48287 H N P D I S C U S S I O N P A P E R Carrots and Sticks: The Political Economy of Nutrition Policy Reforms Marcela Natalicchio, James Garrett, Menno Mulder-Sibanda, Steve Ndegwa, Doris Voorbraak (eds.) February 2009 CARROTS AND STICKS: The Political Economy of Nutrition Policy Reforms Marcela Natalicchio James Garrett Menno Mulder-Sibanda Steve Ndegwa Doris Voorbraak (Editors) February 2009 Health, Nutrition and Population (HNP) Discussion Paper This series is produced by the Health, Nutrition, and Population Family (HNP) of the World Bank's Human Development Network. The papers in this series aim to provide a vehicle for publishing preliminary and unpolished results on HNP topics to encourage discussion and debate. 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For information regarding this and other World Bank publications, please contact the HNP Advisory Services at healthpop@worldbank.org (email), 202-473-2256 (telephone), or 202-522- 3234 (fax). © 2008 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433 All rights reserved. ii Health, Nutrition and Population (HNP) Discussion Paper Carrots and Sticks: The Political Economy of Nutrition Policy Reforms Marcela Natalicchioa Menno Mulder-Sibandab James Garrettc Steve Ndegwad Doris Voorbraake (Editors) aAFTH2, The World Bank, Washington DC, USA bAFTH2, The World Bank, Washington DC, USA cFood Consumption and Nutrition, IFPRI, Washington DC, USA dPREM-AFRICA, The World Bank, Washington DC, USA ePREM, The World Bank, Washington DC, USA Paper prepared for World Bank Workshop on the Political Economy of Nutrition Policy Reforms The World Bank, Washington DC, USA, May 21-22, 2007 Abstract: The World Bank and other development partners have been involved in the implementation of nutrition programs for over 30 years. While a number of these programs have become successful and sustainable large-scale operations, many others have been hindered by political and administrative obstacles. The disparate results of these nutrition programs suggest that generating technically sound knowledge about nutrition and providing it to policymakers is not enough to ensure good results. It is also crucial to understand the political context, and the constraints and motivations of politicians, public officials, and other relevant players to initiate, implement, and sustain sound policies. In May 2007 the World Bank held an international workshop on these issues to help increase the impact of nutrition programs and policies at the country level. This paper summarizes the results of that workshop. Drawing from the political economy literature, it presents two frameworks for understanding how to undertake action to put nutrition on the agenda and move it forward, as well as insights on how and why political factors derail reforms and how to keep that from happening. These frameworks are accompanied by a discussion of the politics of nutrition policies, including typical obstacles to policy development and implementation, and possible solutions. To complement the political economy approach, the paper also draws on the insights that management and organizational fields offer regarding change promotion. Experiences from Senegal, Madagascar, Ghana, Tanzania, Benin and India are discussed, sketching out the history of nutrition policies and the factors that promoted change, main obstacles and challenges. The paper closes with an attempt to encapsulate all elements presented in a single analytical framework, and provides plans of action for specific countries as prepared by some of the participants. Keywords: political economy, nutrition, reforms. Disclaimer: The findings, interpretations and conclusions expressed in the paper are entirely those of the authors, and do not represent the views of the World Bank, its Executive Directors, or the countries they represent. Correspondence Details: Menno Mulder-Sibanda, (1818 H Street, Washington DC, USA), 202-458-7724, mmuldersibanda@worldbank.org. iii Table of Contents ACKNOWLEDGEMENTS .......................................................................................................VI ACRONYMS...............................................................................................................................IX PREFACE....................................................................................................................................XI PART I. INTRODUCTION......................................................................................................... 1 PART II. CONCEPTS AND TOOLS:........................................................................................ 5 POLITICAL ECONOMY AND CHANGE................................................................................ 5 1. POLITICAL ECONOMY OF REFORM: FRAMEWORKS, TOOLS, AND ISSUES .................................. 5 1.1 Proactive Political Economy Analysis: An Approach to Support Policy Change ............ 5 ALEJANDRA GONZÁLEZ-ROSETTI ................................................................................................ 5 1.2 Creating Political Capital: A framework for Analyzing Nutrition Policy Reform............ 9 REGINA BIRNER ........................................................................................................................... 9 1.3 How Political Economy Derails Reform: Why, how and what to do? ............................ 12 SUSANNE MUELLER ................................................................................................................... 12 2. THE POLITICS OF NUTRITION POLICY ..................................................................................... 16 2.1 The Politics of Nutrition Policy: The Search for Solutions that Fit the Nature of the Problem ................................................................................................................................. 16 DAVID PELLETIER ...................................................................................................................... 16 2.2. Challenges in Building Attention to Undernutrition in National Processes in Africa... 19 TODD BENSON............................................................................................................................ 19 3. PROMOTING CHANGE: APPROACHES FROM MANAGEMENT AND ORGANIZATIONAL FIELDS... 20 3.1. Rapid Results: A Means to an End?............................................................................... 21 RONNIE HAMMAD ...................................................................................................................... 21 3.2. Bringing Change from Below: Accountability Frameworks and Execution Processes. 25 ERIC CHAMPAGNE...................................................................................................................... 25 PART III: COUNTRY EXPERIENCES.................................................................................. 27 1. SENEGAL............................................................................................................................. 27 BIRAM NDIAYE .......................................................................................................................... 27 2. MADAGASCAR................................................................................................................... 29 VALENCIA RANARIVELO ............................................................................................................ 29 3. GHANA................................................................................................................................. 31 ROSANNA AGBLE....................................................................................................................... 31 4. TANZANIA .......................................................................................................................... 34 FELICITE TCHIBINDAT................................................................................................................ 34 5. BENIN................................................................................................................................... 36 JOSEPH HESSOU.......................................................................................................................... 36 6. INDIA.................................................................................................................................... 38 RAJESHWAR RAO ....................................................................................................................... 38 PART IV: TOWARDS AN ANALYTICAL FRAMEWORK................................................ 41 MARCELA NATALICCHIO............................................................................................................ 41 iv PART V: BUILDING COMMITMENT FOR NUTRITION................................................. 45 JAMES GARRETT......................................................................................................................... 45 VI. CONCLUSIONS................................................................................................................... 52 ANNEXES ................................................................................................................................... 54 ANNEX 1: WORKSHOP AGENDA ................................................................................................. 54 ANNEX 2: QUESTIONS FOR PANELS ............................................................................................ 57 ANNEX 3: LIST OF PARTICIPANTS............................................................................................... 59 REFERENCES............................................................................................................................ 62 v ACKNOWLEDGEMENTS The editors are grateful to the World Bank for publishing this report as an HNP Discussion Paper. Marcela Natalicchio led the organization and editing of this report, and performed additional writing and analysis, with assistance from James Garrett, Menno Mulder-Sibanda, Steve Ndegwa, and Doris Voorbraak. Thanks are due to Marc Cohen, Research Fellow in the Food Consumption and Nutrition Division of the International Food Policy Research Institute (IFPRI) and Yi-Kyoung Lee (Health Specialist, Africa Region 2) for their valuable peer-review comments and suggestions. Many thanks are also due to Carol Wzorek (Consultant, Training Resources Group, Inc.) for facilitating the workshop, Andrianina Noro Rafamantanantsoa (Program Assistant, Health, Nutrition and Population) for her help with the workshop logistics, Nelly Rose Tioco (Administrative Coordinator in the Food Consumption and Nutrition Division of IFPRI) for her help with the word processing of the final document, and Kathryn Bach (Junior Professional Associate in AFTH2, World Bank) for her outstanding editing of the final manuscript. Financial support from the Bank-Netherlands Partnership Program (BNPP) and the Italian Trust Fund for Children and Youth in Africa (CHYAO Africa) are gratefully acknowledged. vi CONTRIBUTORS Agble, Rosanna Consultant, Former Head of Nutrition Unit, Ghana Health Service Accra, Ghana Benson, Todd Head, Uganda Strategy Support Program and Policy Analyst Plan for the Modernization of Agriculture Secretariat International Food Policy Research Institute (IFPRI) Kampala, Uganda Birner, Regina Sr. Research Fellow, Development Strategies and Governance Division International Food Policy Research Institute (IFPRI) Washington DC, USA Champagne, Eric Assistant Professor, School of Political Studies Public Administration Program, University of Otawa Canada Garrett, James Senior Economist Food Consumption and Nutrition, IFPRI Washington DC, USA González-Rosetti, Alejandra Senior Health Policy Analyst Division of Country Health Systems WHO Regional Office of Europe Barcelona, Spain Hammad, Ronnie Sr. Operations Officer, Operations Quality, Knowledge and Results Africa Region, The World Bank Hessou, Joseph Nutritionist, Ministry of Agriculture, Livestock and Fisheries Coordinator of Core Group Nutrition Cotonou, Benin Mueller, Susanne Consultant and Associate, Department of African and African American Studies Harvard University Cambridge, USA vii Natalicchio, Marcela Consultant in Governance Africa Region, The World Bank Ndiaye, Biram Nutrition Specialist UNICEF, Burkina Faso Pelletier, David Associate Professor of Nutrition Policy Division of Nutritional Services, Cornell University Ithaca, NY, USA Ranarivelo, Valencia Ala Maiky Coordinator WWF Madagascar and West Indian Ocean Programme Antananarivo, Madagascar Rao, Rajeshwar Director, Ministry of Women and Child Development India Tchibindat, Felicite Nutrition Project Officer, UNICEF Dar es Salaam, Tanzania viii ACRONYMS AED/BASICS Academy for Education Development/Basic Support for Institutionalizing Child Survival AWC Anganwadi Centers AWW Anganwadi Worker BNPP Bank Netherlands Partnership Program CAS Country Assistance Strategy CBO Community Based Organization CDD Community Driven Development CF Conceptual Framework CHYAO Italian Children and Youth Trust Fund CLM Committee for the Fight Against Malnutrition (Senegal) CNLM National Committee for the Fight Against Malnutrition (Senegal) CSD Child Survival and Development Project DANA National Directorate for Applied Food and Nutrition FAO Food and Agriculture Organization FNP Food and Nutrition Policy GI-N Group Initiateur Nutrition (Madagascar) HNP Health and Nutrition Policy HSR Health Sector Reform ICDS Integrated Child Development Services ICN International Conference in Nutrition ICRW International Center for Research on Women IDA International Development Association IEC Information, Education and Communication IFPRI International Food Policy Research Institute KNFFA Kenya National Food Fortification Alliance MIS/GIS Management Information System/Geographic Information System MMCP Micronutrient Malnutrition Control Program MOA Ministry of Agriculture MOE Ministry of Education MOH Minister of Health MOU Memo of Understanding NEMA National Environmental Management Agency (Uganda) NEP Nutrition Enhancement Program (Senegal) NFNB National Food Nutrition Board (Ghana) NGO Non Government Organization PE Public Expenditure PILSA Projet d'Interventions Locales pour la Securite Alimentaire PREM Poverty Reduction and Economic Management Unit PRSP Poverty Reduction Strategy Program/Paper RRA Rapid Results Approach SDNA Dahomean Service for Food and Nutrition TFNC Tanzania Food and Nutrition Centre ix TNC Tanzania Nutrition Committee TTL Team Task Leader UNICEF United Nations International Children's Emergency Fund USAID United States Agency for International Development VP Vice President WDR World Development Report WHO World Health Organization WB World Bank x PREFACE In 2006, the World Bank published Repositioning Nutrition as Central to Development: A Strategy for Large-Scale Action, which makes the case that the international community has now garnered sufficient knowledge and experience to scale up targeted cost-effective interventions at global and country levels. However, relatively few countries have done that successfully. While we have broad consensus on what the appropriate interventions are, we are less well-versed on how to effect their sustainable implementation at scale. Institutional and political challenges, rather than technical knowledge, are the primary constraints to greater impact of policies and programs on nutrition. In an effort to take this key conclusion forward, the Africa Region, together with the Health, Nutrition and Population (HNP) network and the Poverty Reduction and Economic Management (PREM) group, organized a two-day workshop on the political economy of nutrition policies. . The objective of the workshop was to come to a better understanding of the issues related to sustainable scale-up of direct nutrition action, and to identify follow-up activities. The activities identified were: · comparative case studies on the political economy of nutrition policies in six sub- Saharan African countries, representing different levels of policy development and scale of programming (i.e., Senegal, Burkina Faso, Benin, Gambia, Ghana, Madagascar), complemented with shadow case analysis from Ethiopia, Tanzania and Zimbabwe; and · pilot experiences in building commitment for nutrition at country level as a first step to repositioning nutrition as central to development in four countries: Nicaragua, Benin, Tanzania and India. This report represents a compilation of ideas and inputs generated during the one-day knowledge workshop, which included participation from a broad range of experts, and was followed by a one-day planning workshop by country representatives on the political economy issues of nutrition policies. The discussions during these two days were instrumental in the development of the analytical framework for the comparative case study and the operational pilot. As such, this report is just the starting point for a new series of "knowledge" publications on nutrition policies and programs in a political economy and governance context. Menno Mulder-Sibanda James Garrett Steve Ndegwa Marcela Natalicchio Doris Voorbraak xi PART I. INTRODUCTION The Issue The World Bank and other development partners have been involved in the implementation of nutrition programs for over 30 years1. A number of these nutrition programs have become successful and sustainable large-scale operations2. However, many have encountered political and administrative obstacles that have hindered their ability to meet their objectives and limited their scope3. The disparate results of these nutrition programs suggest that generating technically sound knowledge about nutrition and providing it to policymakers is not sufficient to ensure good results. It is also crucial to understand the political context in which the policymakers operate, including the constraints and motivations of politicians, public officials, and other relevant players that affect their willingness and ability to initiate, implement, and sustain sound policies. A political economy perspective4 can contribute to this objective by identifying and analyzing political and economic interests, the institutional landscape, and the key actors that influence nutrition policy formulation, implementation and sustainability. Thus, to overcome the shortcomings of past interventions, and strengthen the implementation of nutrition policies, the incorporation of a political economy analysis and the development of a framework for action based on that analysis are essential. In May 2007 the World Bank held an international workshop on these issues to help increase the impact of nutrition programs and policies at country level. The ultimate goal was to allow the World Bank and its partners to develop tools and activities to deliver better outcomes at country level. This was to be achieved through the identification of conceptual tools for the analysis of nutrition policy politics, and analysis of country-level political and administrative constraints and opportunities related to nutrition policy. The workshop had two immediate practical impacts. First, the findings were used to inform the design of a series of comparative country case studies of the political economy of nutrition in Africa. These studies are expected to further advance the conceptual framework for analysis and action in nutrition programs. 1The Bank began lending for nutrition in 1977. See Heaver, Richard (2006) Good Work--But Not Enough of It: A Review of the World Bank's Experience in Nutrition, HNP Discussion Paper, The World Bank. 2For example consider the cases of Thailand, Tamil Nadu (India), Zimbabwe, Madagascar, Senegal, and the Gambia. 3See Heaver, Richard (2006.), Op. Cit. 4A political economy analysis is concerned with the interaction of political and economic processes in a society; the distribution of power and wealth between different groups and individuals, and the processes that create, sustain and transform these relationships over time (See www.oecd/dac/governance/politicaleconomy). The World Bank finds that understanding stakeholder interests and power relations is important in order to produce operations which will actually deliver for poor people. The support or opposition to reform and/or capture of benefits by specific interest groups have significant effects on reform design, implementation and sustainability (World Bank 2008a, World Bank 2008b). 