Introduction to the special issue

The most recent Lancet series on maternal and child undernutrition (Bhutta et al, 2013) calculated that even with 90% coverage of specific nutrition interventions (addressing maternal nutrition, infant and young child feeding (IYCF), micronutrient deficiencies and management of acute malnutrition), only 20% of global stunting cases and 60% of wasting cases could be averted. This reflects a widespread understanding that attention is also needed to the broader determinants of malnutrition if reductions are to be achieved at scale.

The conceptual framework for malnutrition from the Lancet series identifies the underlying determinants of nutritional status as, broadly, food, health and care (see Figure 1), encompassing sectoral activities beyond nutrition and health and referred to as nutrition-sensitive interventions. While the broad underlying and basic determinants of malnutrition are identified in the conceptual framework, the framework does not assign weighting or metrics to these domains in terms of their likely impact on malnutrition. There is currently a push to better understand what these other sectors can do and how they can contribute to improving nutrition at scale. The advent and rise of the Scaling Up Nutrition (SUN) Movement and the World Health Assembly (WHA) targets among other initiatives has further increased focus on multi-sector programming to address the underlying determinants of malnutrition, with particular attention on stunting. 

This special issue of Field Exchange presents a snapshot of field experiences and relevant peer-reviewed research to provide insights into the current state of knowledge and action for nutrition-sensitive programming. Many examples of current programming, research, policy guidance and meetings that relate to a spectrum of nutrition activities are included, identified through a call from ENN for content in July 2015. While this compilation is not representative of all that is happening in various countries or across the range of sectors, it provides a useful a snapshot of activities undertaken in the name of addressing the underlying determinants of malnutrition. Here we surmise what is being undertaken to help understand how the concept is understood and applied, to capture good practice and learning and to help strengthen current approaches and inform future work.

Operationalising definitions

It is clear from the diversity of articles submitted to this special issue that many agencies and governments are engaged in work addressing the underlying determinants of nutrition (and in some instances the basic causes (Leroy et al, 2015)), and that nutrition sensitivity means many things to different people and agencies. Working definitions do exist (Ruel et al, 2013): Nutrition interventions refer to actions that aim to change nutrition outcomes, including anthropometry, nutritional status measured by biomarkers, or nutrient intakes and diets and may be nutrition-specific or nutrition-sensitive (see Box 1). Clarity on what definitions mean operationally can help us to plan effective programmes, evaluate our efforts and calculate costs in relation to benefits of this work. Based on these definitions, key points of difference for nutrition-sensitive action are attention to the underlying determinants of nutrition, incorporation of specific diet and nutrition goals and actions, and the potential of these types of programmes to be used as delivery platforms for nutrition-specific actions.

Box 1: Definitions of nutrition-specific and nutrition-sensitive programming

Nutrition-specific interventions and programmes

Interventions or programmes that address the immediate determinants of foetal and child nutrition and development – adequate food and nutrient intake (diets), feeding, caregiving and parenting practices, and low burden of infectious diseases.

Examples: Adolescent, preconception and maternal health and nutrition; maternal dietary or micronutrient supplementation; promotion of optimum breastfeeding; complementary feeding and responsive feeding practices and stimulation; dietary supplementation; diversification and micronutrient supplementation or fortification for children; treatment of severe acute malnutrition; disease prevention and management; nutrition in emergencies.

 Nutrition-sensitive interventions and programmes

Interventions or programmes that address the underlying determinants of foetal and child nutrition and development – food security; adequate caregiving resources at the maternal, household and community levels; and access to health services and a safe and hygienic environment – and incorporate specific nutrition goals and actions. Nutrition-sensitive programmes can serve as delivery platforms for nutrition-specific interventions, potentially increasing their scale, coverage, and effectiveness.

 Examples: agriculture and food security; social safety nets; early child development; maternal mental health; women’s empowerment; child protection; schooling; water, sanitation, and hygiene (WASH); health and family planning services.

Source: Ruel et al, 2013

It is known that programmes have more impact on nutrition if they explicitly include a nutrition goal or outcome objective. It is therefore important to be explicit about any expected or plausible pathways to effect nutrition-related change (sometimes referred to as ‘theories of change’); some sectors have elaborated conceptual pathways (Herforth et al, 2015; Dangour et al, 2013; Fenn et al, 2015), but examples of impact-pathway models for individual programme types are few. How programmes act in different contexts is important to investigate, as different issues (dealt with by different sectors) are likely to be enabling or limiting factors for the complex causal pathway that leads to nutrition outcomes in different situations. Unintended positive (e.g. improved determinants of nutrition) or negative (e.g. opportunity costs) effects may also emerge and need to be captured. Tightly defined research can sometimes lack broader perspectives and flexibility to consider impact pathways, unintended benefits and negative consequences that may emerge during programming if they were not considered in the original research design, e.g. research designed to look at the impact of WASH interventions on diarrhoea will not accommodate impact pathways relating to women’s empowerment (Loevinsohn et al, 2015). A number of research articles in this special issue explicitly highlight that limited evidence of nutrition impact may be due to shortcomings in design, implementation and evaluation (Loevinsohn, 2015, Guatam et al, 2015).

The mixture of articles in this edition suggests a number of ‘operational’ definitions or categories of nutrition-sensitive programming, outlined in Box 2. In order to be considered nutrition-sensitive, a minimum requirement is to align some portion of the programme within a theoretical causal pathway leading to diet or nutrition impact. A nice example of this approach is reflected in an article from Guatemala (Klein, 2015), where impact pathways informed the qualitative study of agriculture value-chain activities in two projects to explore impact assumptions and investigate ways to improve nutrition sensitivity.

