· The macro- environment
No programme exists in a vacuum. It is rooted in a country where conditions prevail that will affect the functioning and achievements of that programme. Such conditions include the socio-economic situation, the distribution of wealth and level of development (including the level of literacy and the condition of women), political ideology, culture, degree of diversity in terms of agro-ecological zones, climatic conditions and ethnicity. These provide the background within which the programme must function and which it must take into account if it is to be successful.
We use the term macro-environment to refer to those specific factors which indicate the degree of commitment of that country to a particular issue, in this case to the improvement of the nutritional well-being of its people.
The Macro-Environment: some lessons learned
FAOs in-depth study of nine programmes (2002) indicated that the following are important elements of a supportive macro-environment:
A supportive and enabling macro-environment is essential to the success of a programme. A government and a population that recognizes the importance of food security and good nutrition and accepts nutritional well-being as a key indicator of national development provides such an environment. The reality, however, is that few countries can boast of a fully supportive macro-environment. Working towards creating it thus becomes a responsibility of the programme itself. To decide what you need to do to achieve a supportive macro-environment, you need first to identify and assess the strengths and deficiencies of the environment in your country. This includes assessing:
the macro policy environment;
the degree of intersectoral collaboration;
the level of governments resource commitment to nutrition;
the role and contribution of the international community;
the adequacy of national technical expertise.
Within these sub-components, you may need to modify the specific questions, to reflect your programme.
Assessing the Macro Environment
· Macro policy
To assess the macro policy environment, answer the following questions through discussions with key informants, observation and by examining documents.
· What supportive policies, strategies and initiatives are in existence to address, directly or indirectly, food security and nutrition issues?
As a minimum, the country should have a well-formulated food and nutrition policy (and a national plan of action on nutrition), a poverty alleviation strategy and a rural (and/or urban, as appropriate) development strategy.
· Is your country a signatory to major, relevant, international declarations, initiatives and codes?
Over the last few decades there have been a number of international position statements, often linked to international conferences, and signed by most countries. Among those relevant to nutrition, the following are the most important
International Declaration on the Rights of the Child (from 1959)
Alma Ata Declaration on Health for All by the Year 2000 (1978)
Code of Marketing of Breast Milk Substitutes (1981)
Nutrition Goals of the World Summit for Children (1990)
Baby Friendly Hospital Initiative (1991)
World Declaration and Plan of Action for Nutrition, International Conference on Nutrition, (1992)
Rome Declaration on World Food Security and World Food Summit Plan of Action (1996 and 2002)
· To what extent are these political commitments actively implemented?
Thailands experience has indicated that policy decisions which bring about deliberate actions are often in response to political concerns, public opinion and awareness.
Quoted from: Winichagoon et al (1992)
By signing international declarations and by formulating relevant policies, the country has taken the first step towards political commitment to improving nutrition. You need to assess now the extent to which the government has acted to implement its stated commitment, and what specific steps have been taken to achieve its goals. For example: What specific steps have been taken to alleviate poverty and achieve a more equitable distribution of wealth?
Has improving access to food been explicitly recognized as a government priority within a poverty alleviation strategy?
Has a national food and nutrition policy been passed by government? Is there a national plan of action on nutrition with targets, and to what extent are these targets being met?
Does legislation exist that limits the advertising of breast milk substitutes, and how is it enforced?
Have any public hospitals achieved baby-friendly status? Is there a programme to make all public hospitals baby-friendly? Is a system in place to monitor compliance with the initiative?
What you are asked to do here is to find tangible evidence of progress towards achieving stated goals. Such evidence-based assessment is crucial. Good intentions and political rhetoric are not enough.
· At what level are the commitments implemented or monitored? At the Ministerial level, the Head of State level, or by a senior ministry such as the Ministry of Planning?
You need to determine who has ultimate responsibility for the political commitments implicit in the international declarations and initiatives which the government has signed. Ask the question: who oversees progress towards achieving stated goals? If no high level government official or ministry has this task, then the likelihood is high that political commitment to improving nutrition is inadequate.
· Are there any other policies that may impact upon your programme?
Examples of such policies are lending policies of the IMF/World Bank, policies on the environment, and on international trade.
Assessing the Macro Environment
· Intersectoral collaboration
Nutrition is a cross-cutting issue. To achieve nutrition improvement, active collaboration is needed from a range of sectors, such as health, agriculture, education, trade, as well as within sectors. For such action to take place, there needs to be an effective mechanism for collaboration and a recognition of nutrition as an essential indicator of national development reflected in sectoral priorities. Collaboration with the civil society, NGOs, international agencies and research institutions is also important. Answers to the following questions will help to assess the extent of intersectoral collaboration at the national level.