1 Second, a set of concrete actions and activities were identified by participants from a few countries (Benin, India, Nicaragua, Tanzania) that had been chosen to carry out activities to create political commitment for nutrition. Funding from the Bank will be available to support a more complete, longer-term set of activities to build political commitment. Objectives of the Workshop The principal objectives of the workshop included the following. Identify the main obstacles to and opportunities for policy reforms. Which actions and factors create favorable conditions for reform? In particular, which actions and strategies seem to work in the least favorable contexts for reform? What insights do experiences in other policy areas hold for nutrition? What sequences of actions are needed to build political commitment? Which actors should be involved, and at what stage? Develop elements of a framework for understanding nutrition policy reform (useful for shaping the case studies). Outline basics of a strategy to build commitment for nutrition at country-level and to support change processes (useful as a basis for identifying commitment-building activities). Workshop Expected Outcomes The workshop outcomes, i.e. the elements of a framework, and country participants that will return to their countries with specific proposals/funds for activities to strengthen commitments and knowledge on the political economy of nutrition policies, were seen as important contributing elements for the following medium-term results: Increased support for nutrition from Bank management (because of the existence of a framework that provides guidance on "how" to work successfully on nutrition issues); Support for operations in selected countries that will pilot implementation of the nutrition activities (as a result of an increased level of commitment with nutrition within the Bank); and Increased political commitment and action on nutrition at the country-level (as a result of increased commitment from Bank staff and Bank-funded activities geared towards increased commitment from government and other relevant actors with nutrition at county level.) 2 Organization of the Workshop and Outputs The workshop was designed to foster interaction and learning between academics and practitioners, and between those who had experience with building political commitment for nutrition and those who were trying to develop a strategy to do so, especially through South- South networking. The workshop also sought to draw on knowledge from outside the field of nutrition, and so brought in experts in political economy, policy processes, and change management. Participants were selected based on their potential contribution to the identification of key elements of policy reform in nutrition through participatory, interactive discussion (See the Workshop Agenda in Annex I). These groups included country policymakers and practitioners, experts in political science and related fields, and experts in change management. Country policymakers and practitioners. They have been directly involved in planning and implementation of nutrition programs. Through reflection on nutrition policy reform in their own countries, they identified main obstacles to and opportunities for action, suggested reasons for success and failure, and considered strategies that worked as well as the ones that did not. Policymakers and practitioners from Benin, Ghana, India, Madagascar, Senegal, and Tanzania presented their cases. Experts in politics and governance. This group included researchers and development practitioners with extensive experience in the development, implementation and evaluation of policy reform, both inside and outside of nutrition policy. Experts in change management. These included experts in understanding and managing organizational and political change. They provided principles and strategies that have proved successful in promoting change in programs and policies in developing countries. The one day-workshop (May 21), produced important insights and concrete ideas for action on nutrition policy reform. The following day (May 22), country participants reconvened to adapt these ideas to their own country contexts. They reflected on the most relevant factors to be analyzed in the case studies, and on appropriate country-level strategies for creating political commitment for reform. Organization and preparation of the paper In the next chapter (Part II), the paper presents concepts for understanding and implementing the political economy of nutrition reforms. The chapter that follows (Part III) presents country experiences with these reforms, and provides a brief history of nutrition policies in the countries. Part III includes a first attempt to identify the factors that have helped move these reforms forward, and the ones that have stalled them. In most cases, the sub-sections in Parts II and III are summaries of the presentations by the contributors, and incorporate insights and comments by reviewers. In developing these sub- sections, the editors have drawn primarily on power point presentations, papers provided by the 3 presenters in the workshop (when available), and their own and the facilitator's notes5. In all cases, the editors have tried to reflect the main ideas presented by the authors.6 In most cases, the editors have directly used excerpts from the authors' papers, but have used discretion in selecting examples or diagrams. Where the editors consulted additional sources, it is indicated in the footnotes (i.e. Tanzania and Rapid Results Approach). Many of these sub-sections are followed by accounts of the participants' discussions, based on the editors' and the facilitator's notes. 5 Power point presentations and papers submitted by the contributors for the purpose of the workshop appear in the references and can be accessed through the authors or the editors. Presentations by contributors were based on a set of questions prepared by the editors (see Annex II). Annexes I and III presents the agenda of the workshop and the list of participants. 6 The manuscript was circulated with the contributors to ensure agreement on the final write up. 4 PART II. CONCEPTS AND TOOLS: POLITICAL ECONOMY AND CHANGE 1. Political Economy of Reform: Frameworks, Tools, and Issues It is possible to make nutrition policies sustainable and effective by changing their institutional landscape. Understanding the political economy of these policies in their country context is essential to the effectiveness and sustainability of such reform. There is a large body of literature on the political economy of reforms, and several frameworks for analysis and action are available. Two frameworks for understanding policy reforms in general were presented at the workshop. The first involves a comprehensive approach to identifying and supporting elements of policy change. This "proactive political economy analysis" provides a holistic framework in which to sketch out the elements and, to some extent, the sequence of the policy process. The analysis also offers tools for identifying key actors and elements of a strategy to support reforms. A second framework focuses on the challenge of creating political capital, which is one of the keys aspects to effecting the policy process described in the first framework. This section presents both frameworks, along with some insights on why and how political factors can derail attempts at reform and how to keep that from happening. 1.1 Proactive Political Economy Analysis: An Approach to Support Policy Change7 Alejandra González-Rosetti This approach helps assess the political feasibility of a policy reform initiative and based on that analysis find appropriate strategies to support policy change. Several dimensions need to be considered when assessing political feasibility. The following tasks are proposed. Analyze the political-institutional context Look into the political dynamics of the reform process Study the decision-making area relevant in the reform process Map and analyze key actors and coalitions The expected results of that approach would be: a) the adoption of a strategic approach to the reform process; and b) to enhance the national policy dialogue with a better assessment of the opportunities and risks of a given reform. As for the political context, the characteristics of the political system, including the formal and informal institutions that structure politics, key political actors, as well as the political, economic and social events, will affect the likelihood of reform. For that reason, it is important that nutrition reformers understand these characteristics, as this will give them a better chance of success. 7With insights and contributions from reviewers and editors. 5 For the policy process, it is important to identify the particular challenges that arise during different stages, from problem definition to implementation and consolidation. Each of these stages will have different "key policy nodes", such as the Executive, Congress or an implementation agency, where the main action takes place. In turn, these policies nodes will have their actors, and particular state-society relations that may affect the chances of reform. For example, the reformers might be confronted with strong opposition groups in society, or they might have strong supporters in the NGOs. Finally, it is also important to look at the governance structure of the organizations involved in the reform, and in particular at their technical and institutional capacity to formulate and implement policy change. Change teams and choice of strategies are key aspects in the evaluation of the feasibility of a reform. The framework suggests that reforms are more successful when actors and agents in support of reform band together, to form groups or "teams for change." Change teams are comprised of people in or out of government who will be responsible for moving the reform forward. For these change teams, the choice of strategies is crucial, and will depend on the characteristics of the teams as well as characteristics of the political context and the policy process. Several factors will need to be evaluated with regard to change teams and choice of strategies when creating change teams and choosing strategies: Formation and use of change teams: location, expertise mix, previous experience, ideology, perception of state-society relations Change team political maneuvering: vertical networks, horizontal networks, state-society networks Change team choice of strategies: speed and scope, brokerage in Congress, choice of legislation, policy dialogue, transition strategies, inducing change, reform process and political calendar synch and social marketing Several tools are available to manage the reform politically and to choose the most appropriate strategies. For example, a strategic map can be used to illustrate who opposes a reform, who supports it, and who is undecided, as well as their level of influence in the decision-making process (Figure 1). A reform process map can be created to trace the different moments of the reform, its main activities, and its location (Figure 2). The figures below illustrate these two instruments. 6 Figure 1: Map for Policy Agenda Source: Gonzalez Rossetti, A. "Strategic Options for the Implementation of the Health Sector Transformation in Turkey", Report prepared for the Ministry of Health of the Republic of Turkey and World Bank", May 2004. 7 Figure 2: Reform Process Map Source: Gonzalez Rossetti, A., "Strategic Options for the Implementation of the Health Sector Transformation in Turkey", Report prepared for the Ministry of Health of the Republic of Turkey and World Bank, May 2004. Finally, what can be expected from this type of analysis? Some cases in which the framework and the tools have been used have produced the following strategy guidelines: Make strategic adjustments to the project's content Streamline the project's activities to reflect the political calendar Fine-tune project content to better support incentives to reform Define supporting strategies Locate in advance critical points in the process (early warnings) For further references, see: González, A. and Munar, W. ¨The Political Economy of Social Sector Reforms¨, Economic and Sector Study Series, Inter American Development Bank, Washington, December 2003; González Rossetti, A. et. al. ¨Guidelines for Enhancing the Political Feasibility of Health Reform in Latin America¨, LAC-HSR Initiative Series, No. 37, Washington, June, 2000. 8 1.2 Creating Political Capital: A framework for Analyzing Nutrition Policy Reform8 Regina Birner Political capital9 is one of the most important assets for those participating in the process of policy reform (see Figure 3). A framework specific to understanding how to create and use political capital is therefore very important. This framework has three main concepts: political capital, which refers to the role of political power; advocacy coalitions10, for which the role of policy beliefs and research in shaping policy- making is crucial; and Policy windows, which helps to understand the role of timing in policy reform. Figure 3 shows how competing coalitions with different levels of political capital can attempt to influence the decision-making process of a given reform from formulation to implementation. It shows as well that timing (policy windows) and other contextual factors (frame conditions) can also affect how effective these coalitions can be. Drawing from her experience in agricultural reforms, Birner asserted that like nutrition policy reforms, the difficulty in policy reforms in agriculture arises mostly from political feasibility rather than technical content. For example, many of the technical recommendations that will appear in the forthcoming 2008 World Development Report (WDR) were made more than 20 years ago in the 1982 WDR. The assertion brings to light that the analysis of the political conditions for nutrition reform is badly needed. In addition to political feasibility, two other obstacles are responsible for failure in reforms in the agriculture sector: (i) administrative feasibility (low level of capacity to implement reforms); and (ii) fiscal feasibility (potentially large financial costs with limited availability of public resources.) 8With insights and contributions from reviewers and editors. 9"political capital which refers to the role of political power,...." In Birner, R. and H. Wittmer (2003), "Using Social Capital to Create Political Capital--How do Local Communities Gain Political Influence? A Theoretical Approach and Empirical Evidence from Thailand", in: The Commons in the New Millenium, Challenges and Adaptation, ed. By N. Dolsak and E. Ostrom, MIT Press, Cambridge, Massachusetts, and London, pp. 291-334. 10An advocacy coalition consists of actors from a variety of public and private institutions at all levels of government who share a set of basic beliefs (policy goals plus causal and other perceptions) and who seek to manipulate the rules, budgets, and personnel of governmental institutions in order to achieve these goals over time. In Sabatier, Paul and Hank Jenkins-Smith (1993), Policy Change and Learning. An Advocacy Coalition Approach, Boulder, San Francisco and Oxford: West view Press (p.5) 9 Figure 3: Conceptual Framework Conceptual Framework Policy Subsystem Policy Coalition A Brokers Coalition B a. Policy beliefs a. Policy beliefs Frame conditions b. Resources b. Resources * Type of political system * Nature of policy process Political capital Political capital * Political culture * International influence Political process Politics of Political decisions implementation by governmental authorities Timing: Implementation process Policy windows Policy impacts Source: Birner (2007) Adapted from Sabatier and Jenkins-Smith (1993) One of the differences between agricultural and nutrition reforms is that nutrition reforms usually do not have such clearly identifiable "losers." This is not to say that nutrition does not have losers. Many countries have various ministries competing for resources for nutrition. Nutrition reforms can be perceived as threatening to the existing situation, particularly when a higher-level coordination authority is being created. Strong constituencies can also be created around specific nutrition programs and might oppose a redesign of policies to better target the malnourished population. A case in point would be the program Vaso de Leche in Peru11. In addition to the opposition from potential "losers" of nutrition reforms, reform processes can encounter a number of obstacles: the difficulty of organizing large, heterogeneous, and relatively powerless constituencies (often women and children, traditionally among most vulnerable and politically weak groups in society) to press for reform; 11"The Vaso de Leche Program, started in 1984, was designed to target children younger than 6 years of age and pregnant or breast-feeding women. However, it has heavy leakage toward older children (from 7 to 13 years old) and the elderly. The treasury funds the program through the municipalities, which buy and transfer food to the registered local mothers' committees. The mothers' committees organize distribution to registered households. This often implies a reduction in rations, as committees tend to increase the number of registered beneficiaries. Distribution takes place in the municipal building, another community building, or the homes of elected local leaders. The ration varies by committee but usually includes 250 ml of milk, cereals, and other products and is often unprepared when delivered" extracted from Maldivia, Martin (2005) Peru: Is Identifying the Poor the Main Problem in Targeting Nutritional Programs?, in Health, Nutrition and Population (HNP) Discussion Paper, Reaching the Poor Program No. 7, Washington DC: The World Bank 10 the difficulty of designing and promoting reforms which do not have a clear institutional home and involve several sectors within the government, typically health, agriculture and other policy fields; and Lack of administrative capacity once reforms take place. The framework can help understand and deal with these obstacles. As constituencies are difficult to organize and nutrition programs and policies often involve different ministries, NGOs and donors, one way to gather support for reforms and influence policy-makers is to form coalitions. If these coalitions include different ministries and actors, they can develop some common understanding of the problem and the solution and ease the transition to a better formula for the institutional location of nutrition. A coalition in nutrition may include elected officials, bureaucrats, NGOs, and academics. They usually share factual, causal and evaluative beliefs about the policy arena that gathers them together, that is, they agree on that state of malnutrition, what causes it, the best solutions to address it, and have similar views on how turn it into policies. Reaching this common view might be a process in itself and something that can be developed as the coalition is formed. It is not uncommon to see that reaching that common view takes time and it might entail resolving differences of previously held views and even going through heated discussions and debates. In order to build these coalitions, many tools are already available to help identify actors and strategies for advocacy. These include stakeholder and influence-network mapping tools. The latter combines network mapping with a visualization of respondents' perceptions of the influence/power that an actor has. Discourse analysis12 as well as interviews with experts can also help to identify the actors' beliefs and concerns. These mixed coalitions need to build political capital in order to become effective. To build political capital and influence policy reform, actors can increase their participation in the policymaking process through lobbying, voting, and public protests. They may use "ideological" arguments (value and belief systems) or scientific evidence in order to advance their cause. In turn, building this political capital requires: (a) financial resources; (b) social capital (level of association with organizations and with powerful elites); and (c) human capital (in particular, political skills). Such advocacy coalitions can then use their political capital to influence the policymaking process by taking advantage of policy windows13, which is when opportunities for change open up within the political system. Political entrepreneurs14 and policy brokers15 can intervene on behalf of coalitions during these policy windows. 