, and to ensure access to safe food.³ The ICN also helped to spur renewed commitment to nutrition as a key public objective. The 1992 World Declaration on Nutrition included a pledge to “eliminate hunger and reduce all forms of malnutrition”, and the accompanying Plan of Action for Nutrition called for a revival or strengthening of planning through a new generation of National Plans of Action for Nutrition (NPANs). The ICN delegates committed “to revise or prepare, before the end of 1994, our national plans of action, including attainable goals and measurable targets, based on the principles and the relevant strategies in the Plan of Action” (Nishida, 2013). Based on analyses of country situations, the NPANs reintroduced multisectoral thinking, and were to be developed with broad participation from governments, both national and local, NGOs, and the private sector. The initial results were promising.
⁴ The experience with NPANs is usefully summarized, with reference to several sources, in Mokoro (2015), Annex I: Issues and Lessons in Multi-Sector Planning.
Governance 89 Figure 6.1 The political economy of malnutrition Source: UNICEF (1990).
The 1990s’ effort took place in an era when planning and state interventions, more generally, were discouraged. Still, nutrition experts recognized and continued to emphasize that malnutrition has many causes, and that addressing it requires concerted actions to improve systems for production, including processing, of food, health, sanitation, and water. Figure 6.1 reproduces an iconic diagram of the linkages between basic, underlying, and immediate causes of malnutrition that was first presented in a Policy Review submitted to the UNICEF Executive Board in March 1990, and that remains, in various iterations, a touchstone of nutrition policy discussion today.⁵ Here, in the language of the time, the multiple causes of malnutrition are elegantly mapped with different horizontal layers that begin with deep, “basic” causes that include economic and social exclusion, discrimination ⁵ UNICEF. E/ICEF/1990/L.6, 9 March 1990. Diagram reprinted from Mokoro (2015), Annex I, p. 282.
90 Ending Malnutrition or vulnerability. These link to unequal control over resources and result in “underlying” causes – impacts on households, and health and sanitation systems – that in turn contribute to “immediate” causes of malnutrition in the form of mutually reinforcing factors of inadequate dietary intake and disease. All these causes culminate ultimately in malnutrition and premature death.
Yet there were few takers outside of the “nutrition community” for a comprehensive approach, and the period has become known retrospectively as the era of “nutrition isolation” – a time when the nutrition community found itself forced to go it alone. Nutrition work became more narrowly focused on addressing micronutrient deficiencies through nutrition-specific interventions, where, it was believed, linkages between actions and results could be more effectively demonstrated. In the end, the second cycle of global nutrition efforts ended with an echo of the first. Few NPANs were ever implemented, international coordination became increasingly fractured and competitive, interventions became more micro- and project-oriented, and donor support ever harder to find.
Seen in perspective, the current moment appears less unique, less “unprecedented”, with the risk of failure more real and more worrisome.
There is, to be sure, much in the present context that can be used to make a case that this time is different. The strength of the underlying science and accumulation of country- and context-specific evidence; the breadth and level of donor support; the availability of a new set of policy instruments classed as “social protection” to address some of the basic and underlying causes of malnutrition; the entry of a host of new social actors in the form of NGOs, CSOs, well-endowed philanthropies, and new social movements; and the emergence of new partnership initiatives such as the SUN movement: all herald a potential for effective action that is arguably far greater than at any time in the past. But the question is whether these factors alone can overcome the political impediments and inertia that overwhelmed past efforts to achieve an accelerated impact to reduce malnutrition. These impediments and inertia have less to do with the availability of knowledge and evidence, or benevolent intentions, and much more to do with nutrition governance – or, to put it another way, the political economy of nutrition action.
Confronting the political economy of nutrition Today, the main sources of friction and inertia remain the same ones that have repeatedly undermined nutrition efforts in the past. Nutrition advocates agree on at least five large and persistent causes of nutrition failure over the years. First, those who suffer most from malnutrition, almost by definition, are the marginal and disadvantaged; in nearly all countries, they Governance 91 are an uninfluential minority, even where malnutrition is widespread, and where those who suffer from malnutrition normally lack a voice and the capacity for effective political action. Thus, national political incentives to address malnutrition are inherently and persistently weak. In the battle for high-level policy attention, the forces of political inertia work constantly to suppress nutrition in “a low-priority cycle” (Natalicchio et al., 2009).
Secondly, effective solutions require actions by a wide variety of actors from different ministries, agencies, and organizations, including private sector entities and other non-state actors, with different disciplines and different narratives for both causes and solutions, and with different and often competing institutional priorities and interests.⁶ Bringing and holding “the nutrition community” together, accordingly, will be no mean feat.
