pelletierfieldseminar11-08-10rev.ppt - cornell … · 11/30/2010 1 nutrition policy development and...

11/30/2010

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Nutrition Policy Development and Implementation in Low‐Income Countries

Challenges,Suggested Improvements,

Research Agendas

DavidPelletier, PhD

Cornell University

November 8, 2010

Outline

1. Introduction, background, orientation (extended)– NPP: A composite case– Relevance to recent global initiatives– Research focus, goals and orientation

2. NPP Challenges and Suggested Improvements– Cross‐country study– Focal countries– Sub‐studies on conflict and consensus

3. Conclusions, Policy Implications and Further Research

NPP= Nutrition Policy Process

1970 1980 1990 2000 2010

The Nutrition Policy Process:The Composite Case ofEsperanza

1970 1980 1990 2000 2010 1970 1980 1990 2000 2010

clinicGMP

Home gardening &poultry

Clinic nutrition education


1970 1980 1990 2000 2010

70% rural

U5MR 180

MatMR 2000

Stunting 45%

Wasting 6%

Anemia

VAD

Seasonal and chronic food insecurity

1970 1980 1990 2000 2010

clinicGMP



Supplem. Feedingin clinics, schools,NGO programs

Nutrrehabunits

Fd Sec Unitin PMsOffice NGO

Comm‐BasedNutr Ed

MOH Comm‐BasedNutr Ed

Fd Sec & NutrUnit in PMsOffice

BF Promotion

MOH Nutr Educ &Nutr Rehab Units

Uncoordinated and competitive NGO Comm‐based programs


1970 1980 1990 2000 2010

70% rural

U5MR 180

MatMR 2000

Stunting 45%

Wasting 6%

Anemia

VAD


EconomicCrisis

Urban food price spike

WHO,UNICEFAdvocacy

WeakCommitment inMOH, MOA, MOE

Weak networkingSkills in FSNUUSAID BF Program

World Bank nutr inhealth sector reform

DonorMicronutrientAgenda

40% AbsorptiveCapacity in MOH

Weak/noevaluations

Donorconflicts

1970 1980 1990 2000 2010

clinicGMP




Nutrrehabunits


Comm‐BasedNutr Ed



BF Promotion


VitA capsules

IFA in clinics


Unified NatlNutr Strategy:‐ Core objectives‐ Diverse implem


1970 1980 1990 2000 2010

70% rural

U5MR 180

MatMR 2000

Stunting 45%

Wasting 6%

Anemia

VAD


EconomicCrisis


WHO,UNICEFAdvocacy






Weak/noevaluations

Donorconflicts

NGO networking, sharing,voluntary coordination,trust building, advocacy

NGO, FSNU,MOH, donor rapport

Sharedcredit

StrategicAlliance for Nutr

MemberTurnover

DonorConflictsresume

Cap Bldg

Better evals

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1970 1980 1990 2000 2010


1970 1980 1990 2000 2010

NPP: dynamic, contingent, emergent, non‐linear, multi‐scale, chaordic, open systems

(“complexity”)

World Bank 2006

“The international nutrition system – made up of international and donor organizations, academia, civil society, and the private sector – is fragmented and dysfunctional.”

Morris et al Lancet Nutrition Series Paper 5 2008

World Bank 2006

Morris et al., Lancet Nutrition Series, Paper 5, 2008

Recent Global Initiatives

Gates Nutrition

ECHUI/REACH

NutritionLandscapingAnalysis

Gates Strategy

Movement on Nutrition:Timeline of Recent Initiatives

Health SystemsStrengthening

1990’sMicronutrient

2000 06 07 08 09 10

UN MillenniumDeclaration

RepositioningNutrition

Gates NutritionStrategy Formed

LancetNutritionSeries

MainstreamingNutritionInitiative

Gates Strategy Released

Launch

MicronutrientDecade

BMGF Founded

Health SystemsStrengthening

Gates Nutrition

ECHUI/REACH

NutritionLandscapingAnalysis

Gates Strategy

Movement on Nutrition:Timeline of Recent Initiatives

1990’sMicronutrient

‐ GAP/FFA/SUN‐ InternationalArchitecture Review

‐ Feed the Future‐ Obama GHI

2000 06 07 08 09 10

UN MillenniumDeclaration

RepositioningNutrition

Gates NutritionStrategy Formed

LancetNutritionSeries

MainstreamingNutritionInitiative

Gates Strategy Released

Launch

MicronutrientDecade

BMGF Founded

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1. Scaling Up Nutrition (SUN)