Within or aside from a pathways approach, programmes may use different instruments to enhance their nutrition-sensitivity. These typically include:

• integrating and measuring nutrition goals;
• targeting nutritionally vulnerable groups;
• using conditionality to increase service use or change behaviour;
• adding or expanding coverage of nutrition-specific actions; and
• working with other sectors to cover more pathways at once, or to cover more proximate steps on a pathway.

A programme in a relevant sector, if it can place itself on a plausible pathway to positively nutrition impact, might be described as indirectly nutrition-sensitive – and sometimes just doing a good job in that one sector is enough for a particular context. But there are ways to make these actions even more directly nutrition-sensitive, if the context demands it.

Box 2: Types of nutrition-sensitive programmes

1. A sector intervention that deals with the underlying causes of undernutrition (WASH, food security, women’s empowerment), with an explicit demonstration of the part the programme could play on a causal pathway to nutrition impact. This intervention can’t claim nutrition impact as it does not directly aim for it or measure it.
2. A relevant sector intervention that integrates strong and sector-appropriate nutrition goals, and measures them.
3. A relevant sector intervention explicitly targeted based on nutrition considerations; this could be targeting households with malnourished children (linking through nutrition-specific services such as a community management of acute malnutrition (CMAM) programme), or targeting nutritionally vulnerable populations.
4. A relevant sector intervention that uses conditions explicitly aimed at improving the human capital determinants of nutrition, such as use of health services or schooling.
5. A relevant sector intervention that incorporates nutrition-specific components, such as IYCF, complementary feeding, or behaviour change communication, in order to scale up their coverage.
6. Relevant interventions from multiple sectors, converging on one population. These may be implemented as a coherent whole with an explicit aim to integrate nutrition-relevant actions across sectors, or may be implemented as separate sectoral programmes but with a broad goal of improving nutrition in the same population.

These programme types are not mutually exclusive; with sensible application, the more of these instruments that can be used to incorporate nutrition considerations into a programme, the more nutrition-sensitive it is likely to be.

Nutrition-sensitive research: evidence and challenges

The content of this edition demonstrates an appetite for operational research, i.e. agencies  ‘piggy backing’ research  onto  programmes (Mayer et al, 2015; Bonde, 2015; Oxford Policy Management, 2015; Moyo et al, 2015; Shwirtz et al, 2015; Lewis, 2015; Adamu et al, 2015; O’Mahony et al, 2015). There is a spectrum of practice from investigation of country-specific, government-supported programmes (Oxford Policy Management, 2015; Shwirtz et al, 2015; Adamu et al, 2015) to cross-country agency initiatives (O’Mahony et al, 2015) and ACF’s nutrition causal analysis (NCA) approach (Gallagher, 2015; Mutegi et al, 2015). Nutrition-sensitive interventions can be complex, so producing strong evidence about their effects can be difficult and expensive. The first challenge for research comes in deciding what effects should be measured: should an agriculture programme be looking at effects on stunting, or a WASH intervention look at impacts on food consumption? Again, a theory of change or programme-impact pathway can help clarify which determinants a project is likely to change, and which it is not.

For instance, a single-sector agriculture programme aiming to improve availability of vegetables and animal-source foods through homestead food production would sensibly measure changes in diets, but may not have a significant impact on stunting unless it was either mainstreaming or working alongside a project aiming to impact the other underlying determinants in health and care (Bonde, 2015).

In this issue of Field Exchange, the large majority of articles focus on stunting and do not include wasting as outcome goal or impact indicator (exceptions include O’Mahony et al, 2015 and Mbura et al, 2015); this may reflect the widespread (though not uncontested) dichotomy between wasting and stunting, with the former being seen as a manifestation of crisis and the latter as an endemic problem to be measured and addressed in more stable situations. This may also reflect the SUN Movement’s focus on stunting in the 1,000-day window, coupled with its interest in nutrition-sensitive programming and attendant funding flows.

 The second challenge comes in understanding what form of research should be applied. There are many research approaches used by contributors to this edition, including published randomised controlled trials (RCTs) (Bernard et al, 2015; Hidrobo et al, 2015; Hotz et al, 2015); randomised trials still underway (Oxford Policy Management, 2015; Shwirtz et al, 2015); case control/cross sectional studies (Siling et al, 2015); descriptive studies (Mbura et al, 2015); case studies/qualitative assessment mixed methods evaluations (Oxford Policy Management, 2015); and opportunistic retrospective analysis (Hoq et al, 2015; McKune et al, 2015). In order to understand programme impact, randomised designs provide strong evidence. While there are relatively few of these studies for nutrition-sensitive programmes, the evidence base is growing (see, for example, agriculture and nutrition research in Burkina Faso (Hotz et al, 2015) and emerging work around cash transfers and nutrition impact in India (Oxford Policy Management, 2015), Pakistan, Niger and Somalia (Shwirtz et al, 2015)).

