In 1994, in one state in India, a window of opportunity was seized by a team of three policy entrepreneurs well-versed in the UNICEF nutrition framework. Reinforced by a small network of strategic allies, and backed by the Secretary for Women and Children, their initiative led to a politically and nutritionally significant change in program policy. The window was created during the planning for the redesign of the national health and nutrition program, a program that has used supplementary feeding for decades and was, in the eyes of the secretary, "ready for a change." With the UNICEF framework in mind, the core team highlighted the ages of 6 to 18 months as crucial to the incidence of growth failure, using recently collected Demographic and Health Survey (DHS) data and promoting the childcare narrative contrary to the then-dominant food narrative. This evidence and narrative exerted significant influence in a series of consensus-building workshops in which participants from 10 states highlighted care and capacity building. In the process, two energetic representatives from indigenous NGOs emerged as advocates to carry and promote the message to the government of one state that supplementary feeding should not play a prominent role in Integrated Child Development Services (ICDS) activities supported by the World Bank. They were able to persuade government to exclude supplementary feeding in one part of that state, a move made possible because political patronage related to food aid had not yet been established in that area. This decision was considered politically sensitive and was approved for only one pilot area. The long-term and wider impact of the decision is not yet clear.
work is associated with a high degree of opportunism and reinterpretation to fit organizational agendas. In Brazil, this took the form of emphasizing the potential link between food insecurity and child malnutrition in advocacy efforts by civil society groups. There is little evidence, however, that the strength of this relationship was explored or confirmed either nationally or locally in Brazil. In India, the framework was used to interpret the DHS data highlighting malnutrition in the 6- to 18-month age group as being due to inadequate caring practices, strongly reinforcing advocacy against the use of supplementary feeding in ICDS. In UNICEF-New York headquarters, the framework was used to justify the micronutrient focus because food, health, care, and capacity building all were involved in micronutrient problems and solutions, in addition to those pertaining to protein energy malnutrition (PEM). In general, all three cases highlight that the UNICEF framework and strategy were used selectively. Stakeholders advance their own preferred notions of critical problems and appropriate actions, a feature of the policy process that is well documented in the literature. While selectivity and creative interpretations may be necessary and unavoidable, there is a high risk of converting the framework simply into an advocacy tool. It can be misused to justify self-serving actions in the absence of legitimate local assessment and analysis. This risk highlights the importance of distinguishing between the basic and the full framework in analyzing how it is used.
Policy entrepreneurs and networks. The three cases clearly reveal the importance of key individuals and strategic alliances within a network of actors promoting policy change. This network need not be large in numbers of individuals. In all three cases, a few committed individuals developed change strategies and seized windows of opportunity for pursuing their shared goals. Strategic alliances among a small number of well-placed or effective individuals occurred at early stages in several cases. At the same time, UNICEF headquarters was developing a strategy for mass promotion of the framework because of its international perspective, pointing to potentially high payoffs for efforts to train and mentor policy entrepreneurs among nutritionists. As noted, some entrepreneurs and networks will use the framework selectively. Because they are often guided by institutional self-interest, the risk is that they will advocate favored problems and pet solutions whether or not they are associated or consistent with sound assessment and analysis.
Influence can lead to authority. Nutrition promoters are typically disadvantaged because they have little authority, institutional backing, and resources for advancing and implementing nutritionally favorable actions. However, as these three case studies and many others in the policy literature reveal, this does not mean that they are without power. In all three cases, the nutrition promoters relied on their ability to influence others, and that influence eventually led to authoritative changes. For UNICEF, this change included the adoption of the framework by headquarters and many field offices, as well as by other stakeholder categories noted in table 4.1. In Brazil, this took the form of a national food and nutrition policy based on the framework. In one state in India, it led to government authorities deciding to focus on care—particularly on infant feeding practices and activities to empower women so that they have time for child-care, instead of pilot supplementary feeding in a few areas. When taken together with the emergence of the human rights perspective, these cases reinforce the notion that efforts to train and support policy entrepreneurs may have many benefits.
Policy process variations on some basic themes. The cases examined here differed significandy in institutional setting, type of policy decisions, identity of the change agents and other stakeholders, countervailing forces, and so on. Yet some overarching themes are worth highlighting: committed and capable policy entrepreneurs, strategic alliances and networks, windows of opportunity, creativity in using the framework, and the use of information and influence as a strategy. In addition, some larger contextual factors may have facilitated these successes—for example, confidence that the framework represents an accurate summary of current scientific knowledge and experience, that a consensus exists or is forming concerning its validity, and that the framework can be communicated easily.
