Political economy challenges in nutrition

Political economy themes in nutrition policy

In the field of nutrition, political economy work has been slow to develop. One early paper by Field and Levinson [1] emphasized the “dynamics of political commitment” for nutrition and development, noting that “major nutrition allocation decisions will be political decisions” ([1], 61). Many of the themes introduced by Field and Levinson in 1975 appeared in more detail—nearly two decades later—in the book by Pinstrup-Andersen [2] on the political economy of nutrition. And ten years after that, a publication on the problems of “combating malnutrition,” produced jointly by the World Bank and the United Nations Children’s Fund, examined a number of themes of political economy again [3]. More recently, however, several studies have made significant progress in applying a political economy approach to better understand the political economy themes described above affecting nutrition policy [4–9].

Our purpose here is not to provide a detailed review of the literature on the political economy of food and nutrition security, which is provided elsewhere [7, 10], but rather to reflect on the key themes that emanate from this body of work. From our review of the literature [7], we identify six major political economy themes (Fig. 1)—these themes are highly interrelated and extend from global to sub-national level—and together create a complex web of challenges to achieving nutrition security.

Six political economy themes in nutrition policy

First, nutrition does not have a natural institutional home; it is often “homeless” in government [2, 11]. In many cases, it does not fit cleanly into a single government agency. From country experiences, this “home” can be within supra-sectoral bodies (such as the Prime Minister’s Office or Vice President’s Office); in line ministries (such as the ministry of health or ministry of agriculture); in cross-cutting ministries or bodies (such as the ministry of development or ministry of planning); or in independent bodies. The location and characteristics of the institutional home is typically shaped by country-specific context, ideas, stakeholders, and importantly, history and politics [12]. As a result, there is often a lack of strong political leadership for nutrition, lack of strong ownership and accountability, and a lack of effective advocacy for nutrition. The fuzzy roles and responsibilities about where nutrition belongs in the government bureaucracy create obstacles to policy innovation and adoption, and to policy implementation.

At the global level as well, nutrition is claimed by several international agencies, including the Food and Agriculture Organization, International Fund for Agricultural Development, United Nations Children’s Fund, the World Food Programme and the World Health Organization, and other members of the United Nations System Standing Committee on Nutrition. Levine and Kuczynski’s [13] institutional analysis of global agencies for nutrition pointed to the lack of an effective policy community among the agencies concerned with nutrition, due to “incoherence, lack of institutional leaders, and persistent underfunding”. However, the subsequent rise of the Scaling Up Nutrition (SUN) movement and REACH (Renewed Efforts Against Child Hunger and undernutrition) initiative have sought to better align the work of these agencies in nutrition. Recent independent evaluations of these initiatives nevertheless reveal mixed reviews on improvements in UN coherence, highlighting the longstanding issues of competition, overlap and inefficiencies [14, 15]. On a more positive note, the first United Nations Global Nutrition Agenda endorsed by the agencies with a core mandate in nutrition was launched in 2015; this provides a shared vision and framework for action for the UN system [16]. Also, the findings and recommendations from the recent evaluations are shaping the new SUN strategy and UN Network for SUN strategy, to be launched in 2016.

Second, the nutrition system and nutrition community are fragmented, from global level to community level. As the final paper of the 2008 Lancet Series on Maternal and Child Undernutrition bluntly stated in its key messages, “The international nutrition system—made up of international and donor organisations, academia, civil society, and the private sector—is fragmented and dysfunctional” (Morris et al. [17], 608). Two decades earlier, Pinstrup-Anderson recognized this fragmentation within the “nutrition community,” with multiple sub-groups competing to get their view of nutrition accepted by others [2]. Levinson identified five sub-groups in the nutrition community: 1) Laboratory or Clinic-Based Nutrition Scientists, 2) Activist Nutritionists, 3) Development Economists and Planners, 4) Social Science Activists, and 5) Nutrition Practitioners [11]. This has since expanded to include public health nutritionists, agricultural specialists and other sub-groups hailing from diverse disciplinary backgrounds. These sub-groups cover different government agencies, many private sector organizations, including for-profit companies, as well as advocacy groups and households and communities.

Building coalitions across these different and disjointed groups, with their own perspectives and interests, is a time-consuming and challenging process for nutrition policy reform. The fragmentation perpetuates unclear lines of ownership and the lack of accountability for results [9]. In part, SUN was an effort to strengthen the global nutrition system and bring together and harmonise the agendas and actions of the multiple stakeholders in nutrition, under the umbrella of different networks. While it has been successful in doing this and advocating for multisectoral, multistakeholder approaches, there is still room for improvement [14].

One particularly strong disconnect exists between agriculture, nutrition, and health, with the three sectors “often moving along parallel paths that rarely seem to meet” despite efforts to “bend these paths more toward one another.” [18] It is becoming clearer that more gains can be achieved—in both nutrition and in complementary sectors—if sector-specific work also aims to address the underlying determinants of nutrition [19]. While the rationale for multisectoral actions is clear, evidence to support this is still limited, and more systematic research needed [20]. From a programmatic perspective, the adage of “planning multisectorally, implementing sectorally and reviewing multisectorally” [21] can guide coordination, reduce efficiencies and mitigate risks and/or harm. [19] Such practice can help support sectoral and geographical convergence (including targeting), clarify roles and responsibilities, and promote a stronger focus on results [22].

Third, the multiplicity of stakeholders involved in nutrition policy creates multiple narratives around nutrition approaches. For example, Rogers [23] identified eight different narratives about nutrition. There is ambiguity about what the priorities should be in the “food and nutrition security” space, and different policy communities and institutions conceptualize and interpret this space differently, as well as the relative importance of their role in this space. Players in the nutrition field can have sharply different perspectives on what the problem is and what the solution is.