Poor research design has hampered impact investigation in quite a few of the articles featured in this edition (Borwankar et al, 2015; Leroy et al, 2015; Guatam et al, 2015; de Groot et al, 2015), with little exploration of pathways (Dangour et al, 2015). Another challenge is how to realise the nutrition objective of a nutrition-sensitive intervention within the short timeframe of the intervention; a number of the programmes described aimed to impact on IYCF behaviour or practices or child anthropometry, but these were not measured as it was unlikely to see a change within the project lifetime (Bery et al, 2015; Lewis, 2015; Moyo et al, 2015). This raises questions about appropriate research duration, which for many of the complex outcomes in nutrition will be longer than standard project-funding cycles. Sustainability of impact is a related issue that is rarely discussed in the context of nutrition-sensitive programmes; only one study in this issue (Maïmouna et al, 2015) has looked at long-term impact (output or outcome), although some are working with and looking to influence national programmes and policies for sustainable impact (Oxford Policy Management, 2015; Shwirtz et al, 2015; Adamu et al, 2015 and Aryeetey, 2015).

 There is also a question about the external validity of many of the small-scale impact studies being implemented and whether findings in one or two local contexts, such as described in Mali (Bery et al, 2015) or in Kenya (Mbura et al, 2015), can be applied to the national level. Efforts to build a collective of evidence from different contexts are underway in some cases, such as by Goal around their Nutrition Impact and Positive Practices (NIPP) approach (O’Mahony et al, 2015) or ACF around NCA (Mutegi et al, 2015). Independent research on impact is not well represented in this issue (Ouedrogo et al, 2015 in Burkina Faso; Oxford Policy Management, 2015 in India), which may be a cause for concern if indicative of agencies most often conducting in-house studies. These may be prone to interpreting findings favourably to support current and future funding requests to donors who increasingly seek value for money, but also where governments and NGOs often do not have strong in-house research capacity, because that is not their core business.

 In summary, several factors – a deep understanding of context, an explicit theory of change and a credible research design – would go a long way to improving the evidence base for nutrition-sensitive programming; these observations concur with the research priorities identified in the Lancet series (Ruel et al, 2013). But this is no small task, and one that implementing agencies and government institutions are often not equipped to undertake alone. The sections below provide a brief summary of some of the key evidence on nutrition-sensitive actions in certain crucial sectors, from the literature and from articles submitted for this special edition.

Agriculture

Investment in agriculture and nutrition has been happening for decades (Siling et al, 2015) with renewed global vigour in scrutinising this area (Dufour, 2015). 

In this edition, a range of articles feature agriculture and nutrition linkages, from nutrition-sensitive agriculture in Zambia (Mayer et al, 2015) to nutrition-sensitive potential of agriculture in the context of school feeding in Haiti (Mallonee et al, 2015), nutrition incentives in dairy contract farming involving the private sector in Senegal (Bernard et al, 2015), among others (Mayer et al, 2015; Klein, 2015; Moyo et al; 2015, Mallonee et al, 2015, Ouedraogo et al, 2015; Bernard et al, 2015; Titus, 2015; Danton, 2015; Dufour, 2015). Agricultural and pastoral communities form a large proportion of the beneficiaries of development aid programmes, and small-scale agriculture is a major provider of both food and income for these families; on a macro scale, agriculture also determines food prices and is the driver of many economies. As such, it might be assumed that raising productivity and incomes should be the major preoccupation of the agriculture sector, and these are certainly important factors in reducing hunger and poverty but, with a nutrition-sensitive lens, this is not all the agriculture sector can do.

Purely increasing income does not reduce undernutrition rates fast: a 10% rise in gross domestic product (GDP) is associated with a 6% decline in stunting and a 7% decline in underweight, so it would take decades to eliminate undernutrition in a typical agricultural economy through this route. Rising income also leads to a commensurate rise in overweight or obesity: a 10% rise in GDP is associated with a 7% rise in obesity in women (Ruel et al, 2013). Thus, in order to be nutrition-sensitive, agriculture programmes need to go beyond income and address the determinants of all forms of malnutrition.

A key nutrition outcome is the quality of diets, and agriculture is the sector with the most influence on what is available, affordable and accessible to be eaten, beyond starchy staple foods. So diets are a product of all of the key pathways from agriculture to nutrition (through changes in production, income and women’s empowerment), and should be a key outcome indicator of agricultural programmes. A review of agency guidelines has formed quite a consensus on Key Recommendations for Improving Nutrition through Agriculture (Herforth et al, 2014) at both policy and programmatic levels.

 One of the most common nutrition-sensitive agriculture-sector programmes is homestead food production. In 2011, a systematic review of published research (Massett et al, 2012) assessed whether this broad category of programmes was effective in impacting nutrition outcomes. It found that anthropometric and biomarker nutrition indicators were rarely affected through these programmes, but that there were often positive impacts on diets (increased consumption of foods produced).While there were limitations to the studies and meta-analysis, it did appear that programmes were more likely to be effective if they included attention to empowering women in agriculture. A more recent set of studies looking at farm-level pathways to nutrition (Winters et al, 2015) backed up the key finding: in general, farming households producing a greater diversity of crops had greater access to a diverse range of foods and children in those households had more diverse diets.

 In agriculture projects, one potential negative impact that has been studied is on women’s time use, as time spent on agriculture competes with time used for other nutrition-relevant activities such as childcare and feeding, as well as resting and socialising. A recent review (Johnston et al, 2015) confirmed that agriculture in general, and interventions in particular, do disproportionately take up women’s time. The impacts on nutrition depended on how this additional time burden was managed, whether by reducing rest time, switching to more convenient foods, reducing time for feeding and cooking, or sharing domestic duties within the household. This context of trade-offs and potential responses should therefore be considered as part of programme planning, in agricultural and other time-intensive interventions.

