Hidden Hunger: Strategies to Improve Nutrition Quality

H. K. Biesalski, R. Birner

• Éditeur: S. Karger
• Année: 2018
• ISBN:
  9783318062533
• Sujet: Medicine
• Sous-sujet: Pediatric Medicine

Hidden hunger has long been an overlooked problem. Vitamin and mineral deficiencies have to be remedied and the availability of calories needs to be increased. As a matter of fact, the number of people who do not have access to a balanced diet has multiplied in rich and poor countries, with lasting consequences for health and well-being. Hidden hunger not only affects childhood growth and cognitive development, but also reduces productivity and well-being later in life, thus keeping the affected population trapped in a circle of poverty and malnutrition. This book illustrates the global fight against hunger by national governments and international organizations. Presented at the Third Hidden Hunger Conference held at the University of Hohenheim in Stuttgart, Germany, it presents a range of strategies being implemented in various regions of the world to improve nutrition quality and combat this international crisis.

Biesalski HK, Birner R (eds): Hidden Hunger: Strategies to Improve Nutrition Quality.
World Rev Nutr Diet. Basel, Karger, 2018, vol 118, pp 17–44 (DOI: 10.1159/000484341)

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The Devil is in the Detail: Understanding the Governance Challenges of Implementing Nutrition-Specific Programs on a Large Scale

Regina Birner^a · Madushree Sekher^b

^aHans-Ruthenberg-Institute, University of Hohenheim, Stuttgart, Germany; ^bCentre for Studies in Social Exclusion and Inclusive Policies, Tata Institute of Social Studies (TISS), Mumbai, India

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Abstract

Nutrition interventions can play a key role in combatting hidden hunger in developing countries. However, when malnutrition is affecting a large share of the population, such programs need to be implemented on a large scale, which involves major governance challenges, such as absenteeism of staff, elite capture, and leakage of funds or food. This paper discusses the underlying reasons of these governance challenges from a theoretical perspective and proposes a participatory research tool called “Process Net-Map” to analyze these challenges empirically. A case study of India’s Integrated Child Development Services Scheme was conducted in Bihar to provide a proof-of-concept of Process Net-Map as a qualitative research tool that is suitable to identify governance challenges in the implementation of large-scale nutrition programs. Applying the Process Net-Map tool made it clear that the “devil is in the detail” when it comes to the implementation of large-scale nutrition interventions. The case study also shows that an understanding of the details of the implementation mechanisms of nutrition programs is essential for designing governance reform options that have good prospects to increase the effectiveness of large-scale nutrition programs in developing countries.

© 2018 S. Karger AG, Basel

1 Introduction

Hunger and malnutrition remain among the most important challenges facing humanity. As the latest report on the “State of Food Insecurity in the World” shows, world hunger appears to be on the rise again after a prolonged period of decline. The estimated number of people with chronic calorie deficiency increased from 777 million in 2015 to 815 million in 2016 [[1], p ii]. An even more widespread problem is micronutrient deficiency, also known as hidden hunger, which affects more than 2 billion people worldwide [[2], p 21]. These figures underline that it is still a major challenge to reach the second sustainable development goal (SDG 2) on the post-2015 agenda, which is to “end hunger, achieve food security and improved nutrition, and promote sustainable agriculture.” One of the sub-goals of SDG 2 is to end all forms of malnutrition by 2030.¹

Nutrition programs have a high potential to address this problem, but in order to reach SDG 2, they need to be implemented on a large scale. One can distinguish between nutrition-specific and nutrition-sensitive programs [3]. Nutrition-specific programs address “the immediate determinants of fetal and child nutrition and development – adequate food and nutrient intake, feeding, caregiving and parenting practices, and low burden of infectious diseases” [3]. A series of papers on maternal and child nutrition published in 2013 in “The Lancet” found that the upscaling of nutrition-specific interventions to a coverage of 90% could reduce the prevalence of severe wasting by more than 60% and the prevalence of stunting by more than 20% [[3], p 8]. The series also highlighted the need to scale up nutrition-sensitive interventions, such as social safety nets and women empowerment programs, which address the underlying determinants of undernutrition and, thus, enhance the effectiveness of nutrition-specific interventions [[4], p 547].

The evidence for the effectiveness of nutrition interventions is typically derived from projects that are implemented on a limited scale by dedicated project staff with the support of generous donor funds. A major challenge is the implementation of such interventions on a large scale by national and local governments, who have to rely on their public administration system. The conditions for such large-scale implementation of nutrition-specific programs are typically quite different from those of donor-funded development projects. They are affected by the well-known problems of public sector management in developing countries, which include a chronic scarcity of operational resources, relatively low payment levels and incentive for staff, and deficient management systems for both human and financial resources. These conditions result in frequent absenteeism of front-level service providers, “leakage” of funds, political interference, and elite capture (e.g., [5–8]).