12Discourse analysis can be characterized as a way of approaching and thinking about a problem. Discourse analysis will enable to reveal the hidden motivations behind a text or behind the choice of a particular method of research to interpret that text. Discourse analysis is meant to provide a higher awareness of the hidden motivations in others and ourselves and, therefore, enable us to solve concrete problems--not by providing unequivocal answers, but by making us ourselves ask ontological and epistemological questions. Cited in www.ischool.utexas.edu/~palmquis/courses/discourse.htm, accessed on 11/19/2008. 13Kingdon, J. 1984, Agendas, Alternatives and Public Policies, Little Brown: Boston, MA. 14John Kingdon first coined the term "policy entrepreneur" in Agendas, Alternatives and Public Policies ([1984] 1995). He defines policy entrepreneurs as "advocates for proposals or for the prominence of ideas" (1995, 122). Kingdon argues that policy entrepreneurs are not necessarily found in any one location in the policy community. 11 1.3 How Political Economy Derails Reform: Why, how and what to do?16 Susanne Mueller Even if we understand the chronology of policy processes and the assets available to actors to promote reform, we must understand the factors that can ultimately derail reform efforts. One of the key reasons for failure is that advocates fail to recognize that informal rules, and not only formal rules and incentives, drive the behavior of actors in the political system. One of the main reasons reforms are derailed is because they threaten groups with vested interests in both the formal and informal rules of the game. Like all systems, political systems have rules. Formal rules are written down and contained in constitutions, laws and organizational directives. Informal rules are normative, consisting of unwritten rules derived from unstated but well-understood reward, sanction, and enforcement mechanisms that govern behavior17. Sometimes these two sets of rules are congruent. Often they are not and many times informal rules override the formal rules that purport to guide the policymaking process. In many African and Transition Economies, the informal rules of the game tend to trump the formal, which in this case has led leads to the centralization and personalization of power, often around the president and a small elite, with few if any checks and balances; to weak institutions, which are deliberately kept that way; and to laws that are ignored or distorted. Doing what is behaviorally necessary to support norms to perpetuate the system tends to be rewarded, whereas challenging it can result in punishment. Hence, the behavior of actors in the system tends towards stasis because it is costly and even dangerous to do otherwise. The end result is the private allocation of public goods. In many parts of the world, the informal rules of the game described above have distorted the allocation of public goods and the behavior of key political and public sector actors as well as that of the public. Perverse systems of rewards and sanctions give rise to perverse and "They could be in or out of government, in elected or appointed positions, in interest groups or research organizations". According to Kingdon: "their defining characteristic is their willingness to invest their resources-- time, energy, reputation and sometimes money--in the hope of a future return" (122). Kingdon posits that policy entrepreneurs may choose to advocate for a variety of reasons. Their "return" may include: 1) promotions of their personal interests, such as promoting one's personal career or protecting their "turf"; 2) policies which reflect and promote their values, or 3) satisfaction gleaned from participation in the policy process (Note of the authors) 15Policy brokers have as their dominant concern keeping the level of political conflict within acceptable limits and reaching some "reasonable" solution to a specific problem. It is a traditional function of some elected officials (particularly chief executives) and, in some European countries, like Britain and France, of high civil servants. (Note of the authors) 16With the exception of par, 3 on p. 14, this section consists of direct quotes from Susanne Mueller's paper (2007) "How Political Economy Derails Reform: Why, How and what to do? Prepared for World Bank Workshop on the Political Economy of Nutrition Policy Reforms, May 21-22, Washington DC, with additional insights and contributions from reviewers and editors. 17Cited in Mueller (2007): North, Douglas. "Economic Performance through Time", The American Economic Review, Vol. 84, No. 3, June 1994, pp. 359-68. 12 predictable types of behavior. They tend to thwart reforms in similar ways, regardless of the sector under consideration. Some Examples: In Uganda, the World Bank sent a team to support the development of a National Environmental Management Agency (NEMA). One key question was where to put it. Placing it in either the Office of the President or in the Ministry of Finance and Planning would have allowed it to exercise actual oversight authority, and given it some clout. . Instead, the president decided to house it in the Ministry of Natural Resources, potentially the country's main polluter. This was because the President wanted to solidify support in the north of the country, the home of the Minister of Natural Resources and possibly also to limit the power of NEMA, which was more a priority for outside donors than for government. This example illustrates how the power of presidential patronage and ethnic arithmetic can adversely affect the ability of oversight agencies to do their jobs by putting them where they do not belong. In Gabon, the World Bank was thinking of supporting a project to upgrade the public expenditure (PE) system, including the formal system of controls, to improve strategies in health and education. A study of Gabon's commitment to PE reform revealed there was none. A formal system of controls existed, but it was not being used. It was either bypassed entirely in favor of presidential directives to the treasurer or was not used at all, with ministries keeping public funds in private banks to avoid the controls of the PE system. Also, expenditures were so highly aggregated that it was not possible to trace expenditures in health or education. Public revenue meant for public goods was being misallocated and made allocations based on the public interest impossible. The inability to track actual expenditures in health and education, among others, made the work of anyone interested in reform impossible. The Bank dropped the project. The examples illustrate the inefficacy of improving the formal rules of systems if they are being bypassed and informal directives govern actual behavior. The tendencies that undermine reform in other sectors may be magnified in nutrition because its programs often involve many different ministries. As such, interventions in nutrition are vulnerable to numerous competing and sometimes different formal and informal rules of the game. This can lead to political turf wars that affect commitment to reform and impede implementation. In addition, the scattered and local nature of many nutrition interventions makes them particularly open to local political interference and clientelism, and exceedingly difficult to monitor or counteract. Some conclusions: If you don't get the political economy it could easily get you and your reform Coming up with ideal technical solutions in nutrition may lead to different results in different political economies Attempting to craft overly generalized "lessons learned" from successful cases of reform will not work for the same reason 13 The allocation of targeted or public goods and accountability to citizens of public expenditures may be subverted if they clash with the incentives or sanctions of the informal political economy Finding champions of reform to propel reform will work only if they are the final decision maker and cannot be subverted by more powerful authorities with opposed vested interests. Also, this may not be sustainable if they lose power but the incentive systems and vested interests that support stasis remain intact Common remedies and its problems Some common remedies ignore the informal rules of the game and lead to ineffective reforms. For example, capacity building often concentrates on changing formal structures and functions, e.g. reorganization, personnel, and equipment. Thus, it does not tackle problems with the informal incentive systems that underlie the behavior of organizations. Another common remedy is to decentralize and promote Community Driven Development (CDD). Although often quite an empowering approach, CDD sometimes assumes rather blindly that to counteract corrupt and repressive political economies, the best solution is always to decentralize or engage NGOs in service delivery. In fact, the institutions and informal rules of the game at the bottom are usually similar to those at the top. Thus, in general CDD approaches must always be aware of the danger that the community-level elite could hijack reforms. However, for nutrition reforms, decentralization has proven to be a positive tool, and empowered actors at the local level can in fact become supporters of nutrition18. The more specific implications for nutrition reform are that attempts to bypass central authorities are unlikely to be a panacea and that it is necessary to understand the political economy both at the national and the local levels. Finally, some general lessons on how to keep the political economy from derailing reforms were: To understand how institutions work both formally and informally, how this affects behavioral incentives, how decisions are made, where vested interests lie, and the relationship between the micro and the macro. Devise reforms that are reasonable and take account of the political economy obstacles Develop an incentive system of rewards for civil servants engaged in nutrition that perform well and to keep the design simple to reduce opportunities for political interference. 18In the case of nutrition reforms, involving the local level, NGOs and beneficiaries has proven to be a good move, as service delivery reaches the level of the community, which might be lacking in health systems, and NGOs and beneficiaries can become strong allies of good nutrition programs. Senegal and Madagascar provide good examples of the positive role of decentralizing programs. The original paper by Susanne Mueller actually stated that there were no benefits in decentralization through CDD. Editors find that experience shows that decentralization and involvement of local actors has positive results for nutrition. 14 Participant Discussion Other key aspects when introducing reforms in nutrition were discussed. The need for political will of higher office. Reforms in nutrition need to have the support of higher authorities or they will get diluted in the disputes among different ministries and actors, and they risk not getting the level of resources and institutional and capacity- building required. Build management and leadership capabilities in the nutrition team, not just technical capabilities. As the nutrition team or coalition will have to engage in political action and later in managing programs, technical knowledge alone will not suffice. Constantly read into the political situation, anticipate changes, and be ahead of the curve. Political commitment to nutrition can be fragile and changing political situations can affect it negatively, if not anticipated. Nutrition programs need to be well-rooted in political and administrative systems and have effective advocacy. The institutional placement of nutrition needs to reflect the priority that it has been given in political and administrative terms. However, constant and effective advocacy will be necessary to maintain that level of priority. There are many competing issues at a given time, and falling off the political agenda is always possible. Build informal coalitions at all levels to exercise effective influence. It is important to have allies in many different positions in government and outside that can help to keep nutrition on the agenda and deal with bottlenecks, bureaucratic intricacies and political turmoil. Nutrition is often an invisible problem, usually with diffuse responsibility for change, and that is why it tends to be neglected. Building coalitions, assigning clear responsibilities, advocacy, and promoting higher institutional visibility can help tackle this problem. Action can depend on donor behavior. Donors can be instrumental in providing political, technical and financial support and being part of coalitions for reforms. How do you package the reform to appeal to different constituencies, and therefore who drives it? The package has to have the ability to reach / convince constituencies. Advocacy. One needs to consider the level at which to try to influence change, and the strategy to take. For example, maybe working at the local level is better, maybe appealing to "rights" is more effective, or maybe there is a need to link to politicians. Understanding of nutrition. The "right to nutrition" often translates into a "right to food", so one needs to work at the actual meaning of nutrition to avoid misunderstandings and false associations that can have policy consequences. How to make nutrition a priority. Politicians may not give nutrition a high priority, but it may appeal to them when placed in a framework that outlines its links to economic growth and productivity, Determining winners and losers. In other sectors, there are obvious winners and losers. In the nutrition field that needs to be discovered in each specific context. Advocacy is not a one-off event. One must create political space for nutrition, but then also give it constant attention as an issue. Otherwise, there is always a chance that it might fall off the agenda. 15 2. The Politics of Nutrition Policy The frameworks and pitfalls presented above are general, and quite useful for framing an understanding of the political economy of nutrition. But, nutrition also has some peculiarities that can make it different from other policy issues. This section takes a closer look at some specific cases of policy reform in nutrition, provides insights on the nature of reform, and identifies typical obstacles found when dealing with nutrition. It also discusses what might be done about them. 2.1 The Politics of Nutrition Policy: The Search for Solutions that Fit the Nature of the Problem19 David Pelletier The World Bank is currently funding a series of studies on nutrition policy change in Africa, South Asia, and Latin America.20. The motivation for the study was the awareness that practitioners in the field of nutrition have yet to develop systematic strategies for addressing the dynamic processes of policy development and reform. The comparative country studies allowed researchers to map out some characteristic features of the nutrition policy process and propose some strategies and tactics to promote political attention to nutrition at country level. The strategies and tactics are addressed to both nationals and international donors, who play an important role in shaping the nutrition policy process. Actors used a variety of strategies and tactics in the various countries. Cultivate and support a small strategic core group within the country Provide core groups time (1-2 years) to come together and develop capacity, confidence, ownership and respect Work with nationals and not against them Help nationals learn from experience Nationals should learn how each donor works Focus on how to build from where the country is A number of features were consistently cited as negative during interviews. Nutrition policies are externally-driven Behavior of donors Personality clashes Behavior of nutritionists (insularity, isolation and ownership, lack of respect and marginalization) Poor or weakened institutional arrangements Loss of entrepreneurs or champions 19With insights and contributions from reviewers and editors. 20For preliminary findings, see Pelletier and the Mainstreaming Nutrition Initiative (2008). 16 Some implications for advancing nutrition are that nutrition programs and interventions are good starting points from which to develop nutrition policy. Nonetheless, they are subject to change within the context of the dynamic nutrition policy process. Thus, the best solution for sustainable improvements in nutrition, that appears to fit the nature of the nutrition policy process problem, is to cultivate, strengthen and support the capacity and leadership for the on-going strategic management of the national nutrition agenda. Strategic alliances appear to be conducive to this objective and nurturing them should be a priority. Strategic alliances should have three main components: (1) a government alliance comprised of professionals that work within the administration; (2) an extended alliance that includes the government alliance but extends to donors, NGOs, private sector, civil society organizations, communities, media, academia, and so forth; and (3) a strategic core group whose members come from the other two, comprised of 2-5 people. The figure below illustrates how potential supporters of nutrition will have to engage in a process with competing narratives regarding what to do in nutrition and how to do it. The narratives in turn will resonate differently depending on the current formal structures, responsibilities and resources, resulting in a specific level and type of commitment. 17 Figure 4: Structures and Competing Narratives National and International Conditions, Narratives, Pressures Ministries, Donors, NGOs, Others Nutrition Nutrition Potential Actors with Other Entrepreneurs Supporters Supporters Commitments Informal Structures & Processes Strategies & Tactics Contested Terrain (which problems and actions?) Competing Level & Type Narratives Competing of Commitment Strategies & Priorities Formal Structures, Responsibilities & Resources Source: Pelletier (2007) The Politics of Nutrition Policy: The Search for Solutions that Fit the Nature of the Problem Prepared for World Bank Workshop on Political Economy of Nutrition Policy Reforms, May 21-22, Washington DC. Finally, the next figure illustrates how a concrete process of alliance and capacity building would look like as it is evolving to deliver results in the fight against malnutrition. Changes have to occur at three different levels: (a) political; (b) technical, and (c) beneficiaries (undernourished mothers and children). 18 Figure 5: From Process to Policy, Capacity and Outcomes From Process to Policy, Capacity and Outcomes Commitment, accountability & capacity among political, bureaucratic and civil society actors Accelerated in Strategic Alliance expanded; undernutrition. alliance ongoing in High visibility; political accountability formed, capacity & resources for nutrition strengthened, commitment Country-level supported nutrition system Programmatic and technical capacity capable of: capacity for scale for generating National design & locally resources; assessment & management of effective experience managing strategy direct and solutions, & capacity; effective activities; development multisectoral M&E results actions at scale action (on-going) actions at scale used responding to research and change M&E Undernourished mothers and children working de- centrally awareness household & access & demand for community services sustaining improved services, actions High, sustained & and practices commitment practices & equitable coverage multisectoral hh sustaining nutrition actions resources & budgets capacities 2007 Time 2015 Source: Pelletier (2007), adapted from Bryce, Jennifer, personal communication. 