 The Food and Agricultural Organization (FAO) guidance on nutrition-sensitive agriculture and food systems highlights that in agriculture, a consumer-centred approach may be at odds with a food-supply driven approach (Dufour, 2015). In other words, nutrition objectives may compete with economic objectives, and policy change at each stage of the food system is needed. Going beyond sensitisation takes time, perseverance, multi-stakeholder dialogue, trial and error and improved learning that involves experience-based evidence, as well as research. An FAO-led regional workshop featured in this issue looked to capitalise on existing experiences and knowledge on linkages between livestock and human nutrition in the Sahel (Dominguez-Sala et al, 2015). Participants explored impact pathways and how to optimise the nutrition impact of interventions; country case studies (two of which we feature) heavily informed discussions (Bonde, 2015 and Bernard et al, 2015).

Social protection/cash transfer programming

Social safety net programmes, which include conditional and unconditional cash transfer (CT) programmes, are increasingly being implemented in development and humanitarian contexts. These programmes currently provide cash, voucher, or food transfers to an estimated one billion poor people and those affected by shocks (e.g. natural disasters). Cash programming and research feature in a number of articles in this edition (Shwirtz et al, 2015; Oxford Policy Management, 2015 and Adamu et al, 2015), in the form of both conditional (Oxford Policy Management, 2015) and unconditional transfers (Shwirtz et al, 2015 and Adamu et al, 2015). There is strong evidence that CTs increase household income and protect household assets from being sold, and it is widely thought that these create a situation that favours behaviours that could protect children from undernutrition. However, the evidence for an impact of CTs on undernutrition is mixed and inconclusive (Fenn et al, 2015). A number of reasons for this have been suggested, including differences in programme design. There is some evidence that CTs are more effective when complemented with other nutrition interventions.

Ongoing research described in this edition should yield results on nutrition impact in mid-2016 (Oxford Policy Management, 2015) and early 2017 (Shwirtz et al, 2015 and Adamu et al, 2015). Many social protection evaluations/impact assessments are underway, and at a recent meeting on nutrition-sensitive social protection programming in Moscow (World Bank, 2015) convened by SecureNutrition (a World Bank project) and the Russian Federation, over 20 countries presented pilot studies and full-scale programmes that are deemed to be nutrition-sensitive and are currently being implemented (World Bank, 2015). The volume of evidence on whether social protection programming can impact nutrition, and how it does in a given context, is therefore on the cusp of increasing significantly to include a compendium of presented case studies (anticipated for Spring 2016; see www.securenutritionplatform.org). At the Moscow meeting, five elements of programme design looked to have the potential to make social protection nutrition-sensitive: promotion of nutrition and health services; delivery of training and capacity building to beneficiaries for good food behaviour; increased resilience to food insecurity; focusing on nutritionally vulnerable populations; and increased coordination between social protection, health and nutrition stakeholders. Effecting increased multi-sector coordination is a theme we will return to later.

Health services and WASH

The other immediate determinant of nutrition status is health, and major underlying determinants of this are use of health services and WASH. Access to adequate, safe and sufficient quantities of water and to sanitation are a human right realised in 2010; the relations with food security and nutrition are explored in a detailed report by the High Level Panel of Experts on Food Security and Nutrition to the Committee on World Food Security (CFS) (HPLE, 2015). WASH interventions have been shown to positively impact many of the childhood diseases that are also associated with undernutrition in children, such as diarrhoea, environmental enteropathy, and worm infections. Consequently, research has investigated whether WASH interventions themselves might impact nutrition through these and, to a lesser extent, through other, indirect pathways. Similarly, use of health systems is intrinsically linked with issues such as improved post-natal practices and higher immunisation rates, which in turn are associated with better nutrition outcomes; there has been less research on these links.

A recent systematic review of the evidence of WASH looked at the effect of interventions to improve water quality and supply, provide adequate sanitation and promote hand-washing with soap on the nutritional status of children. It found a small improvement in child linear growth with some of the WASH interventions reviewed (solar disinfection of water, provision of soap and improvement of water quality). However, this study only focused on the very best quality studies, and even many of these tended to be short evaluations with inadequate methods. There are larger studies ongoing which aim to start to fill this research gap around WASH impacts on nutrition; in the meantime no study reported negative outcomes on nutrition through WASH programmes. There is a continuing debate on appropriate methods to evaluate and synthesise evidence on complex interventions such as WASH. This is nicely highlighted in research summarised in this issue that involved a re-review of a systematic review of the impact of WASH interventions on diarrhoea morbidity jointly from health and development perspectives (Loevinsohn, 2015). The research identified additional pathways (beyond the usual health impacts investigated, typically diarrhoea) that suggested ways in which investments in WASH can more effectively support health and livelihoods.

Other sectors

There are many other nutrition-sensitive sectors and programmes to explore. For example, there are theoretical grounds to suppose that programmes to support maternal mental health or to increase health-seeking behaviour might impact nutrition, but as yet little research. We feature one example from Nigeria where an unconditional cash transfer is already seeing early impacts on antenatal care attendance (Adamu et al, 2015). Some nutrition-sensitive programmes may also act as platforms for delivery of nutrition-specific interventions; we feature examples from Niger (Maïmouna et al, 2015) and northern Nigeria (Quigley et al, 2015).

Multi-sector action

Multi-sectoral engagement is required if the multiple determinants of malnutrition are to be addressed and there are now recorded experiences of sectors coming together to tackle these, both within governments and within development agencies. 