2. Global Food Security Initiative (e.g., FTF)

3. Large bilateral initiatives

– USAID, DFID, Ireland, Spain, Norway, Canada, Denmark, France,

Current Initiatives

Commonly Espoused Principles• Scale up evidence‐based interventions• Multisectoral• Country‐owned, country‐led strategies• Aligned/harmonized external assistance

Overall Research Focus, Goals and Orientation

Policy formulation

Implementation

Evaluation

Termination/ Reformulation

Regional

National

Global

Stage in Policy Cycle

Level of Society Sector/

ProblemStateNon‐state

StateNon‐state

State

The Landscape ofNutrition Policy Research

Agenda settingLocal

District

Discipline & Method

Description

PredictionRecommend‐ technical‐ process

Purpose

Non‐stateStateNon‐state

StateNon‐state

Understanding

Theory BldgTheory Testing

Social ProcessesParticipantsPerspectivesAssets & resourcesSituationsStrategiesOutcomes & effects

Policy formulation

Implementation

Evaluation

Termination/ Reformulation

Regional

National

Global

Stage in Policy Cycle

Level of Society Sector/

ProblemStateNon‐state

StateNon‐state

State

The Landscape ofNutrition Policy Research

Agenda settingLocal

District

Discipline & Method

Description


Purpose

Non‐stateStateNon‐state

StateNon‐state

Understanding

Transdisciplinary: Problem‐oriented, contextual, methodologically diverse


Social ProcessesParticipantsPerspectivesAssets & resourcesSituationsStrategiesOutcomes & effects

Why Transdisciplinary?

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Frameworks, Theories and Models of the Policy ProcessFrameworks, Theories and Models of the Policy Process

Frameworks, Theories and Models of the Policy Process Frameworks, Theories and Models of the Policy Process

Why Transdisciplinary?

NPP:dynamic, contingent, emergent, non‐linear, multi‐scale

Disciplines:Specialized,Partial,

Non‐integrative,Non‐inclusive,Theory‐bound

Complexity and Human Health: The Case for a Transdisciplinary Paradigm.Albrecht et al., Culture, Medicine and Psychiatry 22:55‐92, 1998.

multi‐scale,chaordic,

open systems(“complexity”)

Theory‐boundMethod‐bound

vsProblem‐Oriented

Some Transdisciplinary Tools

The Policy Sciences(a meta‐framework)

Description


Purpose

Problem‐oriented, contextual,

methodologically diverse


Understanding

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Locating NPP Research Within Nutritional Sciences

Kazarinoff and Habicht, J Nutr: 1498‐9, 1991

Systems in Nutritional Sciences

My Research GoalsGoals

• Understand the dynamics of agenda setting, policy formulation and implementation as they affect policy:– Effectiveness (outcomes)

– Appropriateness (all other criteria, such as equity, unintended consequences, ethics, legal norms, democratic norms, transparency, accountability, etc)

• Promote and evaluate possible improvements in these

• Understand reasons for the support for or resistance to proposed improvements

NPP Research Stance and PurposeRealist Ontology: there is a real social world out there (outside the minds of people) but we can only gain approximate understanding of it because there are differences in how social actors and researchers interpret it.