Fragmentation and rivalry are in-built and cannot be wished away. Seasoned hands and conventional wisdom both caution against policy and programmatic initiatives that depend on high levels of cross-sectoral coordination and collaboration: the organizational barriers to such collaboration are both “durable and strong” and “the risk is too great that such coordination will not happen”.⁷ Thirdly, the risks and challenges of engaging the private sector, especially the large transnational food and drink corporations that dominate global processed-food production and distribution, present a special set of major challenges for an inclusive, ‘big tent’ approach to mobilizing nutrition action. The record of hostility to the public regulation of producers of unhealthy processed food and drinks, and their ongoing efforts to circumvent established norms and regulations in both developed and developing countries – e.g., the International Code of Marketing of Breastmilk Substitutes – make issues of conflict of interest a source of deep concern and division.⁸ These concerns are not without warrant. A literature review ⁶ James Levinson once identified at least five different groups in “the nutrition community”, each with its own interests and narratives. Levinson’s list was far from exhaustive, and failed to include public health nutritionists and agriculturalists. See “Institutionalization of Nutrition: International Nutrition in Search of an Institutional Home”, in Gillespie, McLachlan, and Shrimpton (2003). See also Reich and Balarajan (2012).
⁷ Benson (2011), cited in Reich and Balarajan (2012).
⁸ To address these concerns, and additional concerns that the SUN movement’s own approach to conflict of interest is much too permissive, the Geneva-based Global Social Observatory (GSO) was requested to conduct a Consultation Process on Conflict of Interest in the SUN movement. The Final Report of the consultation, published in April 2015, included the following observation: “There is a fundamental inconsistency between the SUN Principles of Engagement and the varied national approaches to implementing the International Code of Marketing of Breast-milk Substitutes. Consistent, authoritative guidance is neededistent, authoritative guidance is needed from ‘those with the mandates at the global level’.” The work of GSO itself raises questions about the attempt to regulate action through promulgation of principles. In a comment in the British Medical Journal, Judith Richter notes that the approach taken by GSO blurs key distinctions between diverging opinions among actors, differing fiduciary responsibilities 92 Ending Malnutrition in The Lancet found no evidence that self-regulation by industry or public– private partnerships enhances policy effectiveness or food quality and safety, but provided significant evidence of the ways that engagement with the private sector served to distort or undermine public health policies and programmes (Moodie et al., 2013). The authors identified several strategies used by large companies to deflect public attention from the negative health effects of highly processed foods, and to block or divert efforts at regulation: distortion and bias of research;⁹ cooptation of policymakers and health professionals; intense lobbying against public regulation including direct attacks on WHO and other international organizations; and public or social marketing campaigns designed to shape public opinion, for example, by reframing public health issues as issues of consumer or personal choice. The authors of the review concluded that any engagement with the private sector must include strong firewalls against private sector engagement in policy and regulatory issues – a recommendation that has been fiercely resisted both by industry and by many donor governments.
Advocacy for a broad partnership approach that includes a strong appeal to private sector inclusion must deal with these concerns, and demonstrate that any mechanisms established to foster private sector engagement in nutrition action will be backed by firewalls and active monitoring to avoid undermining key public policy objectives.
Fourthly, despite the critical importance of nutrition for development and mounting evidence of the high value-for-money of nutrition investments, nutrition has no natural institutional home and, therefore, no natural champion. Delivery of nutrition services is normally the responsibility of agencies or ministries such as agriculture, health, sanitation, social services, or water, which, in many cases, do not see nutrition as a primary responsibility or a primary interest of their constituencies.
The fifth factor is the matter of capacity, not just for the design of highquality, potentially high-impact nutrition policy, but especially for the more challenging and costly implementation and management of those policies, as well as the patient building of institutions through which policies are supported. Achieving the required global expansion of nutrition actions depends on many things going well, and on many people acquiring the requisite knowledge, skills, and resources. Building capacity is a slow process that can be accelerated only with substantial international cooperation. Too often, especially in countries with a heavy burden of malnutrition, sustained of market-led and public-interest actors, and conflicts of interest pertaining to individual or institutional vested interests. “This blurred terminology,” she adds, “hinders SUN participants’ understanding of the ultimate aim of conflict of interest policies: i.e., the protection of integrity, independence and public trust in persons and institutions serving public interests” (Richter, 2015).
⁹ See also Rowe et al. (2009).
Governance 93 nutrition action depends on sustained financing, which is only possible through sustained external support.
All five factors work continuously, like gravity, to weigh down nutrition action. To overcome them, strong levers are needed that go beyond focus and commitment. In the remainder of this chapter, we address three groups of questions concerning the political economy of nutrition governance, and particularly focus on the role of the multilateral system as a promoter, sustainer, and enabler of country-level commitment and action to provide answers to them.
Key issues in global governance for nutrition A first set of questions asks: how can the political momentum gained in recent years be sustained against the persistently powerful economic, social, and environmental forces that work to disperse and undo nutrition efforts over time? Achieving nutrition impacts is a work of years, if not decades, with measures that must be monitored over half-decades and longer. Policy must be sustained beyond a single champion in the presidency or a leading ministry, and must survive regular changes in government. Against the prevailing forces of entropy, the case for focused, sustained action and investment in nutrition must be made repeatedly, and government and donor propensities to change emphases must be resisted or overcome. The need for complementary action across sectors does not by itself automatically give rise to coordinated planning; rather it presents a recurring challenge to governments and their constituencies.
Secondly, if a global strategy and effort are required, how can the world community best organize to sustain a significant effort over at least a decade and beyond? In particular, what can and must be done at the global and regional levels to enable effective action at the country level?
What institutional arrangements and structures are required to support this activity? And how can these activities and structures adapt or respond to new information and events?