There remains a lack of clarity over how best to work together given the very different mandates, training and technical languages used by different sectors. Common traits that seem to make multi-sectoral actions work better include a mutual understanding of the problem at hand and of the complementary roles of the sectors involved; a supportive institutional culture of collaboration and adaptation within the organisations involved; and strategic capacity at supervisory levels to plan, monitor and manage the process (Garrett et al, 2011). There are also different levels of cross-sectoral working: from no interaction at all, to informal or occasional collaboration, to structured coordination, to full integration (Harris et al, 2011). The World Bank recommends to “plan multisectorally, implement sectorally, review multisectorally” (Alderman et al, 2013); in practice, what type of intersectoral arrangement is required, and whether it is required at all for the issue and context at hand, should be addressed in programme planning. Different shapes and forms of intersectoral coordination feature in a number of articles from both agency and government perspectives (Gallagher et al, 2015; Drimie et al, 2015; Shaheen et al, 2015; Mwendwa et al, 2015; Mutegi et al, 2015 and Sardjunani et al, 2015). Communication between and within sectors is key; framing nutrition according to sectoral priorities has been key to multi-sectoral engagement in Zambia and Indonesia (Sardjunani et al 2015 and Phiri, 2015). Recognising that the primary role and impact of agriculture – a common nutrition-sensitive partner – is around food and diets rather than ‘nutrition’ may be a better way to frame conversations and engage agriculturalists.

Government experiences

While many of the articles in this special issue have been written by international agency staff, we also feature articles by senior national government and allied staff in four SUN countries (Ghana, Zambia, Pakistan and Indonesia) regarding their experiences around multi-sectoral coordination, advocacy and communication, financing, planning and research (107, Shaheen et al, 2015, Sardjunani, 2015 and Phiri, 2015). These document a process that has been followed which includes awareness-raising and capacity-building in other sectors, political lobbying and ultimately joint planning and implementation. In Zambia, a very active civil society network has seen strong and innovative advocacy on nutrition influence political commitments, spark legislative change and influence relevant policy (Phiri, 2015). However, despite greater commitments to nutrition by the Government, coordination of nutrition interventions across sector ministries has been challenging. Experiences around SUN in Indonesia reflect huge investment and tenacity in engaging across multiple ministries and greater nutrition profile in existing national policies, plans and budgets. However, sustaining commitment and translating policies into programmes also remains a huge challenge (Shaheen, 2015). Pakistan has had positive experiences since joining the SUN Movement in 2011 (Sardjunani, 2015), although it is still too early to say whether the multi-sector approach is working. In India, nutrition-sensitive social protection programmes are being implemented and steered by government with some success (Oxford Policy Management, 2015).

What all these articles have in common is the finding that multi-sector programming is easier said than done. An ENN-led review of the Common Results Framework (CRF), as a tool and construct promoted as part of the SUN Movement, concluded that the development of a national multi-sector CRF, with inclusion of all its features, is a process that may take years, rather than months (Walters, 2015). The processes of galvanising political and key stakeholder interest and ownership, development of multi-sectoral approaches, and monitoring and evaluation frameworks are complex and resource-intensive activities. Sustained commitment of a variety of different sectors and stakeholders is required to establish a relevant, feasible and workable CRF and deliver on it. There is also an important question about how multi-sector CRFs resonate with fragile and conflict-afflicted states (FCAS) and the particular challenges FCAS face. The ENN CRF review asserts that capturing experiences from more SUN countries in FCAS contexts would assist in learning about how the humanitarian perspective is incorporated into the CRF process and how the humanitarian approach can consider multi-sectoral, multi-stakeholder processes.

Findings from a regional conference in West Africa (Huré et al, 2015) highlighted that multi-sector programming needs improved nutrition management tools and enhanced targeting in policies that recognise the priorities of each sector, account for implementation capacity of a given sector, and invest in decentralised multi-sector governance. Development of impact measures and strengthened evidence of effectiveness of multi-sector interventions are also necessary.

Reflections on what is needed

Reflecting on the experiences shared in this issue, it seems legitimate to ask whether it is easier to implement multi-sector programming when development partners are leading implementation with limited government involvement. This is not to suggest that planning without government is the way forward, but to recognise the particular complexities that governments face and the need for joint planning and action. Furthermore, might it be even more straightforward in humanitarian contexts, where cluster and inter-cluster coordination mechanisms are established, or in FCAS, where there is often weak national governance and external stakeholders drive programming? On the other hand, it may be harder to plan and implement multi-sectorally within the short financing and reporting timeframe typical for humanitarian donors (Domniguez-Salas et al, 2015 and Mwendwa et al, 2015). ACF is one of the international agencies that has taken a lead in integrated multi-sector programming over a number of years. As described by the authors, establishing multi-sector programming as the model for ACF programming has been a long and difficult process within the agency (Gallagher et al, 2015). Outstanding challenges to fully implementing a comprehensive nutrition security approach across the agency’s sectors are lack of evidence of effectiveness and cost-effectiveness; complexities in measuring effectiveness; limited time, energy and motivation to interact across sectors; and inadequate time for analysis within the humanitarian response cycle.

While the SUN Movement model is predicated on multi-sector planning and programming around nutrition, there are few examples of scaled-up, multi-sector government implementation, and where this has taken place, there is limited documentation describing how it has been achieved. There is a need for greater understanding of the political economy at various levels of government, as well as administrative and bureaucratic hurdles that need to be overcome to undertake multi-sector and nutrition-sensitive programming and to cater for weak or absent governance in FCAS. This is also true of NGO-NGO interactions, or even just departments within organisations; there are always political and institutional dimensions to distinct stakeholders coming together. Processes therefore need to be documented analytically and across a range of contexts with a view to sharing learning. As detailed lesson-capture is something ENN specialises in, we will be doing our very best to assist with this process in the coming years.