“[within a realist ontology]…a participant's perception is not reality as constructivism and critical theory would suggest. Rather, a participant's perception for realism is a window to reality through which a picture of reality can be triangulated with other perceptions.” (Healy and Perry, 2000)

Epistemology:Epistemology:•Critical realism: seek to understand the social world through the perspectives of social actors and direct engagement (e.g., reconstructing national agenda setting processes)

Purpose: • In light of contextuality and complexity of NPP:• I seek to understand problems in context and make “process recommendations” that will

allow policy actors to be more effective and appropriate in their contexts• I seek to apply meta‐frameworks and theory rather than build or test them• The intellectual challenges , insights and contributions lie in the application process

“If you want to truly understand something, try to change it.” Kurt Lewin

Project

GlobalAgendaSetting

NationalAgenda Setting

NationalPolicyFormulation

NationalPolicyImplement‐ation

LocalPolicyImplement‐ation

Global HealthAdvocacy andPolicy Project

*** ** ** N/A N/A

MainstreamingN t iti * *** *** * *

Current and Recent NPP Research Projects

Nutrition Initiative

* *** *** * *

MicronutrientScaling UpDecision Tools

N/A * ** *** **

IndigenousAdaptive Mgt(Hoey, Bolivia) N/A N/A N/A *** ***

Facilitated Policy Formulation(Isabelle M‐L, Mozambique)

N/A N/A *** *** ***

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2. NPP Challenges and Suggestions

Mainstreaming Nutrition Initiative• Funded by World Bank nutrition section

• ICDDR,B, Cornell: 2006‐8

• Objective: develop approaches and experience in moving nutrition from the status of a marginal issue with time‐limited funding to a permanent feature on policy agendas and in MCN programs and policies

1. Cross‐country study (interviews, written case studies, observations)

– 30 respondents (nationals, researchers, NGOs, donors)

– 18 country experiences

2. Focal countries (participant‐observer and interviews):

– Bolivia, Guatemala, Peru

– Vietnam, Bangladesh

3. Conflict and consensus sub‐studies (interviews)

– Bolivia

– Guatemala

1970 1980 1990 2000 2010

clinicGMP




Nutrrehabunits


Comm‐BasedNutr Ed



BF Promotion


VitA capsules

IFA in clinics


Unified NatlNutr Strategy:‐ Core objectives‐ Diverse implem


1970 1980 1990 2000 2010

70% rural

U5MR 180

MatMR 2000

Stunting 45%

Wasting 6%

Anemia

VAD


EconomicCrisis


WHO,UNICEFAdvocacy






Weak/noevaluations

Donorconflicts

NGO networking, sharing,voluntary coordination,trust building, advocacy

NGO, FSNU,MOH, donor rapport

Sharedcredit

StrategicAlliance for Nutr

MemberTurnover

DonorConflictsresume

Cap Bldg

Better evals

Cross‐country Study

What factors influence the

development of the national nutrition

What are some promising avenues for future efforts?

agenda?

Country Experiences

Pelletier,D., Frongillo, D., Frongillo, EA., Gervais, SG., Menon , P., Ngo, T. (n.d.) The Nutrition Policy Process: The Role of Strategic Capacity in Advancing National Nutrition Agendas. (in submission)

InterviewsWritten accountsObservations

Thematic coding

Societal Conditions

Catalytic Events

Structural Factors

Points of Contention

Strategies & Tactics

Benin, Burkina, Ethiopia, Kenya, Madagascar, Malawi, Mali, Mauritania, Senegal, Tanzania, Uganda, The Philippines, Thailand, Bangladesh, Bolivia, Chile,

Guatemala, Haiti, Peru

Observations

Respondents: 12 nationals, 12 donor/NGO, 6 nationals in donor/NGO

Societal Conditions

Catalytic Events

Structural Factors


DisastersWarCivil unrestEconomic downturns Sector reforms Elections

Food crises Nutr surveys, Small‐scale projectsPositive experiencessalt iodizationvitamin A supplPRSP windows

Institut arrangements for leadership,coordination,implementation

Limited authority &budget control

Divergent mandates, interests and power

food programstargetingmicronutrient strategies

GMPstunting vs underweight

RUTF for HIV etc.