These evolving narratives are captured by Jonsson’s description of seven historical periods in the development of the nutrition field, with each period promoting a single dominant paradigm of how to address malnutrition [24]. For example, over time, groups focused on inadequate consumption of food as the core problem and on food supplementation programs as the main policy solution; then groups focused on poverty as the core problem and on poverty alleviation as the main solution; then groups focused on food as a human right as the core problem and on government obligations to fulfil that right as the solution. These different narratives about malnutrition in part stem from the complex multilevel determinants of nutritional status, which become embodied in different framing efforts that cut across, bring together, or divide the multiple stakeholders involved. Moreover, the evidence to support these narratives varies in both level and quality [20, 25]. This can cause tension between different groups—for example, champions of nutrition-specific interventions cite the high-quality evidence for efficacy, effectiveness, and cost-benefits to strengthen their arguments, and point to the limited evidence available for nutrition-sensitive interventions, such as agricultural interventions, on improving nutrition outcomes—?thus exacerbating existing conflicts and differences in opinions.

An earlier survey of over 500 nutritionists revealed that “infighting of nutrition community and absence of consensus on priorities” was the most commonly cited disappointment among these practitioners [26]. The inability of the nutrition community to communicate issues simply and clearly to policymakers and resolve internal conflicts may have constrained collective efforts to advance nutrition policy. This is in contrast to policy communities for other global health issues, notably HIV/AIDs, which have successfully commanded the attention of global and national policy makers—despite having a less severe disease burden than malnutrition [27]. The ability of the HIV/AIDs community to strategically frame both problems and solutions and to change the narrative to respond to the evolving context [28], presents important lessons for nutrition that are yet to be realized.

Fourth, the limited capacity of nutritionists to engage in the broader political dynamics of managing nutritional policy has been highlighted. This characteristic was reported by Field and Levinson in [1], and it still persists, illustrated by a more recent complaint about the limited training that nutritionists have in managing the politics of the nutrition policy cycle [4]. Nutrition experts, at least according to some observers, are more interested in the science of nutrition than in the messy business of shaping, promoting, and implementing nutrition policy [29]. This reflects Alan Berg’s earlier diagnosis of the nutrition community’s negligence in “preparing people to work operationally in nutrition” [30]. More recently, there have been attempts to assess capacities and gaps in nutrition more systematically and to identify the skills required to respond to existing and emerging needs in nutrition [31, 32]. However, this debate has not fully addressed how such capacity in practical politics can be developed, institutionalised, scaled up or funded in the nutrition field.

Yet, a key issue remains: the relative lack of power of nutritionists in promoting policy reforms. The nutrition profession is not as organised or mature as other professional groups, such as physicians, competing in the health and development space. The relative lower professional standing of nutritionists and their discordance makes it much harder to establish credibility and command the attention of decision-makers.

Fifth, the role of the private sector in achieving nutrition security has been, and continues to be, a highly contentious issue. While there is acceptance that the private sector in its various forms does have a role to play, there is little consensus on what this should look like and how it should be regulated [33]. Many international organisations and non-governmental organisations remain deeply sceptical of the private sector. Much of this scepticism relates to a longstanding issue around compliance with ethical codes of conduct, particularly the International Code of Marketing of Breast Milk Substitutes and its associated subsequent resolutions. Lack of trust continues to stymie the nutrition community’s engagement with the private sector, and ongoing tensions with the food industry may contribute to potential partnerships with other private sector enterprises, for example in service delivery, technology and innovations, not being fostered [14].

The nutrition field is also fraught with ethical issues, and this has become increasingly complex as attention has expanded to malnutrition in all its forms, including overweight and obesity [34]. Balancing public health needs with commercial interests and managing conflicts of interest requires transparent systems and mechanisms. Steps have been taken to improve governance for public-private partnerships for nutrition, including the UNSCN Private Sector Engagement Policy [35], and more recently the SUN Business Network’s toolkit for engagement with the private sector (Guide to Business Engagement) and other guidance [36, 37], but contention remains. Compared to other networks in the SUN Movement, the SUN Business Network has been slow to start and not yet achieved what it set out to do (in part due to resource constraints), especially at country level. Of the challenges identified in the independent evaluation of SUN, “mistrust and opposition” to the private sector was perceived to be the hardest to resolve and likely to take years to address [14].

The sixth theme relates to the challenge of demonstrating and attributing results to the implementation of nutrition policy. Improving nutrition in practice is complicated and context specific; it requires careful strategic planning, informed by the situational analysis (including political and economic analysis), with prioritization of programmatic interventions to be funded with limited resources. As with other fields, there has been persistent difficulty in translating knowledge into practice and demonstrating tangible results at scale. This theme appeared in the early paper by Field and Levinson [1], and has continued to recur [8, 30]. Leroy and Menon called for more research in nutrition on moving from “efficacy to public health impact.” They argue that the lack of research on implementation is due to both the “lack of funding and limited expertise and/or interest among biologically or clinically oriented scientists” ([29], 628). With nutrition’s multicausal aetiology, it is both methodologically and practically challenging to address confounding and attribute results to specific actions.

Decision-makers and donors like to see tangible results and the hitherto lack of progress on nutrition outcomes has trapped nutrition in a “low priority cycle” [9]: “Poor [programmatic] results feed back into the low visibility for nutrition, as they are not attractive to political entrepreneurs and public officials to take them up in their own portfolio of accomplishments. This in turn creates fewer incentives for further investments in the area” [9]. More recently, however, documenting success stories in nutrition [38, 39] and learning from other public health experiences [40, 41], has enabled the sharing of lessons and demonstrated that success can be achieved at scale in relatively short time frames; although the challenge of attributing results to specific interventions remains.