Ultimately, we do not yet have the evidence to know whether it is actually worth the effort (in terms of impact) to plan and programme multi-sectorally as opposed to using scarce resources to ensure wider and fuller coverage of sector programmes like WASH, social protection, etc., which are intrinsically (or indirectly) nutrition-sensitive. We are working on intuition that coordinated efforts are better. Given the above call for evidence, the time seems particularly ripe for constructing detailed case studies across a range of countries and contexts to fully understand how best to facilitate the inter-sector planning and implementation process for nutrition-sensitive work. Some of this is being done under the Stories of Change initiative, which will be reported on later in 2016 (see www.transformnutrition.org)

Conclusions

This editorial has tried to bring a programmatic lens to lessons learned and good practice, as well as debates and challenges around nutrition-sensitive interventions, including providing a rationale for work on nutrition in non-traditional sectors; clarifying definitions as they relate to operations; and weaving together key international evidence with field articles to provide a snapshot of current knowledge and action. Several key issues have emerged from this ‘reality-check’:

1. there remain questions around whether, when, and how to work multi-sectorally for nutrition;
2.  there is a need for more rigorous research on nutrition-sensitive interventions, including appropriate research designs and indicators; and
3.  there is still work to be done on the detail of definitions for nutrition-sensitive action if they are to be usefully operationalised for government and development partners.

First, as reducing malnutrition requires the work of several sectors, a key challenge to nutrition-sensitive programming is connecting across the sectoral ‘worlds’. To this end, donors, NGOs, consultants, researchers, etc. can learn from each other and often make efforts to do so. There are email lists, video conferences, websites, discussion forums, libraries, conferences, workshops, field visits, etc.; each has a variety of pluses and minuses. At this level, however, becoming ever more specific about ‘why’ we come together could support objective expectations for outputs, and learning of the type that is deep enough to sustain momentum. This will be greatly helped by the seemingly growing evidence base for multi-sectoral engagement.

Readers may be aware that development partners have created a range of online communities, often (but not always) international in focus and which connect across many countries. To that end, we have drawn up a very small and informal sampling in Box 3 and encourage readers to explore these and other entities themselves and alert us to other online communities you turn to for information. As focal points of knowledge and learning between agencies and individuals, these communities have a lot of opportunities to be used more strategically. While it is not reasonable to expect these entities to align under a common banner, it is worth at least considering more regular contact between one another as the shared issues in nutrition-sensitive programming are many. Sometimes it is through technical productions: the iterative and multi-stakeholder launches of the Global Nutrition Report are a good example ­that a common momentum for exchange can be found.

Second, there is a clear need for more rigorous evidence on the role of agriculture, WASH, health service provision, education and social protection in reducing undernutrition and addressing its determinants. By ‘rigorous’, we mean:

• evaluations with clear impact pathways showing the theoretical impact of a programme;
• strong methods, which often include randomised intervention groups, relevant indicators, large samples and targeted qualitative work in order to understand contexts and interpret findings; and
• the inclusion of detailed costs, activities, and programme effects at all stages of the impact pathways, so that cost-benefit can be calculated not only for the high-level goals but also for the intermediate outcomes which are important from a sectoral perspective.

The more robust evidence we have, the more programmes can focus squarely on implementation and track intermediate outcomes/outputs. Until that time, we need more rigorous evaluations, which require collaboration between researchers in the south and north – with methodological expertise – and implementing agencies and government actors with operational expertise. The goals of operations and research are not immediately compatible, but this is feasible, as a number of the articles in this issue show.

 Finally, operationalising the Lancet definitions still poses some fundamental challenges when it comes to examining them in programming terms. In particular, the Lancet definitions are elaborated by a particular segment of the nutrition community primarily concerned with child stunting as the global outcome of interest and action prioritised in the first 1,000 days. The definitions are therefore limited to foetal and child undernutrition and development. In addition, ‘nutrition in emergencies’ is underspecified in these definitions, and classed exclusively as a nutrition-specific intervention.

The continuing debate around terminology and how it is applied to the programmatic context has led to a spectrum of programming undertaken in the name of nutrition sensitivity, with the possibility of nutrition funding being spent where it is not going to create the most impact. This also complicates tracking nutrition-sensitive spend at country level; while SUN guidance and tools on classifying nutrition spend around nutrition-sensitive programming are available and used by countries (Shaheen, 2015 and Sardjunani, 2015), they still require much interpretation and have many challenges at country level. A series of SUN regional financing workshops in 2015 identified a wide range of interpretations of what constitutes nutrition-sensitive programming, with inter-regional as well as inter-country differences. With much of the SUN movement approach based on a fully costed nutrition plan and the global efforts to create resources to finance them, clarified, harmonised definitions are critical.

We conclude on the note that there is much being achieved thanks to the momentum and actions that various initiatives have created, but still much more work is to be done within and between our communities; these debates must engage the widest possible group of nutrition-interest stakeholders – critically governments and those supporting programming at the sub-national level – if we are to fully understand who needs to act and how, what it will cost and what impact we might expect for the elimination of all forms of malnutrition.