Natl or internatl conferences

Visits by high profile actors MDG‐1Lancet series etc.

pFragmented, shifting & short‐term fundingWeak capacity &credibility of nutritionunitsCompetition & rivalryAvoidance and weak accountabilityDecentralizationetc.

mod maln U2 vs U5school feedingvertical vs integrated

long vs short routesetc.

Strategies and Tactics

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“[] the donors and NGOs basically could not get their act together because they were all arguing for their own special interest or their own view of how things ought to be handled for nutrition.” (International researcher and consultant to countries)

Societal Conditions

Catalytic Events

Structural Factors & Behaviors


Strategies & Tactics

Diminished commitment, coherence, coordination and

support for the national nutrition agenda

Enhanced commitment, coherence, coordination and


Pelletier, SCN News 36, 2008

“[] they had a lot of disagreements but they always went ahead with one voice. They sat behind closed doors and didn’t get out, but then


g ,they put on a good face when they came out and had one recommendation. (Donor agency)


“NGOs got together and sort of formed a networking organization or an alliance. They agreed to put their logo all on the national program reports rather than trying to claim

(Logos endorsing the global Framework for Action)

than trying to claim ownership for themselves, and things like that. So there was a period where there were a lot of fairly large NGO‐run programs, and they wanted to make it one national program, and they managed to get their act together to do that.” (International NGO)

Societal Conditions

Catalytic Events

Structural Factors & Behaviors


”Strategic Capacity”

Diminished commitment, coherence, coordination and


Enhanced commitment, coherence, coordination and


Pelletier, SCN News 36, 2008

Strategic Capacity

The human and institutional capacity to:• build commitment, vision and consensus towards a long‐term

national nutrition agenda,

• broker agreements,

• resolve conflicts,

• respond to recurring challenges and opportunities,

• build relationships,

• undertake strategic communications,

• strengthen operational capacities and implementation as part of the national nutrition agenda

Pelletier,D., Frongillo, D., Frongillo, EA., Gervais, SG., Menon , P., Ngo, T. (n.d.) The Nutrition Policy Process: The Role of Strategic Capacity in Advancing National Nutrition Agendas. (in submission)

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Findings from Focal CountriesAgenda setting: generating policy attention

‐Many routes

Electoral (Bolivia, Peru, Guatemala)

Bureaucratic (Vietnam, Bangladesh)

Pelletier,D., Frongillo, EA., Gervais, SG., Hoey, L., Menon , P., Ngo, T., Stoltzfus, RJ., Shamsir Ahmed, AM., Ahmed, T. (n.d.) Nutrition Agenda Setting, Policy Formulation and Implementation: Lessons from the Mainstreaming Nutrition Initiative Health Policy and Planning (re‐submitted)

Findings from Focal CountriesPolicy formulation: deciding interventions, strategies, roles &

responsibilitiesMultisectoral: Bolivia, Peru, Guatemala

Sectoral: MOH vs others

Biomedical: anemia versus stunting


Findings from Focal CountriesCommitment: translating attention into effective action

Political attention vs political commitment vs system commitment

(Bolivia, Peru, Guatemala)


Bolivian President Evo Morales swears in Ministers to the Zero Malnutrition Program

Contention in Policy Formulation:The Case of Growth Monitoring Indicators in Bolivia

• National Zero Malnutrition Program

• Wt‐for‐Age and MEWG (Min Exp Wt Gain) both in use in years prior

• New WHO Growth References, Priority on Stunting, Obesity concern

• ZM program is “opportunity to switch to a uniform national standard based on current international evidence and norms”

• Three‐year conflict among MOH, NGOs, donors

• 4 interviews with MOH actors (favoring stunting indicator)

• 4 interviews with NGOs (favoring MEWG)

Hoey, L and Pelletier, D. (n.d.) The Management of Conflict in Nutrition Policy Formulation: Choosing Growth Monitoring Indicators in the Context of Dual Burden. (in submission)