2.2. Challenges in Building Attention to Undernutrition in National Processes in Africa21 Todd Benson Other researchers have also looked at this question. This section presents some insights from institutional studies on nutrition carried out by IFPRI in various countries in Africa. In Ghana, Mozambique, Nigeria, and Uganda22, ICRW and IFPRI looked at the factors that allowed nutrition to be incorporated into policymaking, particularly in the agricultural sector. Insights were also gained from IFPRI experiences in drafting national food security and nutrition strategies in Uganda and Liberia and a national nutrition strategy in Ethiopia. In each case, building attention to under-nutrition in national policy processes in Africa was a challenge. First, participants in the policy dialogue are usually unclear as to what constitutes a nutrition policy. They tend to think of nutrition as shorthand for "addressing under-nutrition", which is a narrow focus within the broad scope of human nutrition. Also, there is common political puzzle around the issue of nutrition. Why is nutrition usually a low priority for governments when its importance is recognized both as a human rights issue and in its relationship with economic development? 21With insights and comments from reviewers and editors. 22Benson, Todd (2008) Improving Nutrition as a Development Priority. Addressing Nutrition as a Development Priority. Addressing Undernutrition in National Policy Processes in Sub-Saharan Africa, Research Report 156, IFPRI, Washington DC. 19 In general, countries do not see the high prevalence of under-nutrition as either anomalous or indicative of poorly performing governments. Thus, it is not identified as a problem that must be addressed with urgency. One possibility is that governments are unaware. They are ignorant of the effects of under-nutrition in people's lives, of the missed opportunities for economic and human development, or of what needs to be done to reduce it. If this were in fact the case, then one possible solution would be advocacy and raising awareness. But will advocacy be enough to build political commitment? The answer is that it will depend on other factors as well. To begin with, the advocacy efforts should be directed at the political elites, as these societies are state-centered, so that change tends to come from government, and not societal pressures. Moreover, it is unlikely that champions for nutrition will emerge spontaneously from the government ranks, as there is low political demand for action in this policy arena. Also, addressing under-nutrition requires inputs from several sectors, but it is the priority of none. In general, in addition to the advocacy efforts, it will be key to pay attention to circumstances and "windows of opportunity", that can be conducive to policy changes. In terms of the implementation of a nutrition policy, the challenge will be to get an effective cross-sector coordination. As nutrition policies require the establishment of programs in different sectors, a national coordination body is usually created. However, these coordination bodies tend not to be very effective. The main problem seems to be that some trade offs will be unavoidable in deciding where to house this coordination body. These are some of the trade-offs: Maintain high level of political support (President's office, V-P's office, etc) Maintain budgetary support (Finance, Economic Planning) Ensure technical competence (Health, Agriculture, stand-alone agency) Establish sufficient cross-sector coordination authority (Economic Planning) None of these locations are optimal in all respects, so effectiveness of such agencies tends to be compromised along some dimensions. Participants Discussion Certain factors affect the politics of nutrition, and some strategies seem to work. Target population for advocacy and education. Educating the public in their nutrition rights can also influence politicians. It is important to work with all stakeholders to be effective and not just the political elites. Pressure from below is important as well. Developing a nutrition policy. It is important to develop a nutrition policy that is coherent and convergent from its design to its implementation, instead of a juxtaposition of loosely related projects and programs. 3. Promoting Change: Approaches from Management and Organizational Fields Having a framework for action and analysis, and knowing the peculiarities of nutrition as an issue, can be useful to understanding factors that affect the political economy of nutrition. But 20 what exactly should advocates do? In addition to the insights provided by political science, management and organizational fields have developed frameworks for change promotion that can complement the approaches of the political economy of reforms. This chapter discusses two: the Rapid Results Initiative approach, which advocates for rapid change on a narrowly defined policy are, as a way of opening the door for more change in the future; and the Accountability Framework, which helps to bring about change from below through understanding roles and responsibilities. 3.1. Rapid Results: A Means to an End?23 Ronnie Hammad The Rapid Results Approach (RRA) is a management tool used to help make large-scale change happen, typically in less than 100 days. Empowering teams to achieve results quickly can create a virtuous cycle of achievement, whereby short-term successes lead to capacity building and the achievement of longer-term goals. A results-focused learning process, RRA aims to jump-start] major change efforts and enhance implementation capacity. RRA tackles large-scale change efforts through a series of small-scale, results-producing and momentum-building initiatives. By providing a structured process, RRA helps teams and clients unleash their capacity to overcome all too common implementation barriers. At the World Bank, in addition to improving implementation of projects, RRA has also been used to facilitate preparation of Poverty Reduction Strategy Programs (PRSPs) and Country Assistance Strategies (CASs). How it Works RRA speeds up implementation by using a series of mini-projects, with low initial investment, to produce visible results. Ambitious goals are set for project/program priorities with 90, 100, or 120 day targets, resulting in detailed work plans and accountability mechanisms to track progress. The approach brings out hidden reserves of capacity in teams and organizations that come out in times of peak performance, e.g., when there is a sense of urgency, when success can be clearly defined and measured, when roles and responsibilities are well understood, and when there is a sense of excitement and mission. It works because it: stimulates existing capacity and pushes teams to break through organizational inertia; relies on learning-by-doing and an experimental approach where lessons can be drawn from achieving short-term goals that inform future implementation efforts, and policy; 23The original presentation by Ronnie Hammad focused mainly on the case of Kenya. For this paper, the editors have also drawn on World Bank (n.d.) for the basic characteristics of the Rapid Results Approach. Also see Schaffer and Ashkenas (2005) for a more complete description. 21 provides a structured methodology for building and practicing the management discipline required to achieve results, and successful project implementation; draws public attention to key issues and projects and brings stakeholders together to address them; and translates long-term objectives into action on the ground. Key Features of the Rapid Results Approach The key features of the process provide a framework for articulating goals and mobilizing support and accountability for implementation. While there are different methodologies being used by Robert H. Schaffer and Associates (RHSA), The Crosslands Groups (TCG) and within different Bank teams, there are also common elements. The Workout: The Rapid Results Approach is modeled on the Workout, a three-phase approach (i.e., design phase, launch event, and implementation) to team-based problem-solving pioneered by General Electric (GE) in the late 1980s. Senior associates of RHSA and TCG who took part in GE's initiative introduced it to the World Bank a decade later. It is a rigorous and no-nonsense exercise, similar to a town hall meeting, built around democratic principals to encourage broad participation and sharing of information. Participation is cross- functional and cross-level in terms of decision-making authority (45-100 people). Senior level decision makers who are expected to make a go or no-go decision on the spot lead all sessions. As decision-making rarely happens this way in the public sector, an effort is made during the scoping phase of the RRA to ensure this commitment upfront. Once articulated, and made public, ownership is strengthened. Scoping and Sponsorship: During the first mission the job of the lead facilitator (international expert) is to develop the scope of work and determine whether a sufficient level of engagement exists, with appropriate leadership, context, timing, and passion for change. In the process, the lead facilitator (international expert) must learn how decisions are made, recognize who has authority, and determine whether this leadership can hold others accountable. This involves scoping or mapping-upward to find the highest level of support or sponsorship for the Rapid Results goal within the Government, which must be clear about what it wants to achieve. While the process of winning ownership and political commitment is typically a challenge that takes time, in the context of Rapid Results it must happen quickly. Rapid Cycle Goals: These goals must contribute to the overall strategic objectives of the project/program and be achievable in 100-120 days or less. Ideally, they are measurable stretch goals that encourage innovation. They are experimental, capable of generating great energy and enthusiasm because they are clear and exciting. They create a sense of accomplishment and pull the team together. When choosing a Rapid Cycle project and goal the team asks three questions: (i) what will signal the greatest momentum; (ii) where are the potential risks; and (iii) where are we likely to run into the barriers and bottlenecks? The reiteration of the importance of achieving these rapid cycle goals drives project implementation forward and builds the momentum and capacity of the project team. Accountability Measures and Checkpoints/Benchmarks: It is important to include structures of support and accountability, reporting mechanisms, timetables, work plans, milestones, and 22 tracking charts. The implementation plan is thought through step-by-step, work plans are sketched out, schedules are made and tasks are assigned to individuals. Leaders are made directly accountable for the success of the projects. High-level accountability stimulates leaders to do whatever is necessary to overcome the institutional and organizational barriers to change. At the same time senior level sponsors are encouraged to delegate responsibilities to lower level managers along broad areas, building implementation capacity. When is RRA most helpful? There are some situations better suited to the RRA than others. A TTL planning to use the RRA to expedite implementation should consider the following questions. Is this a sector where it is possible to achieve tangible products and services? Is there a sense of urgency, or a political imperative for change? Does the borrower have a clear idea of what it wants to achieve? Does the borrower, as well as other major stakeholders, understand that investing in short term goals is but a first step in a longer-term process of experimentation to produce sustainable results? Does the leadership have enough clout to effect change; is the leadership willing to take risks? Will the leadership come out publicly in support of the rapid result goal? Will the leadership set ambitious goals and be willing to delegate some authority to manage for results? When Does RRA Not Work So Well? It is important to remember that there is no such thing as a cure-all and that RRA is not suited to all situations. There are circumstances when the application of RRA may not work well, including: where relationships among key stakeholders have broken down (e.g. government sponsors and partners and/or ministries are in conflict, vying for power); when goals are intangible and hard to measure, or require long term investment, such as changes in culture, behavior or attitude; when the TTL's goals are not well-aligned with Government's priorities and the objective is to gain buy-in; when there is little time and few resources available for supervision and implementation support; and when leadership is not willing to make immediate decisions and launch immediate action. Fortification in Kenya: an example of RRA in nutrition In the case of Kenya, the use of RRA accomplished in six months what six years of a more traditional approach had not: vitamin A fortification of edible oils. In the late 1990s, it took two years for the government of Kenya to achieve universal iodization of salt. After that, between 2000-2006, using a traditional policy change approach (stakeholder workshops, training and strategy papers), the government could not move forward with the fortification of other products. 23 Cognizant that the traditional approach to policy change was not working, the government of Kenya decided to adopt a RRA in August 2006 to achieve compliance with vitamin A fortification standards of 15% of edible oils/fats in 130 days (2 brands). The RRA approach to fortification of edible oils established a narrow but clear goal which was to place at least 3 edible oil/fat brands on the shelf with a fortification logo in 100 days. The activities included: Development of fortification guidelines by MOH Revision of oil/fats food standard Creation and Implementation of certification regime Design of MOH/KEBS fortification logo Drafting and Approval of MOUs between involved organizations Granting of logo Changes on production lines in oil refineries As a result, 9 brands expressed interest in the initiative and 2 of them got a diamond mark, and a fortification logo was created. On June 2007 a second 100-day RRA was launched, and resulted in the fortification of flour products with iron, zinc, etc. In January 2008, a plan to launch a private-public communications campaign will be initiated to promote the fortification certification system. Why was the traditional approach to policy reform unsuccessful in achieving the fortification of foods in the case of Kenya? It required high levels of attention from senior leadership who were not available It lacked results and its slow progress deflated the interest of private companies The long-term holistic planning with the 19 organizations involved produced only vague goals There was no accountability mechanism or pressure to stop "avoiding conflict" and make hard decisions On the other hand, RRA had a number of advantages that might explain its success. At the operational level, it has a smaller area of focus, which makes it easier for senior leaders to delegate authority, and it has a concrete short-term goal, which allows for the easy identification of the system/operational changes that need to take place. At the policy reform level, it is easier to build trust among partners when you start small and move to larger issues, and 24 it focuses on implementation instead of just planning, and it helps ensure that policy actually produces results. 3.2. Bringing Change from Below: Accountability Frameworks and Execution Processes24 Eric Champagne The Accountability Frameworks Approach argues that change will come about through the introduction of accountability mechanisms to improve results in programs. Effective programs that can deliver good results in the reduction of malnutrition are a key component of creating a positive environment for the sustainability and institutionalization of nutrition programs. "Success breeds success", and many cases have shown that delivering good results stimulates and maintains the interest of politicians and other actors in sustaining these programs. In addition, if strong accountability mechanisms are established at the community level, it has the effect of empowering communities and the potential to create constituencies for nutrition in the future. This approach is particularly useful in the context of decentralization, where the role of local governments becomes more important. In concrete terms, what does it take to build accountability frameworks25 through the public management process? It requires: (a) a clarification of roles and responsibilities among the actors involved in public service delivery programs; (b) the creation of incentives through accountability relationships (citizens, governments and service providers), and (c) building accountability frameworks in the policy design of and World Bank documents for loans. Achieving better accountability in service delivery requires strengthening the beneficiaries' voice26 to motivate policymakers to be responsive to the needs of communities. This involves citizen participation in public policymaking, budgeting, tracking of public expenditures, monitoring of public service delivery, and lobbying and advocacy. The assumption is that once citizens are involved in the policymaking process, there is more pressure on the politicians to keep up effective policies. This should help the sustainability of policies and their institutionalization. In this case, the assumption is that if certain nutrition policies were effective, there would be pressure from citizens to maintain and institutionalize its delivery. The framework also involves developing new arrangements with public and private providers for better and more accessible service delivery. For example "compacts" can be used to define service delivery. A compact refers to a performance management contract under which the service is contracted out to public or private providers. The compacts specify the features of the service that will be delivered--access, quantity, and quality - and details responsibilities and 24For this paper, the editors have also drawn from the World Bank website on accountability frameworks to complement the presentation by Eric Champagne. It also adds insights and contributions from reviewers and editors. 25The accountability framework advocates that both policymakers and providers be accountable to citizens, who should have strong influence over the availability and quality of services. The efficiency, effectiveness, and sustainability of service delivery will be a function of accountability among these three players. See www.sitesources.worldbank.org/EXTBNPP/Resources/TF055370RwandaChapter3.pdf, accessed on 11/20/08. 