 Aaron Buchsbaum, Secure Nutrition

Jeremy Shoham, ENN

Jody Harris, IFPRI

Marie McGrath, ENN

---

References

Adamu, F., Gallagher, M. & Thangarasa, P.X. (2015). Child Development Grant Programme (CDGP) in Northern Nigeria: influencing nutrition-sensitive social policy programming in Jigawa State, Field Exchange 51. Jan 2015.

Alderman, H., Elder, L., Goyal, A., Herforth, A., Hoberg, Y.T., Marini, A., Ruel-Bergeron, J., Saavedra, J., Shekar, M., Tiwari, S. & Zaman, H. (2013). Improving nutrition through multisectoral approaches. World Bank, Washington DC.

Aryeetey, R. (2015). Nutrition-sensitive research in Ghana, Field Exchange 51. Jan 2015.

Bernard, T., Hidrobo, M., Le Port, A. & Rawat, R. (2015). Nutrition incentives in dairy contract farming in Northern Senegal, Field Exchange 51. Jan 2015.

Bery, R., Traore, S. & Shafritz, L. (2015). WASHplus in Mali: integrating WASH and nutrition for healthy communities, Field Exchange 51. Jan 2015.

Bhutta, Z.A., Das, J.K., Rizvi, A., Gaffey, M.F., Walker, N., Horton, S., Webb, P., Lartey, A., Black, R.E. (2013). Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? The Lancet. Published online 6 June 2013. DOI: http://dx.doi.org/10.1016/S0140-6736(13)60996-4.

Black, R.E., Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, Ezzati M, Grantham-McGregor S,  Katz, J, Martorell R, Uauy R, and the Maternal and Child Nutrition Study Group (2013). Maternal and child undernutrition and overweight in low-income and middle-income countries. The Lancet. 2013; 382: 427–51

Bonde, D. (2015). Impact of agronomy and livestock interventions on women’s and child dietary diversity in Mali, Field Exchange 51. Jan 2015.

Borwankar, R. and Amieva, S. (2015). Review of programmes integrating family planning with food security and nutrition, Washington, DC: FHI 360/FANTA.

Dangour, A.D., Watson, L., Cumming, O., Boisson, S., Che, Y., Velleman, Y., Cavill, S., Allen, E. & Uauy, R. (2013). Interventions to improve water quality and supply, sanitation and hygiene practices, and their effects on the nutritional status of children (Review). Cochrane Database of Systematic Reviews 2013, Issue 8.

Danton, H. (2015). Reflections on 30 years of nutrition-sensitive agriculture, Field Exchange 51. Jan 2015.

De Groot, R., Palermo, T., Handa, S., Ragno, L.P. and Peterman, A. (2015). Cash Transfers and Child Nutrition: What we know and what we need to know, Innocenti Working Paper No.2015-07, UNICEF Office of Research, Florence.

Dominguez-Salas, P., Kauffman, D., Breyne, C. and Alarcon, P. (2015). Mainstreaming human nutrition in livestock interventions: lessons learnt from a capacity-building workshop for the Sahel region, Field Exchange 51. Jan 2015.

Dufour, C. (2015). Developing guidance and capacities for nutrition-sensitive agriculture and food systems: lessons learnt, challenges and opportunities, Field Exchange 51. Jan 2015.

Fenn, B. and Yakawenko, E. (2015). Literature review on impact of cash transfers on nutritional outcomes. Field Exchange 49. March 2015, p40.

Gallagher, M. and Morel, J. (2015). Action Against Hunger/Action Contre la Faim: Promoting a comprehensive nutrition security approach and organisational culture to enhance nutrition-sensitive programming, Field Exchange 51. Jan 2015.

Garrett, J. and M. Natalicchio (2012). Working Multisectorally in Nutrition: Principles and Practice from Senegal and Colombia. IFPRI, Washington DC.

Guatam, O.P., Esteves Mills, J., Chitty, A. and Curtis, V. (2015). Policy Brief: Complementary Food Hygiene: An overlooked opportunity in the WASH, nutrition and health sectors, March 2015. LSHTM and SHARE. Complementary food hygiene: An overlooked opportunity in the WASH, nutrition and health sectors

Harris, J. & Drimie, S. (2012). Towards an Integrated Approach for Addressing Malnutrition in Zambia: A Literature Review and Institutional Analysis, IFPRI Discussion Paper 1200, IFPRI, Washington, DC.

Herforth, A., Jones, A. & Pinstrup-Andersen, P. (2012). Prior­itizing Nutrition in Agriculture and Rural Development: Guiding Principles for Operational Investments. Health, Nutrition, and Population (HNP) Discussion Paper. Washington, DC: The World Bank.

Herforth, A. &Harris, J. (2014). Understanding and Applying Primary Pathways and Principles. Improving nutrition through agriculture technical brief series. Brief 1, March 2014. SPRING, Arlington, Virginia.

Hidrobo, M., Hoddinott, J., Peterman, A., Margolies, A & Moreira, V. (2012). Cash, food or vouchers? Evidence from a randomized experiment in Northern Ecuador. IFPRI Discussion Paper No. 01234.

HLPE, (2015). Water for food security and nutrition, Field Exchange 51. Jan 2015.

Hoq, M. & Brogan, J. (2015). Evaluation of an integrated health-nutrition-WASH project to reduce malnutrition prevalence in children under two in Bangladesh, Field Exchange 51. Jan 2015.