MOH NGOs

Position • use HA indicator •Use MEWG indicator

Goals • align with WHO norms• prevent obesity, reduce stunting,address wasting

• detect growth failure early

Claims •MEWG not feasible, too costly, confusing to caregivers•MEWG not effective•MEWG may increase obesity

•MEWG shown to be feasible and understood even by promoters•HA is logistically difficult•HA is slow to change and will de‐

Anatomy of a Contentious Issue

•HA can help distinguish stunting, obesity and wasting

motivate caregivers•HA has excessive measurement error•WHO norms based on technical not operational considerations•IYCF messages <2 years do not cause obesity

Types of Support

• International norms• Programmatic experience•Logical inferences and conjectures

•External eval of MEWG programs•Programmatic experience•Experiences in other countries•Interpretation of Lancet#2•Logical inferences and conjectures

Conclusions• “Understanding stakeholder values, interests, and perceived trade‐offs, therefore,

and knowing how to negotiate those effectively, turns out to be as important as being clear and ‘data‐driven’ about one’s own interests and action agenda” (Briggs, 2008 p. 228).

• “Though there is ample evidence that “conflicting parties can listen, learn, and act together, doing so is anything but a natural achievement" (Forester, 2009 p. 35.

• “Greater intentionality around decision‐making strategies is needed at all stages of the nutrition policy process – from agenda setting to implementation decisions –and with all types of policy choices, even those that look deceptively simple and technical like growth monitoring.”

Hoey, L and Pelletier, D. (n.d.) The Management of Conflict in Nutrition Policy Formulation: Choosing Growth Monitoring Indicators in the Context of Dual Burden. (in submission)

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Guatemala Sub‐Study:“Successful Agenda Setting”

Guatemala Case Study: From “Successful Agenda Setting”To Consensus in Policy Formulation

• Policy formulation encountered deep disagreements

• Sub‐study explored stakeholder views re. “Good Process”

• 20 semi‐structured interviews (Govt, donor, NGO, academic)

• 60‐90 min interviews; 250 pp transcribed data

• Prompted and unprompted views on:

– Key principles for “good process”

– Desired outcomes

– Feasibility in Guatemala

– Willingness to participate

– Willingness to accept decisions

Hill, R., Gonzalez, W and Pelletier, D. (n.d.) The Formulation of Consensus on Nutrition Policy: Policy Actors’ Perspectives on “Good Process.”(in submission)

Involve the “right” people

Involve people the “right”way

5 principles of a “good” process

Desired outcomesExample actions-Invite & engage a diverse & representative set of interested & affected parties-Check back with their groups

-Use available process guidelines & tools for open, democratic dialogue & deliberation on all factual & value claims and view points

-Establish ground rules

-Increased awareness, understanding and consideration among all participants of the existing diversity of knowledge, interests and values around the policy issues at hand

Involve the “right” peopleInvolve the “right” people



5 principles of a “good” process

Desired outcomesExample actions-Invite & engage a diverse & representative set of interested & affected parties-Check back with their groups

-Use available process guidelines & tools for open, democratic dialogue & deliberation on all factual & value claims and view points

-Establish ground rules

-Increased awareness, understanding and consideration among all participants of the existing diversity of knowledge, interests and values around the policy issues at hand

Interview Tool (distilled from the literature)

Clear, organized procedure & objective

Focus on securing common interest

Transparency & Accountability

-Establish ground rules-Use a non-aligned facilitator-Use process observers-Establish a Process Management Committee

-Use tools for reaching “consensus”, conflict management -Foment clarity in expression & collective leadership

-Use clear, iterative decision process, using participant feedback to make adjustments -Send final outcomes to higher level policy authorities

-Building of trust, respect and relationships for future collaboration

-Clear to all participants that all decisions are competent and were made in the common interest

- Decisions resulting from the process influence policy







-Establish ground rules-Use a non-aligned facilitator-Use process observers-Establish a Process Management Committee