Further lessons could probably be derived through encouragement of researchers and practitioners to document their experiences in promoting policy change in general (not solely in relation to the framework) and through forums in which these experiences could be compared and discussed. A tradition of this sort does not exist in the international nutrition epistemic community. It could, however, emerge as a vital feature of the next generation of work in public nutrition.
Heolillhi and Economic Consequences off Malnutrition0
Malnutrition increases the risk of illness and death; it impairs physical and mental development; and therefore it reduces the productive capacity of individuals. Because of its effect on productivity, a high rate of malnutrition reduces the potential of national economies to grow. Simply stated, this is the understanding that drives development agencies to invest in programs to combat malnutrition. Beyond this, malnutrition and ill health are synergistic, so that both malnutrition and illness can be seen as components of any measure of human well-being. Agencies whose primary concern is human welfare therefore invest in improved nutrition for its own sake and for its effects on other direct measures of welfare: healthy development and longer, healthier life.
The basic understanding of malnutrition as a force affecting survival, health, and productive capacity has persisted for 50 years, though the emphasis has shifted as research has contributed to a greater understanding of the precise ways in which malnutrition—
* Beatrice Rogers is the author of this section.
both PEM and specific micronutrient deficiencies—affects individuals, their households, and the larger economy. Specifically, as research has elucidated the effects of specific micronutrients, there has been a shift in focus from a concern with general lack of food (PEM due to poverty) to efforts to address individual micronutrient deficiencies, sometimes through interventions such as micronutrient supplements or food fortification that do not address household food supply or individual food consumption. At its most general, though, the basic underlying narrative linking nutrition with health and productivity has not been fundamentally changed; rather, it has been strengthened as evidence has mounted concerning the connections between nutritional status and human capacities.
Of course, human capacity is also a determinant of nutritional status. An individual's productive capacity determines, to some extent, his or her command over resources (that is, over income); and to a large extent, an individual's income determines the household's ability to obtain adequate food, five in a healthy environment, and even to obtain the education that may guide the choice of health-promoting behaviors.
The causal connections between nutrition and health and productivity are clear and relatively direct. Children who are born well nourished grow bigger and stronger, and as adults they have a higher capacity for work output. Their cognitive capacity—ability to learn, remember, and perform complex tasks—is also greater. Well-nourished children are more resistant to disease; when they are infected, severity and duration of illness are less, and the children are less likely to die. Children who are healthy and energetic are able to learn better, both in school and through active play; better learning capacity and less school absence due to illness affect their likelihood of completing formal education. Adults whose food intake is adequate are generally more productive in work than those whose intake is insufficient, though these relationships depend to some degree on the nature of the task being performed: some kinds of work permit compensation for lower strength and endurance and other consequences of malnutrition; others do not. Moreover, indi-
viduals may compensate for low work capacity by adjusting their leisure time activities in order to protect their work output.
The connection between productive capacity and real income is less direct; it is mediated by the relationship between individuals and the larger economy. Specifically, productive capacity translates into income to the extent that an individual has access to employment, to productive resources (such as land, livestock, tools and equipment), and to other elements of human capital such as education and training. This means that the effect of improved nutrition of individuals on their households and on the larger economy depends on the social and economic infrastructure: the labor market and other aspects of the mesoeconomy.
The basic understanding that nutrition is essential to both health and productivity has not changed, but experience has contributed to a better understanding of what kinds of interventions—nutrition programs, health programs, and social and economic policies—are effective in improving the nutritional status of populations, and what are realistic expectations for their impact; and this has indeed changed policy with regard to nutrition. Thinking has changed among development practitioners and public nutrition professionals along two major lines. First, there has been an evolution from the belief that economic growth per se would resolve problems of malnutrition through the reduction of poverty rates to recognition that growth strategies must be specifically designed to address poverty. Second, there has been recognition that specific nutrition interventions may be needed in the short and even the medium term, to complement the growth in real income in improving nutritional outcomes. An important element in this evolution has been research that demonstrated the importance of intrahousehold dynamics in determining individuals' access to food and other household resources. Income at the household level may not translate into nutritional improvements if it is not used to improve household food availability and the consumption of vulnerable members—a function in part of who in the household makes decisions and of which members are given preference in consumption. Second, there has been a recognition that malnutrition cannot be addressed by the simple provision of supplementary food. Malnutrition is the result of a complex of factors (as reflected in the UNICEF framework of food, health, and care), and food, to be effective in reducing malnutrition rates, must be provided, if at all, in the context of interventions that address the other aspects of the nutrition problem.