26Beneficiaries voice: citizens can use their collective voice (relationship with policymakers) to influence policy, strategies, and expenditure priorities at national and local levels, according to their wishes and preferences. See www.sitesources.worldbank.org/EXTBNPP/Resources/TF055370RwandaChapter3.pdf, accessed on 11/20/08 25 arrangements for financing, performance supervision, and monitoring. Without compacts, it is hard to impose sanctions for poor performance or provide rewards when performance is good. As a result a triangle of accountability relationships should be created (See Figure 6). If accountability mechanisms are in place, a system of checks and balances is established through which the clients/citizens hold both the national policymakers and public/private providers accountable, through voice and client power27 respectively. At the same time, the national policymakers should control public/private providers through the compacts. Local policymakers are in between these three main actors, and also monitor the performance of public/private providers, and are held accountable by both the national policymakers and the clients/citizens. The accountability framework is an approach to improve service delivery and to maintain effective policies that respond to public needs. As such, it can be useful to numerous policies, including nutrition. Using such a framework to design World Bank-funded investments should contribute to the process of creating a constituency for good nutrition policies comprised mainly of its recipients. Therefore, nutrition policies should go hand in hand with the creation of accountability frameworks in this area and the capacity building during decentralization processes. Figure 6. Triangle of accountability relationships Triangle of accountability relationships National Policy makers COMPACT / VOICE Local Policy Makers MANAGEMENT CLIENT POWER Clients / Citizens Public / Private Providers Source: World Bank (2004) 27Client power: citizens can also exercise power as users or clients over service providers and hold them accountable for the availability, quantity, and quality of services. Improved information about services being provided at the local level, as well as a choice of providers, can represent important elements of client power. See www.sitesources.worldbank.org/EXTBNPP/Resources/TF055370RwandaChapter3.pdf, accessed on 11/20/08 26 PART III: COUNTRY EXPERIENCES 1. SENEGAL28 Biram Ndiaye History From the 1950s to 2000, it is possible to distinguish three main eras in the fight against malnutrition: (i) a technical approach (1950-1970), in which the government focused on research on food and nutrition, with an emphasis on studying the nutritional value of local production and its utilization by households; (ii) a crisis management approach (1970-2000), in which the government adopted a more reactive approach whereas food and nutrition programs were created to respond to emergency situations such as the drought in 1973, or the deterioration of the economic situation experienced by poor households due to the 1994 devaluation of the Franc; and (iii) a proactive approach (2000 to date). In 2000, Senegal adopted a proactive approach, which meant that programs were guided by a comprehensive policy document supported by all stakeholders to tackle malnutrition in the country, incorporated and sustained nutrition in the national development agenda, and increased the national budget allocation by $2.5 million per year. As a result, Senegal has seen an improvement in child malnutrition and in the administration of Vitamin A supplementation and consumption of iodized salt. The institutional layout has also changed over time, evolving from informal coordination, to a central coordinating unit housed in the Office of the President (CNLM), to a unit housed in the Office of the Prime Minister (CLM). This coordination unit is comprised of representatives from all technical ministries and NGOs involved in nutrition in the country. Their main mission is to ensure the national policy on nutrition is implemented through an array of programs, projects and actions. The management unit moved from the technical ministries (1950-1970) to a National Executive Bureau (2000-today). The management unit housed in the National Executive Bureau ensures the good functioning of the CLM as well as the implementation of the main national program against malnutrition in the country, the PRN. Factors of Change How was this change possible? Three external factors were cited as drivers of change: Advocacy by international partners, which lobbied the government to put nutrition in the agenda. A paradigm shift from a project approach to a more programmatic approach in the international development community, and particularly an effort to mainstream nutrition into development, which helped to switch to the cited "proactive approach". The paradigm shift in the fight against malnutrition also involved a greater emphasis on prevention and less on food distribution/security, which accounts for changes in the type of policies and programs adopted since 2000. 28With insights and comments from reviewers and editors. 27 Three internal factors were cited as most influential in driving change: Political will of higher authorities to support nutrition. Leadership of nutritionists. Good governance in program management. In regards to the good governance in program management, in the new institutional environment, established in 2000, the performance of the National Executive Bureau has been crucial. It has operated in an inclusive manner, building bridges between actors, playing an active networking role, and using a strategic approach to communicate program results. It has recruited its staff using transparent and competitive procedures, which has helped to strengthen its credibility. The Bureau has developed teambuilding activities to create a vision for the organization and it has introduced a performance management system. It has become a learning organization with strong adaptive abilities. The result has been the generation of a good inter-agency cooperation dynamic and coordinating body that is able to bring resources and funding to all nutrition activities. As for the international factors, the role of the World Bank has been essential in driving this process in the last 10 years. The World Bank contributed to raising the profile of nutrition in the country, supporting an increase in coverage by funding large-scale interventions, and facilitating dialogue with other donors. Obstacles Despite progress toward a sustainable, institutionalized nutrition policy, certain challenges and obstacles remain. Chief among them is the difficulty in establishing a sustainable financing mechanism for nutrition interventions through a combination of the central government budget, local government budgets, and international assistance. Another challenge is the limited capacity of local actors, who are becoming important partners in nutrition policy (given the community- driven approach and strong decentralization policies under way). Finally, it is important to continue the efforts to promote the integration of nutrition into the country development agenda, as well as to promote public-private partnerships at all levels. Participants Discussion (with additions from presenter) Certain strategies seem to have been successful. It is important to exercise influence over key actors to keep them interested in supporting nutrition. In particular, this includes the Minister of Finance and those involved in the PRSP process. It is a process of exposing others to ideas on what to do and how to do it. It is key to use a multisectoral approach while paying attention to context, so interventions are appropriate to cause and make sense given the partner's own perception of the problem. 28 Senegal has created a political space, and management seeks to analyze actors and identify the face of the issue that meets the interest of potential "partners." The first Prime Minister played an important role in setting direction ("Do this") and creating the legal and political space, leaving day-to-day management to others. Management capability is essential. As such, the development of negotiating skills, an understanding of context, and management training are important. The ability to continuously adapt is key. Ideology (nationalism, socialism) is an important element to consider for the discourse on nutrition to generate action and commitment from politicians, Putting nutrition in the agenda will require leadership, as it is a process that will not occur spontaneously. It takes a lot of advocacy and strong commitment and ability to gather the support of numerous stakeholders and politicians to succeed at it. A continuous focus on "results" seems to have worked in favor of a positive change in Senegal. It led to excellent results that could be used to further advocate for continued support of nutrition programs, and to strengthen the country's image of seriousness with donors. Given the characteristics of the political system in Senegal, placing the Committee for the Fight Against Malnutrition in the Prime Minister's Office was a good idea, as its role is just coordination, and it does not replace the other ministries. The focus of the Committee has been on building bridges among actors. Personal connections are important to such a role, as is building a credible and inclusive program (with good management, results, transparent decision-making and action). Everyone understands the workings and roles of NEP (Nutrition Enhancement Program), and its many partners share in its success. 2. MADAGASCAR29 Valencia Ranarivelo History Madagascar has been working on the problem of nutrition for the last 18 years, and it has made progress on institutionalizing a community-based nutrition program at national scale since 2004. Malnutrition has been reduced at a rate of one percent annually over the last 7 years, and the government has managed to build an impressive network of over 5,500 community nutrition sites. It has also put in place a national nutrition policy and a national nutrition office. Notwithstanding this impressive progress, Madagascar still faces challenges in its fight against malnutrition. One in every two children is underweight, and the institutionalization of the nutrition policy is not yet fully accomplished. In what follows, some key contributors to the country's success and some of its remaining challenges are laid out. 29With insights and comments from reviewers and editors. 29 Factors of Change The fight against nutrition started as a small community nutrition research component of a Structural Adjustment Package in 1989. This component later evolved into the first Food Security and Nutrition Project (1991), but there was still no vision of a national policy towards malnutrition. In 1992, Madagascar participated in the International Conference on Nutrition. As a result, even though the National Nutrition Action Plan was not implemented, the government and the World Bank took interest in the subject. This interest led to the creation of Seecaline I, a community based nutrition project in 1993, which established 362 sites in communities in two provinces, and the same number of health workers. The project was renewed in 1998 as Seecaline II. Both projects were outside the government structure and reported directly to the office of the Prime Minister. In the second phase, the project was scaled up to cover all provinces (6) and expanded from 362 to 3,600 sites. It also drew the collaboration of the Ministry of Health and the Ministry of Agriculture. Following political motivation, the project was further scaled up to cover all districts and reached 5,500 sites nationwide. The institutionalization of the nutrition policy finally took place in 2004, with the approval of a National Nutrition Policy and the inclusion of its financing in the Poverty Reduction Support Credit. In 2005, the National Office for Nutrition was also established. Seecaline became its executive unit charged with the implementation of the National Community Nutrition Program. A National Nutrition Council has also been created in order to coordinate efforts in the implementation of the National Nutrition Policy. This Council will gather representatives from the Prime Minister's Office, some technical departments, civil society and donor representatives. How was this evolution of nutrition policy possible? Creation of a constituency (beneficiaries). Seecaline I and II were very successful projects and they became very popular in rural communities, so much so that people started to worry in 2002 about what would happen upon project closure. These projects generated demand for further action in nutrition. Formation of a coalition around nutrition and the generation of policy solutions. In 2003, a number of studies were conducted to see how to move the nutrition agenda forward. In addition, the Seecaline task manager and its communications director made efforts to engage key stakeholders and donors who had an interest in nutrition. As a result, the idea of updating the National Nutrition Action Plan (never ratified) came about. A Group Initiateur Nutrition (GI-N) was formed. The GI-N was comprised of a group of technicians (previously part of a coalition), ministries and other stakeholders, and in two years, the GI-N produced a National Nutrition Policy, which was ratified in 2004. A working group within the GI-N was in charge of drafting the decree to establish the National Office of Nutrition. The coalition was linked to the Office of the Prime Minister. 30 Political support from the Prime Minister. The president elected in 2002 signed the Millennium Development Goals, but more importantly he appointed a Prime Minister with a personal commitment to the issue of nutrition, and who took active interest in its promotion. Obstacles and challenges The government of Madagascar has unquestionably made strides in the institutionalization and scaling up of a national nutrition program, but challenges remain. One of the challenges is the coordination of actions with other Ministries. As the National Office of Nutrition is still new, it needs to earn credibility vis-à-vis other more established Ministries within government. The other main challenge is to ensure that the national nutrition program evolves from being a donor- supported project to being led and funded by Government. Participants Discussion Strategies for change. In 2003, a series of nutrition studies took place in Madagascar to solidify the evidence base to be used for advocacy. A coalition of stakeholders working from different ministries and nutrition programs consistently and frequently met with various partners regarding the future of nutrition to understand their interests, their goals and get their suggestions. The immediate goal of the group was to update the 1992 strategy. For that, an existent small committee grew into the Groupe Initiateur Nutrition, with links to the Prime Minister. Reaching consensus and the role of outsiders. The Groupe Initiateur Nutrition (GI-N) had a consultant to take things forward and mediate among stakeholders to reach a consensus while solving conflicts arising from different views and interests; someone who knew issues, the country, and the players, but not associated with the program. In this process, it was key to come up with a common definition of what nutrition is, among the different partners. Making nutrition programs credible. It is important to establish credibility and to gain respect of others. 3. GHANA30 Rosanna Agble As in many other countries in Africa, Ghana started its fight against malnutrition after Independence. Since then, it has attempted to develop an institutionalized and more stable nutrition policy. Support for nutrition peaked in the aftermath of the International Conference on Nutrition (1992), but has waned in the last six years, in particular outside the Ministry of Health. What follows is an account of the main events in the history of nutrition of Ghana, and an attempt to identify the enabling factors of and obstacles to a more sustainable nutrition policy. 30With insights and comments from reviewers and editors. 31 History After gaining Independence (1957), the government of Ghana took its first step in the fight against malnutrition by establishing a National Food and Nutrition Board (NFNB). This governmental agency was under the direct control of the president and functioned as an independent Ministry, with its own budget and branch offices nationwide. Its main role was quite narrow and focused on educating the public on good nutrition practices and the use of local produce for food. Nutrition was essentially equated with the art of cooking, and the nutrition program focused primarily on food demonstrations. One of the main limitations of this body was that untrained relatives of political leaders comprised its staff, and it was therefore perceived to be politicized agency. As a consequence, with the military coup of 1966, the agency was dissolved and its board and key staff members were either arrested or fled the country. After the military coup, the nutrition policy that the government pursued from 1966 to 1969 suffered from many shortcomings. The main problem was that the government did not have a clear vision for its nutrition agenda, as "nutrition" was perceived to be about food and good cooking. As a consequence, the nutrition program was housed in the Ministry of Health and staffed with untrained personnel, who were seen as inferiors by health professionals. It was not adequately funded and overlapped with other programs within the Ministry. After a while the Ministry improved the recruitment for its nutrition program and a 3-year technical nutrition program was created. Changes and explaining factors Since 1984, some positive changes have taken place. Better projects were implemented and a National Plan of Action on Food and Nutrition was drafted. The factors associated with these positive changes include the following. The role of international agencies and conferences. The international agencies helped change the image of nutrition in a positive way. Also, international conferences, especially the International Conference on Nutrition (ICN), were influential in raising political interest around the issue and prompting domestic action. In preparation for the conference, different Ministries drafted plans on nutrition and really took ownership of them. The Minister of Development participated in the conference, which led to the inclusion of nutrition in the country development plans, and was accompanied by a media specialist. This meant there were embedded advocates for nutrition among those who would be actively involved in setting and communicating the development agenda. Qualified personnel at both regional and national levels. The fact of having qualified personnel at all levels was key to allowing work on the National Plan for Food and Nutrition to proceed. Role of Advocates. The Director-General of the Ghana Health Service and the Minister of Health became advocates of nutrition and moved its agenda forward. (It is important to have a leader to push the agenda.) 32 Common plan of action. Having a common action plan allowed different Ministries to work together on the same platform. Negative influences There are other factors that have affected nutrition programs negatively, derailing the institutionalization of a nutrition policy. Frequent changes of Ministers/Directors (having champions instead of broader coalitions). The departure of the Minister of Agriculture affected the level of collaboration with the Ministry of Health. The departure of Director-General of Ghana Health Service and the Minister of Health curtailed support for the 2001 West Africa Nutrition Focal Point. Advocacy efforts were lost. Decentralization and Different Priorities at the Regional/District levels. District directorates have discretion to determine their priorities. In addition, they work on a limited budget and with less qualified personnel. Without a strong presence at these levels, nutrition programs may not be supported. Unexpected changes in donor focus and priorities. Emergencies. They may lead to diversion of resources, away from nutrition. Training focus. Dual focus on nutrition and disease control led to neglect of nutrition at district level. Main lessons learned: With change of governments, organizations seen as "political" suffer. It is important to advocate and engage other sectors in getting nutrition on the agenda. Dedication, vision and perseverance on the part of nutrition actors are necessary. There is always competition for funds. Seek opportunities to integrate nutrition ("Nutrition lens" approach). 