Hotz, C., Loechl, C., de Brauw, A., Eozenou, P., Gilligan, D., Moursi, M., Munhaua, B., van Jaarsveld, P., Carriquiry, A., & Meenakshi, J.V. (2012). British Journal of Nutrition. Large-scale intervention to introduce orange sweet potato in Mozambique increases vitamin A intake.

Huré, C. (2015). Regional conference on responding to challenges of undernutrition in West Africa, Field Exchange 51. Jan 2015.

Johnston, D., Stevano, S., Malapit, H., Hull, E. & Kadiyala, S (2015). Agriculture, Gendered Time Use, and Nutritional Outcomes: A Systematic Review. IFPRI Discussion Paper.

Klein, A. (2015). Increasing nutrition-sensitivity of value chains: a review of two Feed the Future Projects in Guatemala, Field Exchange 51. Jan 2015.

Leroy, J.L., Ruel, M. & Verhofstadt, D.A. (2008). The micronutrient impact of multisectoral programmes focusing on nutrition: Examples from conditional cash transfer, microcredit with education, and agricultural programmes. Innocenti Review.

Lewis, A. (2015). Integrated food security programming and acute malnutrition prevention in the Central African Republic, Field Exchange 51. Jan 2015.

Loevinsohn, M. (2015). The cost of a knowledge silo: A systematic re-review of water, sanitation and hygiene interventions, Field Exchange 51. Jan 2015.

Mallonee, N., Streubel, J., Mersilus, M. & Heymsfield, G. (2015). The nutrition-sensitive potential of agricultural programmes in the context of school feeding: lessons from Haiti, Field Exchange 51. Jan 2015.

Masset, M., Haddad, L., Cornelius A. & Isaza-Castro, J. (2012). Effectiveness of agricultural interventions that aim to improve nutritional status of children: systematic review BMJ 2012;344:d8222

Mayer, A.M., Smit-Mwanamwenge, M. & Wahl, C. (2015). The potential of nutrition-sensitive Conservation Agriculture: lessons from Zambia, Field Exchange 51. Jan 2015.

Mbura, D., Chiedo, C., Mutea, F. & Reese-Masterson, A. (2015). Improving food and nutrition security for households with underweight children in Taita Taveta County, Kenya, Field Exchange 51. Jan 2015.

McKune, S. & Hood, N. (2015). Impact of food aid on two communities in Niger. Field Exchange 51, Jan 2015.

Moyo, A. Chishimba, E.B. & Corbett, M. (2015). Nutrition-sensitive agriculture in Zambia: work in progress, Field Exchange 51. Jan 2015.

Mutegi, K. & Korir, J. (2015). Nutrition-sensitive multi-sectoral planning: experiences on Link Nutrition Causal Analysis (NCA) in Kenya, Field Exchange 51. Jan 2015.

Mwendwa, D., Njiru, J., & Korir, J. (2015). Integrating MIYCN initiatives across sectors in Dadaab refugee camps in Kenya, Field Exchange 51. Jan 2015.

O’Mahony, S. & Barthorp, H. (2015). Nutrition Impact and Positive Practice: Nutrition-specific intervention with nutrition-sensitive activities, Field Exchange 51. Jan 2015.

Ouedraogo, M. Khassanova, R. & Yago-Wienne, F. (2015). Implementation challenges and successes of an AG4Nut project in the eastern region of Burkina Faso, Field Exchange 51. Jan 2015.

Oxford Policy Management India (2015). Briefing on the Bihar Child Support Programme, India, Field Exchange 51. Jan 2015.

Phiri, E. (2015). Role of communication and advocacy in scaling up nutrition: lessons and plans from the Zambian experience, Field Exchange 51. Jan 2015.

Quigley, P., Sokpo, E. &Godden, K. (2015). Building the ‘enabling environment' via a multi-sector nutrition platform to scale up micronutrient supplementation.

Ruel, M., T. & Alderman, H. (2013). Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition? Lancet. Published Online: 06 June 2013. DOI: http://dx.doi.org/10.1016/S0140-6736(13)60843-0.

Ruel, M.T. & Alderman, H. (2013). Intersectoral approaches to combatting malnutrition. Lancet, forthcoming.

Sardjunani, N. & Achadi, E.L. (2015). SUN Movement experiences in Indonesia, Field Exchange 51. Jan 2015.

Shaheen, M.A.& Khan, A.A. (2015). SUN experiences: lessons from Pakistan, Field Exchange 51. Jan 2015.

Shwirtz, Z., Fenn, B., Mioli, R. Sangrasi, G.M. & Gallagher, M. (2015). The REFANI Project in Pakistan: adapting research to a multi-sectoral programme for impact measurement, Field Exchange 51. Jan 2015.

Siling, K., Dibaba, A. & Myatt, M. (2015). Use of a two-stage approach to identify intervention priorities for reduction of acute undernutrition in Abaya district of Ethiopia. Field Exchange 51. Jan 2015.

Carletto, G., Marie Ruel, M., Paul Winters, P. & Zezza, A (2015). Farm-Level Pathways to Improved Nutritional Status: Introduction to the Special Issue. Journal of Development Studies 52 (8) Zambia, Field Exchange 51. Jan 2015.

The World Bank (2015). Global Forum on Nutrition-Sensitive Social Protection Programmes, Field Exchange 51. Jan 2015.

Titus, S. (2015). Process learning: field testing a social and behaviour change guide for nutrition-sensitive agriculture, Field Exchange 51. Jan 2015.

Walters, T. (2015). Understanding the SUN movement Common Results Framework: lessons learned from five countries, Field Exchange 51. Jan 2015.