Adequate incomes and effective health-promoting practices are both essential to ensuring good nutritional status of poor populations. These two concerns are united in the relatively recent concept of household food security, which includes three components: first, availability of food (in the market or through home production), access to food (through adequate income or productive resources), and use of food, which includes storage and preparation of food to maintain nutrient quality; second, allocation of food among individuals within households; and third, the ability of individuals to make biological use of the food, a reflection of their illness status and activity level.
In the 1960s, protein shortage was considered the key nutrition problem. Research at the time and into the 1970s focused on the development of protein concentrates and isolates from novel sources and on means of increasing the protein content of conventional foods—technological solutions to the nutrition problem. The United Nations formed the Protein Advisory Group to advise the secretary general on nutrition interventions. However, subsequent analysis of household food consumption patterns showed that if diets were adequate in quantity, then protein too would be adequate, with the possible exception of cassava-based diets. This change in understanding implied that the solutions to malnutrition lay not in the realm of food technology but in the economic arena of access to sufficient food by the poor, and thus focused attention on the importance of poverty alleviation. In the early 1980s, Sommer's research (1984) showing the role of vitamin A supplementation in reducing mortality was one factor in catalyzing a shift to focus again on specific nutrients rather than overall food adequacy, raising the possibility of technological solutions.
In 1971, a conference was held at the Massachusetts Institute of Technology on nutrition and development. This conference provided an opportunity for senior nutrition and development professionals to interact with academics studying the relationship of nutrition to economic development. This focus on nutrition as an input to development was advanced further with the 1973 publication of The Nutrition Factor by Alan Berg, a publication whose preparation was used strategically to advance the idea that nutrition was an essential input into economic growth.
The World Food Conference in 1974, held at FAO in Rome, focused attention on what was perceived as the world's food crisis. In the early 1970s, bad weather in many food-exporting regions of the world and policy changes among some key importing nations resulted in food shortages and high prices, making many nations' food policies unsustainably expensive. Research in the wake of the conference demonstrated at the global level that distribution and access to food rather than aggregate food supply was at the root of nations' food problems.
In the 1970s and 1980s, Amartya Sen's work on famine and entitlements (for example, Dreze and Sen 1989) received considerable attention in the development community. Sen focused on the importance of entitlements in ensuring food adequacy. He made a persuasive case that income distribution and poverty alleviation must be explicitly considered in economic policy if adequate nutrition is to be ensured and contributed to the shift in focus from economic growth per se to growth with equity. Within the Bank, Reut-linger and Selowsky (1976) published an influential study showing that relying on economic growth alone to ensure dietary adequacy among the poor would take an unreasonable amount of time. With a focus on poverty alleviation came an explicit commitment within the Bank to address basic human needs, including health.
Another development in the 1970s and 1980s was the significant advance in the ability to collect household-level data through sur veys. More powerful computers and better analytic techniques made possible the widespread use of household surveys to analyze the determinants of nutrition problems and the outcomes of nutrition-related policies and programs. Advances in computing technology and in data collection and analytic techniques have continued to the present, leading to more sophisticated understanding of nutrition problems and their solutions. Major survey efforts such as the DHSs and the living standards measurement surveys (LSMS) have provided researchers with the opportunity to track health and economic indicators at the household level. With advances in survey technology, it has become possible to monitor more closely the nutritional impacts of programs and policies. Such techniques have been particularly useful in analyzing household behavior and intrahousehold dynamics.
The importance of intrahousehold dynamics as a determinant of nutritional outcomes was given prominence in a 1975 Conference on Women in Development sponsored by USAID. The conference reflected and promoted a growing interest in intrahousehold dynamics, interest that has resulted in a continued stream of research through the 1980s and 1990s, up to the present, elucidating mechanisms by which specific interventions may result in improved nutrition. Much of this research was funded by or performed within the World Bank, and conferences on the topic held in 1983 and 1990 included both academics and practitioners from the Bank and other development agencies. At present, the body of research is sufficiendy large and consistent that intrahousehold dynamics are indeed taken into account in designing nutrition and other development interventions.