-Use tools for reaching “consensus”, conflict management -Foment clarity in expression & collective leadership

-Use clear, iterative decision process, using participant feedback to make adjustments -Send final outcomes to higher level policy authorities

-Building of trust, respect and relationships for future collaboration

-Clear to all participants that all decisions are competent and were made in the common interest

- Decisions resulting from the process influence policy

“Good Process:” Summary Findings1. Key principles for good process: Strong resonance with literature2. Desired outcomes: have impact on decisions, build trust, be inclusive3. Feasibility in Guatemala: difficult, but yes4. Willingness to participate: yes (all 20)5. Willingness to accept decisions yes (all 20)

6. Are others willing to participate? Yes: 15 of 197 Are others willing to accept decisions? Yes: 11 of 187. Are others willing to accept decisions? Yes: 11 of 18

Hill, R., Gonzalez, W and Pelletier, D. (n.d.) The Formulation of Consensus on Nutrition Policy: Policy Actors’ Perspectives on “Good Process.” (in submission)

Conclusions and Implications• Strong interest in the fidelity of decision processes ( “evidence‐based”)

• Strong agreement on core principles, willing to participate and willing to accept decisions

• Actual behavior may vary from interview responses, will depend heavily on the actual quality of the process and must be studied in a real‐world context

• Countries embarking on ‘country‐owned, country‐led’ initiatives would do well to first seek stakeholder agreement on the design and implementationwell to first seek stakeholder agreement on the design and implementation of an explicit, inclusive and transparent decision process

Hill, R., Gonzalez, W and Pelletier, D. (n.d.) The Formulation of Consensus on Nutrition Policy: Policy Actors’ Perspectives on “Good Process.” (in submission)

NPP Overall Conclusions (emphasizing “what’s new”)

1. Agenda setting may be easier than once thought (in some contexts)

2. “Political will” is too simplistic

3. We have seen the enemy and it is US

4. More and better evidence is not the answer (under current conditions)

5. Stronger implementation capacity is necessary but not sufficient

6. Strategic capacity is a fundamental priority

– Enables agenda setting

– Can deepen, broaden and sustain commitment

– Can envision, lead, forge consensus and resolve conflicts

– Can navigate structural obstacles and exploit windows of opportunity

– Can integrate evidence into robust policy deliberation

– Can envision, promote and sustain a long‐term capacity‐bldg effort

– Can make “country‐led and country‐owned” a reality

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Further Research

1. Stimulate and evaluate: a) deliberation on the design, and b) the implementation of “good process” for policy formulation in

real‐world settings (incl. integration of values, interests, contextualrealities along with ‘evidence’ based interventions

2. (Not discussed here) Develop and evaluate methods for strengthening program implementation and adaptive management based on real‐time feedback on bottlenecks and innovative solutions

“If you want to truly understand something, try to change it.” Kurt Lewin

feedback on bottlenecks and innovative solutions(Hoey’s and Isabelle M‐L’s research)

3. Stimulate and evaluate efforts to strengthen strategic capacity at national level (as part of #1 and #2 above)

Emerging Opportunities:• TOPS/USAID (“Technical and Operations Performance Strengthening”)• Nepal Integrated Nutrition Project• GHAPP, SCN, REACH, SUN• Additional applications of the Program Assessment Guide

AcknowledgmentsMNI CollaboratorsEd Frongillo, Cornell USCPurnima Menon, Cornell/IFPRIBecky Stoltzfus, CornellSuzanne Gervais, CornellLesli Hoey, CornellRenee Hill, Cornell/ U IdahoW d G l USCWendy Gonzalez, USCKarin Lapping, Save the Children/TuftsDominic Frongillo, Cornell/CCETien Ngo, CornellTahmeed Ahmed, ICDDR,BShamsir Ahmed, ICDDR,B

Funding: The World Bank

…and countless in‐country collaborators

pelletierfieldseminar11-08-10rev.ppt - cornell … · 11/30/2010 1 nutrition policy development and...

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