33 4. TANZANIA31 Felicite Tchibindat The history of nutrition policies in Tanzania can be divided into 5 stages, with two main turning points: the "golden years of nutrition" (1974-mid 1990s) and the "derailment era" (mid 1990s- 2000). The first turning point marks the best moment in the nutrition policy trajectory. The second turning point marks the beginning of the deterioration of the situation of nutrition policies that seems to continue until today. History The Beginning (1940). Creation of a nutrition unit under the MOH. The Awareness (1953-54) Establishment of a multisectoral advisory committee focused on food and nutrition activities (triggered by a famine) Birth of Nutrition Institutions (1962-1969) (Independence occurred in 1962) 1. A multi advisory committee became the Tanganyika National Freedom from Hunger Committee (to lessen country's reliance on food aid) 2. Creation of the Tanzania Nutrition Committee (TNC) under the MOH (1963): they established nutrition services and a training school, carried out surveys, and provided food aid; they had a strong political commitment to combat malnutrition. 3. First Nutrition Plan developed by TNC (with support of UNICEF, WHO, and FAO) in 1965-1969 Strong Political and donor support for social service provision and nutrition (1967-72) 1. Arusha Declaration to nationalize the economy (1967) and the political decentralization of 1972 led to a social sector expansion (with support of donors, including the World Bank) 2. Strong political support (from the president) to alleviate malnutrition 3. Formation of nutrition units in the MOA, MOE and MOH, which led to demand for a national nutrition coordinating unit. Golden Years (1974-mid 1990s)--triggered by a severe drought and a food crisis 1. In 1974, the TFNC (Tanzania Food and Nutrition Centre) was created as a parastatal organization; SIDA main contributor of funds; focus on food supply. 31During the edition of this presentation, we have drawn substantially from Dolan, Carmel and James Levinson (2000), Will We Ever Get Back? The Derailing of Tanzanian Nutrition in the 1990s, Discussion Paper No. 17, Tufts University, Food Policy and Applied Nutrition Program. 34 2. Iringa Nutrition Surveillance Project (1979-1982) findings called into question the "food cycle model" and led to the development of the UNICEF CF (conceptual framework), which argued that the fight against malnutrition could not have a exclusive focus on food, but that it required multiple interventions from different sectors, i.e. agriculture, health, sanitation, etc. Results showed that community- based programs were very successful at reducing malnutrition rates. 3. Iringa Joint Nutrition Support Programme (1983-1988) supported by donors puts the CF and nutrition multi-sector planning to the test. 4. Child Survival and Development Project (CSD), with support of UNICEF, applied the Iringa principles. 5. Development of the Micronutrient Malnutrition Control Program (MMCP) after surveys and studies indicated severe problems of micronutrient deficiencies. 6. Development by TFNC of first Food and Nutrition Policy (FNP) in 1976, in response to food crisis (1973-75), adopted only in 1991. It had only limited influence on direction of external agencies and institutions supporting TFNC. The Derailment (mid 1990s-present?) 1. New donors with different agendas/preferences. They initially had a strong commitment to community-oriented programs, but it later got diluted. 2. In 1990, the World Bank started an HNP project (Health and Nutrition Project), modeled after the CSD program (community interventions). At the same time, the WB saw it as supporting the implementation of the Health Sector reform. In the end, only 3% went to nutrition activities. The HNP included the incorporation of nutrition in district plans, but it didn't work too well. 3. World Bank HNP concluded in 1999 and the World Bank moved its focus to micronutrients. However, in 2000 support form WB and other donors for micronutrients also ended. 4. In 1997, with support from the World Bank, the country engaged in a Health Sector Reform (HSR.) The discourse and donor/government attention switched almost exclusively to Health Sector Reform. The nutrition and community-based initiatives disappeared from the agenda. 5. Other factors also contributed to bumping nutrition off of the agenda: (1) the planning Commission lost power under the HSR (the Planning Commission headed the CSD and was supportive of community-based approaches to nutrition); (2) the TFNC was the government focal point for nutrition and emerged during HSR as an anachronism (vertical, centralized agency; (3) during 35 HSR, district health plans gave more attention to hospitals and clinics, with the result that nutrition was no longer seen as community-based but under clinic- based maternal and child health; (4) UNICEF had been a driving force on nutrition during the 1980s and 1990s, but during this transition, it found itself without advocates in nutrition (due to personnel transfers). It found itself during this transition, due to personal transfers, without advocates in nutrition. 6. In 2000, the agenda in the country was focused on the Bank-assisted Health Sector Development Program. UNICEF, however, refocused on community nutrition. Factors of Change Positive: Political support of president for combatting malnutrition Development of strong and successful community-based programs against malnutrition (led to scale up and more funds) Advocates: UNICEF, TNFC, National Commission Negative: Donor-led agenda, and no nationally-rooted agenda to fight against malnutrition to guide donor support Lack of power of potential supporters of nutrition, when agenda was turning away from it Strong role of Health Sector Reform in steering government agenda away from nutrition Donors' change of focus from community-based nutrition to micronutrients to HSR 5. BENIN32 Joseph Hessou During the 1960s, Benin started developing and implementing several types of programs and projects to address food and nutrition insecurity, and established one of the best university programs in nutrition in Africa. However, today, nutrition does not feature in the Poverty Reduction Strategy (PRS) under preparation, despite the fact that malnutrition continues to pose a major public health problem. 32With insights and contributions from reviewers and editors. 36 History In 1960 Benin gained its independence, and within three years the government had created a nutrition unit within the Ministry of Rural Development in order to fight child malnutrition. The unit was known as the Dahomean Service for Food and Nutrition (SDANA). With substantial support from FAO and the Dutch government, it grew to become the National Directorate for Applied Food and Nutrition (DANA). The government wavered in deciding where to house DANA, and the office was transferred twice between two Ministries, the Ministry of Rural Development and the Ministry of Health. For the 30 years after independence, DANA was the national authority on nutrition. It received support from various donors and developed several programs to fight malnutrition, such as with Vitamin A supplementation. However, this began to change after Benin participated in the ICN (1992), where a multisectoral approach to nutrition was promoted. As a result of this conference, the government developed a National Plan of Action to fight micronutrient deficiencies and developed its first Food and Nutrition Plan of Action in 1995. A National Committee on Food and Nutrition (CNAN) was established in 1994, chaired by the Ministry of Agriculture, with DANA as the secretariat, and the Ministry of Health as the vice-chair. In 1994, the CNAN developed a National Plan of Action to fight micronutrient deficiencies, but it was actually adopted in 2004. Salt iodization, however, started in 1994. The Committee had no budgetary authority and was largely ineffective in shaping nutrition programs. Nonetheless, it managed to implement universal salt iodization in the 1990s through a multisectoral initiative that brought together several ministries, and received support from UNICEF. In the 1990s, the Ministry of Health also became an important player and carried out several programs focused on nutrition, with the support of UNICEF, USAID (AED/BASICS), and WHO. In 1996, the government of Benin also took an IDA loan for a community-based food security project (PILSA), with an important nutrition component. As mentioned, despite its success, the project never developed into a national program and was discontinued in 2000. Overall, Benin has received support from multiple donors, who have brought the participation of several national partners to the nutrition field, but it has failed to translate that cooperation into a coherent national policy. In fact, as many nutrition programs are entirely funded by external donors, they tend to disappear once the funds dry up. As a result of this dependency, as these external partners redefined their priorities and put nutrition in the backburner, the government of Benin also relegated this issue and did not include it in its development agenda. Factors that favor or derail change There are several positive factors that have contributed to the best moments of building a nutrition policy for the country. The presence of a "champion" in the Ministry of Rural Development. From 1991 to 1995, one of the former deans of the Abomey-Calavi Faculty of Agronomy was 37 appointed Minister of Rural Development. He contributed to building the government's commitment to nutrition. Influence of international conferences. These conferences helped to change the image of nutrition within the country and to put it at the forefront of development. They key conferences were: World Summit on Children; Ending Hidden Hunger; ICN; and The World Food Summit. Institutional capacity at the local level. The implementation of PILSA showed that a strong partnership between local governments and NGOs offers a sustainable strategy for nutrition programs. Challenges: It is necessary to build political commitment as the issue has disappeared from the agenda. Think of strategies to scale up successful nutrition programs from the outset. Promote a core group of leaders in nutrition to advocate, nurture political commitment, and cultivate its institutionalization. Elaborate a national nutrition policy document to guide Benin's programs and actions in nutrition 6. INDIA33 Rajeshwar Rao The problem in India is not so much about institutionalization of nutrition program or the existence of a national policy, but rather about persistent malnutrition despite years of nutrition- related policies and interventions. History India has a comprehensive National Nutrition Policy and National Plan of Action on Nutrition. In addition, it has a National Policy for Children (1974), which provides a conceptual basis for an integrated approach to issues concerning children. The Integrated Child Development Services (ICDS) Scheme was launched during the Fifth Five Year Plan (1975-1982) in 33 community development blocks in the country. It entailed a paradigm shift from child welfare to child development and an emphasis on integration and convergence of sectoral social inputs for the well being of infants, children and pregnant and lactating women. After the World Declaration on Nutrition of the International Conference on Nutrition (1992), India drafted a National Policy on Nutrition (1993) and a National Plan of Action on Nutrition 33With insights and contributions from reviewers and editors. 38 (1995). This plan identified nutrition with development and outlined a multisectoral strategy for achieving national nutrition goals. The instruments associated with this policy included: 1) universalization of a nutrition safety net; 2) intensification of micronutrient malnutrition control activities; 3) popularization of low-cost nutrition foods; and 4) fortification of common foods with essential micronutrients. It highlighted the role of 14 sectors: agriculture, civil supplies, education, environment and forest, family welfare, food, food processing industries, health, information and broadcasting, labor, rural development, urban development, welfare and women and child development. Results and Obstacles Nutritional status has improved widely in many states, with some experiencing a transition in nutrition or the double burden of under-nutrition and over-nutrition. However, India continues to have one of the highest proportions of childhood malnutrition in the world. One of the most important interventions in nutrition in India is the Integrated Child Development Services (ICDS) carried out by the Ministry of Women and Child Development. Community participation is significant in this program. At the grassroots level, an Anganwadi Worker (AWW) provides services at an Anganwadi (meaning courtyard) Center. Today, ICDS operates 5,724 projects across the country with 805,000 Anganwadi centers. Its supplementary nutrition program reaches 67.33 million women and children. The government of India is committed to universalizing the ICDS, allowing it to reach every household in the country. Despite the impressive size and reach of the program, statistics in India still remain dismal. 58 out of 1000 live births do not complete their first year of life 67% of infant deaths take place within 48 days 46% in 0-3 years are underweight About 4 out of 5 children in the 6-35 months age are anemic 44% are fully immunized 21% receive Vitamin A supplement The ICDS has already identified strategies for improving its program. Achieving ICDS universalization with quality Strengthening basic infrastructure and service delivery in AWCs Restructuring program management/revised ICDS implementation Strengthening nutrition and health education Fostering public-private and community partnerships Strengthening partnerships with NGOs and voluntary sector Better targeting: addressing the needs of those areas (states/districts/blocks) where prevalence of malnutrition among children is more pronounced. Micronutrient supplementation/fortification The Ministry of Women and Child Development has also initiated a consultative process for re- designing the ICDS implementation framework. Several ideas have emerged from this process. 39 Look for more flexibility at the local level Strengthen partnerships with NGOs, public and private sector Reach the most vulnerable Strengthen local capacity Empower ICDS functionaries 40 PART IV: TOWARDS AN ANALYTICAL FRAMEWORK34 Marcela Natalicchio As seen in the previous sections, both research and country experiences have suggested common obstacles, as well as insights and strategies to move nutrition forward in the development agenda of countries. In fact, there are striking similarities in the factors mentioned in the different sections. This suggests that these factors should form the basis of any analytical framework for understanding and implementation of reforms. The experiences and studies discussed also demonstrated how commitment for nutrition is built at country level. In what follows, we present the outline of an analytical framework that captures (a) the main obstacles to putting and keeping nutrition on the agenda, and implementing effective nutrition- promotion policies, and (b) possible solutions and strategies that can be used to overcome those obstacles. Common Obstacles Nutrition policies and programs in many countries are trapped in what can be termed a "low priority cycle"35. Issues like nutrition can end up in low priority cycles for a number of reasons. For one, it has low visibility because the nature of the problem is such that its symptoms are hard to detect without knowledge of how to look for them. A malnourished child will get sick more often, but their parents will only acknowledge the sickness, failing to see its root cause, which is malnutrition. Unfortunately, doctors and nurses can make the same mistake, treating the effect and not the root cause of the sickness. This low visibility translates into lack of demand for nutrition interventions on the part of those suffering the effects of malnutrition, and those in the health sector. Second, nutritionists are often not given equal standing as physicians and their opinions within the health system are under-rated or ignored. Their status within the bureaucracies is also lower. Third, donors, whose role as an important source of funding often allows them to influence the health agenda, have not given malnutrition the same attention that they have devoted to HIV, malaria, or other similar health problems. The low visibility issue gets reflected in its institutional placement. Nutrition departments tend to be quite small, regardless of the Ministry in which they are located. These departments are usually under-funded, and are therefore unable to recruit sufficient personnel or implement their programs and activities. Furthermore, even among existing personnel, few have the qualifications needed to design and implement sound nutrition programs. As a consequence, these departments have little coordination capacity to put all projects and programs in nutrition under a common and consistent plan. The factors described above result in low-quality service delivery, and limited progress in reducing malnutrition. These results reinforce the low priority given to nutrition, thereby worsening the situation. Donors also play a role in reinforcing this cycle: as they provide 34With insights and contributions from reviewers and editors. 35Natalicchio, Marcela (2008) Making Nutrition Central to Development, Prepared for the Annual APSA Conference, World Bank Course on Social and Political Analysis at the World Bank, Boston, MA, August 27. 41 fragmented support, giving small funding to different agencies with no coordination, they contribute to the outcomes described above. The role of donors is particularly important given that many countries have nutrition policies and programs that are donor-driven and depend almost completely on external funding. Figure 7. "Low Priority Cycle" Low Priority Cycle - Low visibility issue - Small Department - Low funding - Little coordination capacity - Deliver marginal services Fragmer ntedpport - Limited impact su dono Source: Marcela Natalicchio (2008) Making Nutrition Central to Development. Prepared for presentation at the Annual APSA Conference, World Bank course on Social and Political Analysis, August 27, Boston, MA. Given this scenario, change will only occur if there is an explicit intention to break this cycle through a reform. In the case of a reform, the main issues involved in moving it forward will be related to its political feasibility rather than more technical aspects. The problems with the political feasibility have to do with: (1) potential "losers" from the reform; (2) difficulty in organizing a constituency (the ones that benefit the most are malnourished children and mothers from poor, rural areas), (3) the lack of an institutional home, leaving malnutrition the responsibility of many and of none at the same time, and (4) the lack of administrative capacity to implement the reforms. Putting Nutrition on the Agenda Several elements have been identified as factors that can contribute to putting nutrition on the agenda. Understanding the context. Understanding the political economy landscape in which the reform will take place is a first essential step to determining the best strategies to pursue. 