In the early 1980s, several publications advance^! the hypothesis that nutritional stunting was not a health or a productivity problem, but rather a healthy adaptation to a food-poor environment—the small-but-healthy hypothesis (Seckler 1982; Sukhatme and Margen 1982). While these studies were widely cited, they did not significantly influence policy; rather, they gave rise to a body of research that countered the doubts they raised and confirmed the links between nutrition and health and productivity.
The 1980s were the era of structural adjustment. Many developing economies were thrown into crisis because of excessive debt and unsustainable economic policies; the World Bank promoted structural adjustment through the provision of loans made conditional on fiscal austerity and measures to reduce the public provision of consumption goods. Such measures were widely seen as damaging to the welfare of the poor. The book Adjustment with a Human Face (1987), by Jolly, Cornia, and Stewart of UNICEF, forcefully criticized structural adjustment for its damaging effects on welfare. Although the analysis in the book is subject to question, it created a powerful narrative that caused tremendous pressure on the World Bank to rethink its policies and incorporate a specific concern for the social dimensions of adjustment. Subsequent Bank lending for structural adjustment explicitly incorporated safety-net programs for the poor.
Events of the 1990s included the 1992 ICN and the awarding of two Nobel Prizes to economists whose work has focused on nutrition. In 1994, the prize was awarded to Robert Fogel, an economist who has suggested that malnutrition was a binding constraint on economic development in Europe dating back to the 16th century. The 1999 prize was awarded to Amartya Sen, an economist whose work has emphasized poverty alleviation and measured success in terms of positive nutritional outcomes. An influential article by Pelletier (1994) synthesized data to demonstrate larger than expected impacts of malnutrition on mortality. Within the Bank, the publication of the Comprehensive Development Framework in 1999 represents a commitment on the part of the Bank to human development, a concept that incorporates health, education, and other interventions that improve human capabilities. Despite the importance of nutrition for both health and development, nutrition itself is not explicitly mentioned in the Comprehensive Development Framework. Yet the framework could provide an opportunity for advocates to make the case for investment in nutritional improvement.
Analysis: How Does Policy Change?
The basic understanding of nutrition as a critical input for human health and development, and the importance of these for productivity, has not fundamentally changed over time. The two parts of the argument, one focusing on health and the other on economic productivity, are not competing but rather complementary narratives. As a result, advocates within development agencies may choose one or the other, as best fits the organization's philosophy UNICEF, with a mandate to address the health and nutrition of children, naturally emphasizes the health effects of nutrition, while the World Bank, with a mandate to promote economic growth and reduce poverty, emphasizes the links to productivity and income.
If the general understanding of the field has not changed, then how has policy been moved forward? Some of the events briefly noted above provide examples of the differing ways in which policy can be changed.
A clear example of the power of synthesizing available information is Berg's 1973 book, The Nutrition Factor. Berg argued that nutrition was a binding constraint on economic development, because malnutrition impairs productivity. This was not simply a presentation of scientific data; policymakers were invited to participate in preparation of individual chapters, and they were invited to seminars presenting the results. As a nutrition adviser, the author was well placed to have an influence within the Bank, and a newly appointed president of the Bank was receptive to new ideas. Furthermore, the Bank had begun to invest in other aspects of human resource development at the time, so the actions promoted by the book were consistent with the direction that Bank investment was taking. By demonstrating that nutrition programs could be viewed as investment rather than simply consumption, the book provided justification for a politically attractive course of action. Furthermore, the book suggested specific actions that could be implemented, so that once policymakers were persuaded, the next steps were clear. Many within the Bank credit this book (and the strategic process of its development) with causing the increase in explicit nutrition investments beginning in 1975-76. It is a tribute to the soundness of this reasoning that development practitioners as well as academics have focused little attention in the past decades on the question of nutrition as an investment in productivity; within the Bank, this relationship is accepted as a given.
The success of this process in influencing Bank policy neatly fits the framework of policy change suggested by Sutton (1999). While Berg's book presented no new, groundbreaking data, it did provide a scientific analysis of a development problem. Networking was effectively used by an advocate with close links to the dominant community. The person most in authority was persuaded to be interested in the issue, and a focus on nutrition converged with other policy directions of the Bank at the time. The book presented a clear, simple, understandable narrative of cause and effect and spelled out specific actions that would support the goal. Moreover, the organization had the flexibility, the staff, and the resources to implement the actions that were recommended.