· Is there a mechanism (a food and nutrition committee or council, for example) for intersectoral collaboration in nutrition? If yes:
What is its mandate?
Where is the mechanism located and which ministry is responsible for its functioning?
Which ministries participate, and at what level (minister, permanent secretary, head of department, other)?
Are there non-governmental sectors represented?
Does it meet regularly, and is attendance good?
Does it have a permanent secretariat? And a budget?
Are there any examples where the committee has influenced national decision-making?
Food and nutrition councils or committees exist in many countries, but few are effective or active. If participation is insufficiently broad, or if sectoral representation is insufficiently high, then clearly nutrition is not viewed as a priority by the relevant sectors.
· Are nutrition outcomes included in relevant sectoral policies, plans and programmes?
There is an assumption on the part of some sectors that nutrition will somehow improve as a result of their plans and programmes, and that no specific attention to nutrition is needed. Agriculture, for example, may assume that by increasing national food production, household food security will improve, and hence nutritional status. Experience has shown that explicitly stated nutrition outcomes are needed in order to ensure a positive impact on nutritional status. This is true also of other sectors. As a minimum you should assess the health and agriculture sectors.
Achieving intersectoral collaboration
Effective intersectoral collaboration is difficult to achieve. Two essential preconditions are the acceptance at the highest level of nutritional well-being as an indicator of national development, and the recognition of the need for an integrated approach to tackling nutrition problems.
Assessing the Macro Environment
· Resource commitment
If the nutritional well-being of its population is indeed considered a key goal and indicator of a countrys development, then there should be evidence of this in the form of a budget devoted to nutrition activities. Most countries provide some funding to nutrition activities, to support a few staff positions and a very limited number of activities. What is important is not the absolute amount of government funding for nutrition, but the proportion this represents of the national budget, or at least of the sectoral budget of which it is a part, and how this proportion compares with the proportion devoted to other key activities. These figures can be obtained from the Ministry of Finance or from the ministry that houses the nutrition unit. You need to consider also whether funding for nutrition is included in budgets of other sectors or units e.g. agriculture may fund relevant food-based activities, clinic-based nutrition services may be provided by the maternal and child health unit, and IEC activities by the health promotion unit.
Is national funding important, or should we rely on external support?
Some quotes from FAOs in-depth study of nine programmes (2002):
The governments of the Philippines and Zimbabwe, and to a large extent Brazil, have shown a clear commitment in this regard, and national funding has been made available and sustained for many years. In these countries, the supportive macro policy environment is translated into a tangible investment in nutrition.
There is a danger in such reliance [on external funding]: ...political events can lead to the withdrawal of donor support. There is also the danger of donor-fatigue: simply put, the donors decision that it is time to move on to something else or somewhere else.
Assessing the Macro Environment
· International community
International, bilateral and non-governmental agencies can make important contributions to improving nutrition in a country: by raising the profile of nutrition, lobbying national governments, by demonstrating their own commitment to nutrition through investment in nutrition programmes, and by making available technical expertise.
In some cases however there is a tendency for the international community to impose its own priorities, and to support only those activities which fall within such priorities. In some cases too there is a lack of coordination among the agencies, leading to both overlaps and gaps in the range of nutrition issues addressed and the absence of an integrated approach to tackling nutrition problems. In recent years, there has been an attempt to resolve these difficulties, by creating a coordinating committee that brings together all agencies with an interest in nutrition.
To assess the role and contribution of the international community, answer to the following questions:
· Is there a coordinating committee, and if so, what is its membership, how regularly does it meet and what decisions does it take?
· Are nationals (nutritionists and other) members of the coordinating committee, and if so, what positions do they hold in government?
· What is the real contribution of nationals to decision making?
· If no active committee exists, how does the international community decide what nutrition activities to support? Is there evidence of donor-driven decision making? Can nationals influence decision making and secure support for activities that they have assessed as priorities?
To answer these questions, we suggest you look also at the programme you are assessing and attempt to discover how and why it came into being. Through discussions and an examination of documents, you should find out who made the decisions, who chose the specific nutrition activities, and why these were selected. You should also seek to determine whether priority national nutrition problems are being addressed, and if not, why not.
Assessing the Macro Environment
· Technical expertise
A precondition for the success of a nutrition programme is the availability of high quality technical expertise. If such national expertise does not exist, funders provide international experts but, unless there is a serious effort to build capacity, the programmes sustainability will be in doubt, and the country will consistently fail to achieve self-reliance. The countrys ability to negotiate successfully for support for its own priorities will also be severely constrained.