42 It is important to identify the political-institutional context, the political dynamics, decision-making areas relevant to the reform, and key actors and coalitions. In so doing, it is important to consider not only the formal rules of the political system but also the informal ones. This diagnostic will identify the supporters and the opposition to the reform. Creating and nurturing "coalitions" for reform. These inclusive coalitions will be in charge of advocating for reform in the nutrition area and making sure that the reform gets the attention of key players in the political system so that it has a good chance of getting approved and implemented. It is important to include representatives from government and from outside of government, and in particular to consider the donors. These coalitions do not have to be formal; informal connections in key places can be crucial. In this regard, it is important for participating nutritionists to have managerial and leadership capabilities in addition to technical skill. These coalitions can make use of advocacy tools (i.e. PROFILES) and strategies that have proven to be very effective in gaining the support of policy elites as well as donors. It is important to target different audiences and develop appropriate messages for each of them. During the process of coalition formation, it is also crucial to work with nationals and not against them. Develop a common view. In order to push the agenda, it is important that all interested parties develop a common view of the problem and the solutions to present a simple, compelling and unified narrative to politicians. Develop appropriate strategies for success. Understanding the players and the political context should help in the development of better strategies. Also, it is critical to learn from other countries' experiences. A body of systematic knowledge should be generated. Understanding donors and how each of them works is key. Making good use of windows of opportunity such as international conferences on nutrition or previous successful projects has proven to be a pathway for more ambitious reforms. Finally, it is important to devise good institutional arrangements for nutrition so as to reduce dependency on champions. Adoption, Implementation and Sustainability Getting nutrition on the agenda is only the first step in establishing effective and sustainable nutrition policies. . Other elements are crucial once the reform moves into the adoption, implementation and sustainability stages. During the reform process, it is important to make simultaneous changes in the political, technical and community arenas. In addition to putting nutrition on the agenda, capacity building to implement technically sound programs needs to take place, as well as efforts to enhance local capacity and awareness. A coherent policy needs to be developed to avoid the typical juxtaposition of programs. 43 It is important to develop effective cross-sector coordination, which can be challenging and may require management training and working with partners on a trial and error basis. It is key as nutrition will require actions in different sectors. It is important to devise an adequate institutional arrangement for nutrition that can combine strong political support, effective coordination mechanisms, and good technical skills. The coordination body as the most visible agency of nutrition needs to gain credibility and trust of its partners. Keeping and sustaining interest in nutrition. Advocacy efforts have to be constant and should continue even once nutrition is on the agenda. Different mechanisms can be used, including personal relationships, the mobilization of-opinion makers, and advocacy campaigns. It also important to look for technical solutions that speak to the interests of partners. Challenges Some aspects appear to be particularly challenging during the reform process, even in cases in which relative success has been achieved. Developing a sustainable financing mechanism that combines budget and external resources. Developing capacity of local actors, who play a key role in the community interventions that have proven very effective in reducing malnutrition. Keeping the issue of nutrition on the development agenda. Make inter-agency coordination work effectively. Lining up priorities between the central and local levels. Changing donor focus and priorities. In this section, we have presented the elements of a framework for understanding and action in reforms in nutrition, as they emerged from the studies and country experiences presented. As mentioned, there was a high level of agreement regarding the factors that are crucial to reform. However, participants agreed that more systematic knowledge of these factors and strategies needs to be generated based on previous experience. Following the workshop, the World Bank launched a six-country comparative study in Africa to further develop the framework. At the moment of this publication, all six case studies were close to completion, and a comparative synthesis was about to take place. At the same time, several initiatives are being considered to disseminate this framework widely within and outside the Bank, provide relevant training to both World Bank staff and in country technical personnel, and launch pilots for reform in two African countries. Also, various countries were selected to develop activities geared towards building commitment to nutrition. The next section provides an account of the plan of action that these countries developed, the activities carried out, and their accomplishments and challenges. 44 PART V: BUILDING COMMITMENT FOR NUTRITION. PLANS OF ACTION AT COUNTRY LEVEL James Garrett The second day of the workshop aimed to give participants a chance to learn from each other and apply insights from Day One. The primary objectives were to: a. sketch out plans for strengthening political commitment in their own countries; and b. present the plan and get feedback from the group. This section presents the ideas developed by the country participants, and also updates what has actually happened in the focus countries of Benin, India, Nicaragua, and Tanzania. These country plans and experiences provide insight into how to encourage participants to translate their knowledge into action, and about what others may expect when trying to build political commitment at the country level, including opportunities and obstacles. Participants developed a country plan based on the following questions: 1. With regard to nutrition, what is the current situation, and what are the desired goals for your country? 2. What are the "driving forces" (things that help move toward the goal) and "restraining" forces (things that can inhibit reaching the goal)? 3. What are the most important driving and restraining forces? Prioritize your list. 4. What strategies for action can you or others follow to eliminate or reduce the restraining forces and capitalize on the driving forces? 5. Who specifically needs to be influenced to make the strategy a reality? How could that be done? 6. What additional steps could be taken to move the action strategies along? A. Country Plans and Experiences Benin At the workshop, Joseph Hessou outlined the following actions to strengthen commitment: · Organize a workshop involving the key players in order to discuss nutrition issues and the strategies to energize action. The media and specialists in communication will be invited. · Elaborate a nutrition policy document in order to have consensus on how to tackle nutrition concerns/problems in Benin. · Undertake dynamic and efficient advocacy and lobbying to convince government, parliament, local authorities, or community leaders to be part of progress in nutrition development. 45 Specific actors he cited to bring into the initiative included President Dr. Boni Yayi; the head of Parliament, Dr. Nago Mathuri; the Minister of Finance and Development; the Minister of Health; the Minister of Agriculture; and the Minister of Women, Childhood, and Family. A donor group, including the country representative of the World Bank, and commune leaders (mayors or leaders of municipalities) should also be incorporated. Mr. Hessou identified some immediate openings for actions. He planned to brief the Minister of Agriculture (his home ministry) on the results of the workshop on his return, and to ask the World Bank to press the case for nutrition as central to development during an upcoming visit. The World Bank representative could meet, for example, with the President, the President of Parliament, various ministers, and the leader of the current national committee on food and nutrition. A press conference would be held at the end of the visit to maintain visibility and enhance commitment to the issue. Upon his return to Benin, Mr. Hessou led the establishment of a small intersectoral core group interested in promoting action on nutrition. This interministerial group would serve as the government counterpart to this initiative. A stakeholders' visioning retreat was held in November 2007 to develop a broader understanding among a comprehensive set of actors of the nutritional challenges in Benin and to secure their commitment to a workplan for longer-term actions to reduce malnutrition. Technicians as well as ministers attended the retreat. A study of the history of political commitment to nutrition in Benin, funded by the Italian Trust Fund, was also presented and helped to understand how nutrition gets on and falls off the political agenda in Benin. This analysis suggested entry points for action as well as actors and factors to consider in designing a plan. The core group then worked to modify and implement the workplan developed at the retreat. The actions of this group have affected government policies and donor operations. For instance, the Council of Ministers adopted the resulting workshop report and accompanying road map on nutrition policy reform in January 2008. The road map envisaged the creation of a national policy unit to define the parameters of a national nutrition program and the mechanisms for its roll out. The draft decree to create the National Council for Food and Nutrition, with a Permanent Secretary under the President, was ready for validation, then signature by the President, by early 2008. The Poverty Reduction Strategy Program would also now be able to more substantively reflect what actions to take on nutrition. The current PRSP included nutrition, but did not specify any mechanisms to trigger scaling up of direct nutrition action. The core group is now working more closely across sectors. Although Mr. Hessou, for example, is based in the Ministry of Agriculture, he and the core group are working with health sector colleagues to better position nutrition within government. A World Bank-funded study on health and nutrition conditions in Benin will feed into a health sector project in the Bank's business plan for Benin. In Benin, nutrition has historically been fragmented over three ministries and numerous NGOs. Action has been paralyzed for years. The grant activities have brought together these different stakeholders in a partnership arrangement (core group) to facilitate the policy reform process. 46 With support for the core group, Benin is now likely to be able to consolidate its nutrition programs defined on the basis of community needs, and not stakeholder needs as was the case before. This makes the action even more attractive to other donors, such as UNICEF. Nicaragua Participants from Nicaragua were not able to attend the workshop, but World Bank staff wanted to take the commitment-building process forward, as part of ongoing activities on nutrition in Nicaragua. The World Bank used a technical assistance grant to provide additional funds to support the involvement of Bank staff and so accompany the use of the BNPP funds. The World Bank had sponsored a workshop on nutrition in Nicaragua in May 2007. This workshop promoted discussion among a diverse range of actors, representing a diverse set of opinions, of the underlying concepts about how to reduce malnutrition. Although the Government was interested in prioritizing nutrition, it did not want to develop a specific investment project, and so the BNPP had no specific government counterpart with which to work. However, given this interest, and building on the workshop, the Bank commissioned an overview of the nutrition situation in Nicaragua, including an institutional inventory. (This paper was later strengthened and updated.) Unsure of how to proceed, in September 2007, Bank staff and consultants visited Nicaragua to listen to ideas from stakeholders, including the Government, NGOs, and donors, about challenges for nutrition in Nicaragua. Staff decided a more in-depth study of the political and institutional landscape was needed before forming a core group. This report was commissioned and completed in early 2008.An expert on change processes prepared a separate report on options and recommendations for building political commitment in this context. Interestingly, through the process of preparing the reports, a group of advocates for nutrition emerged. This group was composed of individuals who worked outside the Government (including consultants and staff from NGOs and donors), but often had close ties to it. This group, named "Friends of Nutrition," included people who were key players in Nicaragua but personally committed to advancing the nutrition agenda, rather than a commitment due simply to position or institution. The final organization of the group is not yet set, but the group is currently leaning towards becoming a coalition institutions (including government, donor agencies, and NGOs) and individuals. The Friends, with Bank funding, sponsored two workshops, one in April and another in June. The first workshop was small, and intended to help with the formation of the group and its strategy. Government officials also attended, including the Secretary General of Health attended. The workshop presented concepts, experiences, and lessons from other countries about how to create political commitment for nutrition. It also presented the report on the political economy of nutrition in Nicaragua. Building on these and their own ideas, this group began to develop an action plan and to consider how the Friends and the Government could best work together. 47 A more technical workshop, sponsored by the Government and the group, was held in June. This workshop was larger, and included national and local government officials from the health system. It aimed to develop a wide vision for action on nutrition among a wider group of stakeholders, specifically beyond the Friends and outside the central level of Government. The workshops presented information on conceptual frameworks, the nutrition situation in Nicaragua, and best practices from international reviews as well as from other countries. The Friends have continued to provide technical support to the Government. For example, Friends have provided comments on the Government's new nutrition strategy and have interacted with the Government's technical committee on food security and nutrition (COTESAN. The many Friends are also quite active across the spectrum of action and advocacy for nutrition and health in Nicaragua and Central America. The establishment of the Friends has provided a network for information-sharing on these topics. The Friends are now coordinating with the Government to produce a strategy for advocacy and strategic communications on nutrition. Parallel to this effort, the Bank has worked with the government to incorporate nutrition indicators into the Country Assistance Strategy (CAS) and to coordinate with a Bank-funded health project. The Friends and the Bank team are also working to document the commitment- building process. Studies and reports (on nutrition conditions, on the political landscape) provided inputs into the workshops and the action plan. The experience in Nicaragua suggests that working organically (from the ground up) and outside the Government is possible, but poses special challenges. At the same time, such an approach encourages country ownership and adaptation of the principles of commitment-building to the local political reality. Nevertheless a group like the Friends still needs an institutional base and independent financing. The leaders of the Friends, so far, have worked voluntarily, an approach, which is not sustainable. It is also a delicate matter to determine how to interact with the Government, without being seen to support it uncritically. So far, the personal relationships, and the technical nature of assistance (appreciated by the Government), are maintaining the connection. Now that the Friends have developed an action plan, options include hiring someone to help implement it and to develop funding sources for the long-term. A communication consultant could help to enrich the planned activities, disseminating results of best practices in Nicaragua and building consensus across the political spectrum and among both nutrition and non-nutrition actors. India The participant from India noted that India had a large-scale program, the Integrated Child Development Scheme ((ICDS), in place. Still, 46 percent from 0-3 were underweight, with the largest preponderance of these children in about 6 to 8 states, with 150 to 200 high-burden districts. 48 The goal would be for India to halve malnutrition in the next 5 to 7 years, primarily by reaching new areas. The program would need to be flexible and responsive to conditions at local levels, with a focus on improving Infant and Young Child Feeding. The principal positive forces included strong political commitment, including understanding of the importance of nutrition at various levels, commitment to measuring ICDS impact, and adequate budget support. At the same time, current evaluation mechanisms were weak, professional capacities were inadequate and inconsistent at national, state, district, and project levels. Some elements of the action strategy would be: · Workshops to raise awareness among policymakers and political executives at regional, sub-regional levels · National and regional Information, Education and Communication (IEC) campaigns to raise awareness among society, perhaps with a popular celebrity as nutrition ambassador · Field visits by key officials at the state, district, and project level to see best practices · Identify and disseminate information on best practices through the print and electronic media · Enable MIS/GIS mechanisms for better targeting Key audiences for these measures would include Ministers, Secretaries, and Directors, and elected representatives in the high-burden states and districts; various Secretaries and other high officials from the range of agencies and ministries who can affect nutrition, such as Women and Child Development, Sanitation, and Finance and Planning; and the media. The analysis and actions described for India were a good initial step, but the Government administration soon underwent several changes. CARE-India then presented ideas on how to carry this work forward. They developed a detailed plan to pilot efforts in one or two states. Communications and advocacy with parliamentarians, ministers, and other NGOs and research groups was a main element of the plan. The project would link to ICDS implementation under the new Bank project. But the key contact in CARE left before the work could begin. Tanzania In Tanzania, driving and constraining forces tended to coalesce around institutional lines. The donor partnership group, NGOs, universities, and line ministries were keen on giving action on nutrition greater priority. The Tanzania Food and Nutrition Centre (TFNC) had long led initiatives (operations and research) on nutrition, but over time had become less and less active. Many still looked to TFNC for leadership. Although it was no longer forthcoming, no agency, including the Ministry of Health, seemed willing to step up to be the new leader, possibly as this would involve clashing with TFNC. The participant from Tanzania, a nutrition adviser from UNICEF, identified a number of actions to shake loose from this inaction. 