Against this background, the question arises: how can national governments in developing countries overcome the governance challenges of implementing nutrition programs at large scale? This question has received limited attention in the literature, so far. There is a growing number of studies on the governance problems of education and health services (e.g., [9, 10]). There is also a growing literature on large-scale interventions that can be characterized as nutrition-sensitive, such as direct cash transfers and other types of social safety nets [11]. While this literature is also relevant for large-scale nutrition-specific programs, there is a need to focus on the challenges that are particularly pertinent for the implementation of nutrition-specific interventions. The field of “implementation science” in the nutrition literature addresses this question. Our paper aims to make 2 contributions to this emerging field. One is theoretical: we use concepts of the New Institutional Economics (NIE) to identify the governance challenges that can be expected to occur in large-scale nutrition-specific programs. The second contribution is empirical: we present a qualitative research tool called “Process Net-Map” to identify the governance challenges that can be identified in practice. To provide a proof-of-concept for this research tool, we conducted a case study of the implementation of India’s Integrated Child Development Services (ICDS) Scheme in Bihar. The ICDS is a prime example of a large-scale nutrition-specific program, which is implemented by the public administration of a developing country. Bihar is particularly suited for the case study, as it is one of the states of India where child malnutrition rates are particularly high and governance conditions are particularly problematic (see [12], and the literature quoted here).

This paper is structured as follows. The next section presents a theoretical analysis of the governance problems that can be expected in large-scale nutrition-specific programs. Insights from the literature are used to illustrate these challenges. Section 3 describes the case study context and Section 4 introduces the Process Net-Map tool. The results of the case study are presented in Section 5 and discussed in Section 6. Section 7 presents some conclusions.

2 Theoretical Considerations

This section first defines the concept of a “governance challenges” and then identifies different types of governance challenges and their underlying reasons. The theoretical concepts used here mostly belong to the “NIE,” a branch of economics that deals with the institutional and governance dimensions of economic systems [13].

2.1 The Concept of a “Governance Challenge”

The term governance, which comes from the Latin word gubernare (i.e., “to steer”), has different meanings in the academic literature. It has been used by political scientists to analyze the management of common pool resources [14], by institutional economists to study vertical integration in the industrial sector [15], and by business administration and legal scholars to assess organizations that have boards of governors [16]. In the 1990s, the concept appeared on the international development agenda. “Good governance” became increasingly recognized as a precondition for the effective implementation of development projects and programs [cf. 17].

Drawing on the NIE literature, we define governance as the formal and informal institutions that influence human behavior.² In line with the literature on good governance, governance challenges are then defined as characteristics of formal and informal institutions that that jeopardize positive development outcomes. To classify such governance challenges and identify their underlying reasons, we distinguish 3 different types of governance: the market, the state and the “third sector,” which includes organizations that are referred to as non-profit organizations, non-governmental organizations (NGOs), civil society organizations and community-based organizations (CBOs).³ Each type of governance involves its own challenges. The economic literature refers to challenges that affect the functioning of markets as “market failure.” Using the same terminology, governance challenges in the other 2 sectors can be labelled “state failure” and “community failure” [cf. 18].

For the analysis of governance challenges, it is useful to consider that nutrition-specific programs have often 2 components. One is an advisory or educational component: advising or educating mothers and other caregivers on maternal and child nutrition, the need for breast feeding and the role hygienic conditions. The second component typically involves the distribution of food items, such as dietary supplements for pregnant and lactating women and children. In principle, market, state, and third sector institutions can be involved in both components.

2.2 Governance Challenges Faced by the Private Sector

As will be discussed below, major governance challenges in large-scale nutrition programs arise due to the inefficiencies of large bureaucracies. Therefore, the question arises as to why market institutions, which may be more effective, do not play a larger role in addressing the problems of maternal and child malnutrition. It is essential to recognize the different types of market failures that make large-scale government involvement necessary. For the case of agricultural advisory services, these market failures have been analyzed [18] and similar arguments apply to nutritional advisory services.

Nutrition Advice as a Merit Good: In economic terms, advice on maternal and child nutrition has the character of a “merit good,” that is, a good that people undervalue because they are not aware of its benefits, especially not its long-term benefits. Therefore, there is no demand for such a good and without demand, private service providers do not emerge. If people are poor, they may not demand such services even if they were aware of the benefits, because they cannot afford them. Moreover, poor people typically have a high time discount rate, which means that they are not willing to pay for services today if the benefits arise only in the long run. Some of the benefits of improved fetal and child nutrition indeed arise in the long run (i.e., during adulthood or even in the next generation). Considering the nature of nutritional advisory services as a merit good, governments have to at least finance the provision of such services to address this market failure. This does not, however, imply that government employees need to provide nutrition advisory services because the government can contract NGOs or private service providers to deliver such advisory services. The challenges of such arrangements are further discussed in Section 2.4.1 below.

Information Asymmetry: The food items to be delivered by nutrition-specific programs, such as dietary supplements, can partly be considered as merit goods, as well. Hence, they are affected by the same problem of market failure as advisory services. Yet, one can observe that there is some willingness to pay for commercial baby foods, including infant formula, even among poor households. Therefore, there are private sector providers of such food items that operate not only in only in industrialized, but also in developing countries – even in remote rural areas where poverty levels are high. An important market failure that arises with regard to commercial baby food is due to information asymmetry. The customers of infant formula are often unaware that breast feeding is better for nutritional outcomes, especially under problematic hygienic conditions. Moreover, it is difficult for customers to verify the health claims that companies often use to market commercial baby foods. This market failure can be addressed by government regulation, and to some extent also by information campaigns and by ...