A second example of policy change is the implementation of interventions focused on the alleviation of micronutrient deficiency starting in the 1980s. Sommer and his colleagues' work on the role of vitamin A in immune function in the 1980s (Sommer and others 1986; Sommer, Katz, and Tarwotjo 1984) showed that provision of vitamin A had benefits beyond prevention of known deficiency diseases; it also affected mortality from other causes. This research altered the cost-benefit calculation for vitamin A intervention. This is clearly a case of new data advancing the policy agenda. The work also focused new attention on existing data concerning other micronutrients. In addition, Sommer's work may have been influential because supplementation and fortification of the food supply was a course of action easier to implement politically than actions to address PEM, with its links to poverty and entitlement. There was disillusionment with the prospects for multisectoral nutrition planning (Field 1987); a focus on micronutrients suggested actions that could be undertaken within the nutrition sector, without attempts at multisectoral coordination. Furthermore, this information came at a time when development agencies were strongly focused on measurable results, and provision of micronutri-ents was seen as an intervention that could demonstrate results more quickly than interventions addressing poverty-based food shortage. Many public nutrition professionals point to Sommer's work as a key factor in the shift in focus of development agencies away from PEM and toward specific micronutrient deficiencies.
Pelletier's analysis (1994) of available data on malnutrition and mortality similarly altered the cost-benefit equation for investing in nutritional improvement by showing that the effect of even mild and moderate PEM on mortality was much greater than previously known; this work has received much attention within development agencies and provides an important advocacy tool for those wishing to promote nutrition within their own agencies. Clear policy change has not yet resulted, perhaps because other key factors—political attractiveness, clear actions to be taken, convergence with other agency goals and activities, well-placed advocates, receptive senior policymakers—have not been in place. Nevertheless, the potential clearly exists.
A more gradual and less dramatic policy change has been the incorporation of a concern for intrahousehold dynamics into the design of nutrition interventions. Rather than a single, groundbreaking piece of research, there has been a gradual buildup of data supporting the importance of analyzing nutrition (and other) projects in terms of the roles of household members. Attention focuses on time use, decisionmaking power, and access to consumption goods and productive resources. Good networking among researchers and practitioners—and selected key events that synthesized information—have created awareness among those in a position to implement the actions suggested by the research, an example of research gradually changing the dominant discourse.
As seems clear from the above examples, policy change has taken place as the result of a convergence of factors. A simple narrative alone is not enough. The following are some of the key factors:
• A relatively simple and plausible understanding of a cause-and-
effect relationship (the "narrative");
° A reasonably strong and consistent body of supporting evidence;
° Individuals in key positions motivated to advocate for a policy change;
° Clear recommendations for specific actions;
° Actions implied by the narrative that are politically attractive, or at least acceptable;
° Convergence with other institutional goals;
° Receptivity on the part of decisionmakers; and
0 The promise of measurable impact.
New information can be important in changing policy (as was the case with Sommer's research showing the effect of vitamin A supplementation on mortality), but documents synthesizing existing information can be equally effective if used strategically (as in the case of Berg's The Nutrition Factor).
As new techniques of data collection and data analysis become available, it becomes easier to collect information on the nature and causes of the nutrition problem and the effectiveness of interventions. For example, improved household survey methods, increased ability to analyze large survey data sets, and improved analytic techniques have made it possible to look at nutrition at the household and individual levels rather than relying on nationally aggregated indicators. Such data can be important in advocating for policy change.
Challenges to an existing narrative should not be viewed as a threat. Such challenges can advance knowledge by provoking new research; new information can clarify and strengthen the narrative, if it is sound.
The strategic use of information involves advocacy; information alone is not enough. Advocacy needs to be planned with specific attention to the appropriate target audience. For example, arguments based on economic consequences of malnutrition are more persuasive in the World Bank, with its mandate to promote economic growth. In UNICEF, with its mandate to improve health and nutrition for their own sakes, evidence of nutrition-health links would be more persuasive.
For advocacy, it is important to have a group of influential individuals both inside the organization (for influence) and in the academic and research communities (to add credibility), all providing a common message. For advocacy to be effective, there needs to be an advocate in an influential position within the agency, with access to key decisionmakers. The importance of personality must also be recognized: effective advocates should be policy entrepreneurs with a good sense of when and how to advance a point of view. Advocacy is also more effective if the advocate has a clear set of actions to recommend.
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