49 Upstream, she suggested: · Create awareness among higher government levels on need for reform for nutrition to get accountability and results · Conduct a nutrition audit to see how nutrition actions play out in each sectoral policy · Identify and train nutrition entrepreneurs to become part of a core team for advocacy across government Downstream, she suggested: · Show and share results at sub-national level of what can be done · Identify and foster champions for nutrition at subnational levels · Strengthen nutrition unit in the line ministry She also specified allies and advocates to help implement these actions. For example, advocates should seek ways to discuss nutrition with the advisor to the President or Prime Minister; identify a specific champion in the Parliament who could press for accountability, especially in the high-burden regions and districts. Donors, local government authorities and regional councils, along with line ministries and potentially the TFNC Board, could also press for action. The media might also be contacted, so that they could ask questions that might influence action by the TFNC Board and line ministries. One of the most difficult issues seemed to be how to reform TFNC, or otherwise promote institutional leadership within Tanzania. Some attempts had been made to reform TFNC from within, but they had been unsuccessful. A suggestion was now to hire a specialist in change management, to devise and implement a new strategy for change. UNICEF and the World Bank proposed a number of activities to build commitment. Most of these complemented attention that nutrition was already receiving from the Government as well as UNICEF, the World Bank, and other development partners. The BNPP funds were to be used to expand activities already underway and being led by the development partners, including launch of a new Bank-produced study on the nutrition situation in Tanzania or an organizational analysis of TFNC. However, before activities could begin, the nutrition adviser moved to a regional position, and no one in the Bank office or development partners was able to continue the work. B. Overall Progress and Observations A guiding principle for building commitment seems to be inclusion and participation of all actors in nutrition. Almost all country plans involved government agencies and their staff, government leaders (parliamentarians and ministers), NGOs and CBOs, donors, and private sector representatives. Grant activities were intended to catalyze and support action, while allowing country actors to lead. To now, country-level actions have largely taken place in Benin and Nicaragua. Among the most important actions was the emergence of a core group to lead actions. In addition, the Bank and these groups worked to generate evidence on nutrition conditions and political 50 economy at country-level, which could promote dialogue and support advocacy efforts. Creation of a common vision and understanding among key actors seemed critical. Identifying country actors who were ready and capable of devising and implementing such a strategy, however, was difficult. The need for a World Bank counterpart in country to guide the work was another challenge. The existence of the grant has also energized work on nutrition within the Bank. The workshop described in this report, for instance, brought together staff and funding from the Bank's Africa 2 Region and the Poverty Reduction and Economic Management unit (PREM). It built on initiatives already ongoing on the political economy of nutrition and of service delivery, respectively. A technical assistance grant in Nicaragua was designed to complement trust fund activities, largely by providing funds for Bank staff to accompany the process. And the Italian CHYAO trust fund financed case studies on political economy of nutrition in a number of African countries, including focus-country Benin, which will serve as important knowledge inputs into grant activities. . 51 VI. CONCLUSIONS The purpose of this section is to provide a reflection on the extent to which the workshop has accomplished its stated objectives, and the way forward. Combining the knowledge of academics regarding the politics of reform (generally and in relation to nutrition) and the insights of practitioners in the nutrition field has proved very useful. Analyzing the rich experiences of practitioners in several countries allowed for the identification of typical obstacles and challenges in the nutrition arena, as well as possible solutions to them. At the same time, academics provided a range of concepts that offered frameworks and concepts that practitioners could use to analyze their experience. Furthermore, the presentation of both general insights on the politics of reforms and concrete experiences at the country level helped workshop participants to come up with concrete actions and activities to be pursued at country level in order to create a higher level of commitment for reforms. In order to more systematically test the hypotheses regarding factors that seem to make a difference in nutrition sector reform, comparative case studies were launched in September 2007. With funding from the Italian Trust Fund for Children and Youth in Africa (CHYAO), case studies began with four countries in Francophone Africa. The choice was made to focus on francophone countries (a) because the literature on the subject for Francophone countries is more limited than for Anglophone countries, and (b) to allow for the comparison of cases in countries with similar political and cultural legacies. The countries selected were Madagascar, Senegal, Benin, and Burkina Faso, three of which participated in the workshop. Madagascar and Senegal were selected as cases in which (a) the reforms of the nutrition sector had made considerable progress, and (b) malnutrition rates were known. Additional funds from Bank-Netherlands Partnership Program (BNPP) and the Africa Region Flagship Study Program allowed us to incorporate two more cases in Anglophone Africa. This should allow us to test for differences between countries with different political and colonial legacies. We chose Gambia and Ghana, with Ghana also being one of the participants in the workshop. Gambia was chosen as it had also achieved a high level of government commitment, and had even created a special agency, NANA, in 2000 to ensure the improvement of nutrition standards in the country. NANA proved to be quite successful. As in Senegal and Madagascar, Gambia pointed to the challenges of sustaining the commitment over time. In fact, the three cases shared similar challenges. Among them were the sustainability of funds, either from budget sources or donor sources; the management and political skills required to maintain interest in sustaining the effort by politicians and donors; and coordination of the multiple partners usually involved in nutrition. As of the publication of this workshop report, the six case studies are almost complete, and the report detailing and comparing the results should be ready by March 2009. In addition, we are in the process of analyzing "shadow cases" for which case studies will not be conducted, but which will be analyzed through secondary sources. The countries selected are Tanzania, Ethiopia and Zimbabwe. We hope that the publication of this comparative report and the identification of a framework for nutrition reform action and analysis will be instrumental in garnering support for the sector from Bank management, and promoting the adoption of a more systematic strategy in 52 nutrition loans. The framework should also inspire support from other relevant donors in the field, and produce a higher level of harmonization at country level, in an area that is characterized by donor fragmentation and lack of synergy. The upcoming comparative analysis and framework will also constitute the basis for training within the Bank and among nutritionists and donors, in an area where knowledge is incipient. The workshop was able to identify the need for training on this subject among nutritionists who agreed that the more technical focus of their training leaves them ill-prepared to handle the political and administrative aspects of nutrition reforms and to manage the daily operations of coordination agencies or large nutrition programs. Since the 2007 workshop, the World Bank management has expressed an increased interest in investing in nutrition, particularly in Africa. Its current president, Robert Zoellick, has said on numerous occasions that the Bank should increase its commitment and level of investment in this area. More funds have been made available in the last year for specific actions, but the Bank still lacks a consistent and forceful strategy that is reflected by systematic and clear actions at country level. This will be the challenge in the months ahead, and we hope to make inroads with analytical as well as more active dissemination contributions, such as regional workshops and trainings for both Bank and non-Bank staff. Finally, in terms of the creation of an increased level of political commitment at the country level, chapter V has provided a detailed account of what has been accomplished in the selected countries. As shown, progress has been uneven and it has encountered various obstacles in different contexts, In addition, in part as a result of spillover effects of successful country experiences in Senegal and Madagascar, other countries have shown an increased level of commitment towards nutrition and are working on their institutional set up and the creation of large-scale programs. Among them, Burkina Faso and more recently Mali seem to be heading in that direction. The latter will start conducting a political assessment in the coming months. However, it seems that in order to have a larger impact, more awareness should be created at the regional and national levels to spur action by governments. At the same time, donors also have to increase their own level of commitment towards nutrition and increase levels of both coordination and funding for these types of programs. Given the budget limitations of many African countries, which suffer from the worst malnutrition rates, it is unlikely that they will be able to combat malnutrition without the sustained assistance of the donor community. 53 ANNEXES Annex 1: Workshop Agenda WORLD BANK WORKSHOP Carrots and Sticks The Political Economy of Nutrition Policy Reform May 21, 2007 Agenda 8:30-9:00 am. Opening Remarks Menno M-ulder-Sibanda, Senior Nutrition Specialist, Africa Region, The World Bank The Mechanics of the Workshop Carol Wzorek, facilitator, TRG 9: 00 - 9:30 am The Evolution of Public Nutrition Policies in Senegal Presenter: Biram Ndiaye, National Coordinator, National Committee Against Malnutrition, Office of the Prime Minister, Dakar, Senegal 9:30 ­ 11:00 am The Political Economy of Reforms: Main Themes and Lessons Chair: Steve Ndegwa, Senior Public Sector Specialist, Africa Region, The World Bank Creating Political Capital: A Framework for Analyzing Nutrition Policy Reform Regina Birner, Sr. Research Fellow, Development Strategies and Governance Division International Food Policy Research Institute (IFPRI) How Political Economy Derails Reform: Why, How and what to do? Susanne Mueller Consultant and Associate, Department of African and African American Studies Harvard University The Challenge of Proactive Political Economy Analysis: A Suggested Approach to Support Policy Change Alejandra González Consultant, GTD International 54 11:00 am Coffee Break 11:15 -11:45 am Country Experience: Benin Presenter: Joseph D. Hessou, Nutritionist, Ministry of Agriculture, Livestock and Fisheries, Cotonou, Benin 11:45 pm ­ 12:45 pm The Politics of Nutrition Policy Chair: James Garrett Senior Economist, Human Development (Health, Nutrition and Population), The World Bank Challenges in Building Attention to Undernutrition in National Processes in Africa Todd Benson Research Fellow, Food Consumption and Nutrition Division International Food Policy Research Institute (IFPRI) The Politics of Nutrition Policy: The Search for Solutions that Fit the Nature of the Problem David Pelletier Associate Professor of Nutrition Policy, Division of Nutritional Sciences, Cornell University 12:45 am ­ 1:45 pm Lunch Break 1:45 - 2:45 pm Country Experiences Madagascar Nutrition at a Crossroads Presenter: Ms.Valencia Ranarivelo National Director PNNC Seecaline, National Nutrition Office, Antananarivo, Madagascar Ghana Fifty Years of Political Independence in Ghana: What Progress for Nutrition? Presenter, Ms. Rosanna Agble Consultant, former Head of Nutrition Unit, Ghana Health Service, Accra, Ghana 2:45 - 3:00 pm Coffee Break 3:00-4:30 pm Promoting Reforms: Key Issues in Organizational Change, Management, and Strategic Communications Chair: Marcela Natalicchio, Consultant PREM, The World Bank 55 Welcome to the Swamp Helgi Eyford Associate, Four Worlds Centre for Development Learning / Director, Research and Training, Calgary Multicultural Centre Rethinking Public Service Delivery Programs through Accountability Frameworks and Execution Processes Eric Champagne Assistant Professor, School of Political Studies, Public Administration Program, University of Otawa, Canada. Rapid Results: A Means to an End? Ronnie Hammad Sr. Operations Officer, Operations Quality, Knowledge and Results, Africa Region, The World Bank 4:30 - 5:30 pm Country Experiences Tanzania Community-based Nutrition Interventions in Tanzania: A Lost Decade? Presenter: Ms Felicite Tchibindat Nutrition Project Officer, UNICEF, Dar es Salaam, Tanzania India Nutrition Actions in India: Current Challenges Presenter: Mr. Rajeshwar Rao Director, Ministry of Women and Child Development 5:30-6:30 pm Moving Forward: Key Pathways and Actions for Nutrition Policy Reform · Group Work / Presentation and Comment in Plenary 6:30 pm Wrap Up and Concluding Remarks Menno Mulder-Sibanda 56 Annex 2: Questions for Panels Session The Political Economy of Reforms: Main Themes and Lessons 10 minute presentations Objective: Identify issues and provide lessons in policy reform and change. Suggest how they could apply to nutrition. Questions: Why, how, and when do reforms move forward or get stuck? What factors or sequences of change inhibit or promote policy reform and change ­ including initiation, implementation, and sustainability? What frameworks, conceptual models, or typologies can we use to guide our thinking for research and action? How might such reforms be best studied and implemented? What is essential? What should be avoided? How might these insights and lessons apply to nutrition? Session The Politics of Nutrition Policy 10 minute presentations Objective: Identify and provide insights into the specifics of policy reform and change with regard to nutrition, particularly political and institutional issues. Questions: What factors inhibit or enhance policy reforms and change in nutrition? What factors help move nutrition forward -- including initiating, implementing and sustaining attention to and action on nutrition? What makes nutrition policy reforms the same or different from reforms in other policy areas? How does this modify insights from the previous panel? How are these reforms best studied and implemented? What is essential? What should be avoided? Session Promoting Reforms: Key Issues in Organizational Change, Management, and Communications 10 minute presentations Objective: Present strategies and approaches that can promote policy reforms and change in nutrition, with special attention to building consensus and ownership among key actors, and promoting sustainable action by them. Questions: What political, organizational, and communication strategies, techniques, and approaches can be used to promote policy reform? What concrete examples show how to use these strategies and approaches? What are their strengths and weaknesses? 57 Under what conditions might they be most and least effective? What factors need to be taken into account to adapt them to country context? To the issue of nutrition? Sessions Country Experiences 15 minute presentations Objective: Provide concrete examples of country experiences in promoting action on nutrition. Identify main obstacles to as well as opportunities for action, and elements of strategies for success, or reasons for failure. Questions: Briefly, what is the history of attention to and action on nutrition in the country? What have been the key events and factors (positive and negative) that have led to changes of course for nutrition (attention, action)? * What is the current situation? What are current challenges, obstacles, and opportunities to move nutrition forward? What next steps are being planned? *Presentation or discussion may pay special attention to the activities or strategies the country has used to get action on nutrition, and their results. The roles of political and institutional factors as reasons for success or failure may be highlighted. 58 Annex 3: List of Participants Susanne Mueller Consultant and Associate, Department of African and African American Studies Harvard University smueller@fas.harvard.edu Alejandra Gonzalez Senior Health Policy Analyst Division of Country Health Systems WHO Regional Office for Europe rossetti@es.euro.who.int Regina Birner Senior Research Felow, Development Strategies and Governance Division International Food Policy Research Institute (IFPRI) r.birner@cgiar.org David Pelletier Associate Professor of Nutrition Policy Division of Nutritional Sciences, Cornell University dlp5@cornell.edu Todd Benson Research Fellow, Food Consumption and Nutrition Division International Food Policy Research Institute (IFPRI) t.benson@cgiar.org Eric Champagne Assistant Professor, School of Political Studies, Public Administration Program, University of Otawa, Canada echampagne@uotawa.ca Helgi Eyford (Four Worlds) Associate, Four Worlds Centre for Development Learning Director Research and Training, Calgary Multicultural Centre heyford@shaw.ca Ronnie Hamad Senior Operations Officer, Operations Quality, Knowledge and Results Africa Region, The World Bank Rhammad@worldbank.org 59 Mario Bravo Senior Communications Officer, Communications Network The World Bank mbravo@worldbank.org Alan Berg Consultant, Human Development Network The World Bank alanberg@earthlink.net Valencia Ranarivelo (Madagascar) Former National Director PNNC Seecaline, National Nutrition Officer Ala Maiky Coordinator, WWF Madagascar and West Indian Ocean Programme Antananarivo, Madagascar ranarivale@yahoo.fr Biram Ndiaye (Senegal) Former National Coordinator, National Committee Against Malnutrition Office of the Prime Minister, Dakar, Senegal Nutrition Specialist, UNICEF Burkina Faso bndiaye@unicef.org Khadidiatou Dieng (Senegal) Former Senior Nutrition Advisor, Senegal Nutritional Enhancement Program National Coordinator of Senegal Nutritional Enhancement Program Dakar, Senegal kdieng@clm.sn Joseph Hessou (Benin) Nutritionist, Ministry of Agriculture, Livestock and Fisheries Coordinator of Core Group Nutrition Cotonou, Benin jedhessou@yahoo.fr Rosanna Agble (Ghana) Consultant, Former Head of Nutrition Unit, Ghana Health Service Accra, Ghana ragble@hotmail.com Felicite Tchibindat (Tanzania) Nutrition Project Officer, UNICEF Dar es Salaam, Tanzania ftchibindat@unicef.org 60 Rajeshwar Rao (India) Director, Ministry of Women and Child Development krrao@nic.in Menno Mulder-Sibanda Senior Nutrition Specialist, Africa Region The World Bank mmuldersibanda@worldbank.org James Garrett Economist, Food Consumption and Nutrition, IFPRI j.garrett@cgiar.org Steve Ndegwa Senior Public Sector Specialist, Africa Region The World Bank sndegwa@worldbank.org Carol Wzorek Facilitator, TRG cawzorek@verizon.net Marcela Natalicchio Consultant in Governance, Africa Region The World Bank mnatalicchio@worldbank.org Doris Voorbraak Senior Public Sector Specialist, PREM The World Bank dvoorbraak@worldank.org Aline Couduel Senior Economist, Latin America, Social Protection The World Bank acoudouel@worldbank.org Meera Shekar Senior Nutrition Specialist, Human Development The World Bank mshekar@worldbank.org 61 REFERENCES Agble, Rosanna. 2007. Fifty Years of Political Independence in Ghana: What Progress for Nutrition? Prepared for World Bank Workshop on the Political Economy of Nutrition Policy Reforms, May 21-22, Washington DC. Benson, Todd. 2007. Challenges in Building Attention to Undernutrition in National Processes in Africa. Prepared for World Bank Workshop on the Political Economy of Nutrition Policy Reforms, May 21-22, Washington DC. Benson, Todd. 2008. Improving Nutrition as a Development Priority. Addressing Undernutrition in National Policy Processes in Sub-Saharan Africa. Research Report 156. Washington, DC: International Food Policy Research Institute. Birner, Regina and Heidi Wittmer. 2003. Using Social Capital to Create Political Capital--How do Local Communities Gain Political Influence? A Theoretical Approach and Empirical Evidence from Thailand. In The Commons in the New Milleniu: Challenges and Adaptation, ed. N. Dolsak and E. Ostrom. Cambridge, Massachusetts, and London: MIT Press. Birner, Regina. 2007. 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