To create (and replenish) a body of national technical expertise to run its programmes, a country needs at least one of the following:
A high quality national research and training institution capable of providing training to the postgraduate level; or,
Access to such an institution within the region; or,
A funded programme of human resource development and in-service training to upgrade staff. Such programmes often exist within World Bank loan agreements.
Ultimately a country should seek to establish a national institution, or participate fully in a regional one. In addition to training, such institutions provide excellent support to nutrition programmes: they can undertake small research studies within programmes to answer specific questions, and can also assume responsibility for its monitoring and evaluation. They can also assume some responsibility for maintaining a focus and momentum for action on nutrition issues.
The importance of national research and training institutions
FAOs in-depth study of nine programmes (2002) revealed that those of Mexico, Thailand and the Philippines benefited from close collaboration with strong national research and training institutions. These institutions provided programme staff, training inputs and technical advice, as well as undertaking small research activities within the programmes. In the case of Mexico, programme evaluation was contracted out to a research institution, with the result that this programme can provide strong evidence of its positive impact on nutritional status.
You can assess the adequacy of national technical expertise by answering the following questions:
· If there has been a recent human resource needs assessment for nutrition, what were its findings, and has there been any effort to fill identified gaps?
· What is the balance of international and national expertise within the countrys nutrition programmes? Is there any intention to replace international staff with nationals, and to this end, is training (both external and on-the-job) foreseen within the programme?
· Are well-trained nutritionists employed at national and sub-national levels?
· Is there a national research and training institute (or does the country have access to one in the region)? Does the institution provide training in nutrition to the postgraduate level? Does it have an active programme of research? Does it participate in decision making in nutrition and does it collaborate with national nutrition activities?
· Is there a funded programme of human resource development for nutrition? If so, does this programme encompass training at all levels? Is it being actively implemented, and are suitable positions available to employ returning graduates?
You should now have the information you need to make an assessment of the macro-environment within which the nutrition programme functions. Turn to the Summary Report (Annex 1) and answer the questions in Section I. Then carry out a SWOC analysis.
Your programme will be most effective in a fully supportive macro- environment. If you assess the macro-environment in your country to be insufficiently supportive (in any or all of the key sub-components), then you need to take one or more of the following actions:
i) Design and implement a high-profile campaign to create public and political awareness, using all means at your disposal. The emphasis of the campaign should be on food security and nutritional well-being as outcome indicators of national development, and of access to an adequate diet as a human right. Here are some ideas for the campaign:
Use the media (radio, television and newspapers) to highlight the importance of good nutrition, the negative consequences of malnutrition, and the weaknesses identified in your assessment;
Lobby key politicians, spokespersons and public opinion leaders to gain political support and a voice in government;
Secure the support of the international community to lobby for nutrition and to invest in nutrition;
Publicize figures on the prevalence of malnutrition, nationally and in depressed areas and for vulnerable groups;
Lobby for action on declarations, codes and initiatives which the Government has signed; if appropriate, publicize the Governments failure to follow through on the promises implicit in their acceptance of such commitments;
Establish strategic partnerships with the private sector and universities.
ii) Include specific activities (such as components of the campaign described above) within the nutrition programme you are assessing. This is possible if you have judged your overall environment to be supportive, but have identified a few weaknesses that can be addressed within the nutrition programme.
iii) If intersectoral collaboration is poor, you can seek to establish such collaboration first at the district or community level. This is often easier to achieve than collaboration at the national level. If you then implement the campaign described above, it may be possible to extend intersectoral collaboration upwards to the national level in the future.
iv) If the adequacy of suitably trained human resources is a constraint, then you need either to address this within the nutrition programme or secure funding for a programme of human resource development. You should also establish strong working relations with national or regional research and training institutions. Such links are of mutual benefit, since they serve also strengthen the institutions. Finally, draw up a schedule to replace international staff with trained nationals in your programme.
FAOs in-depth study of nine programmes (2002) highlighted the following strengths, weaknesses, opportunities and constraints in relation to the macro-environment:
Has achieved good advocacy, sensitization, awareness-raising;
Benefits from a supportive policy environment, and/or funding commitment from government;
Employs integrated and multisectoral approach, has achieved intersectoral collaboration;
Strong partnerships with national training and research institutions leading to good technical support.
Weak advocacy component of programme;
Weak intersectoral collaboration and links with other development activities or programmes;
Welfare rather than development approach.
Increased national awareness and recognition of nutrition problems can lead to more and improved nutrition actions;
Positive experience with collaborations and partnerships can lead to better intersectoral collaboration, new partnerships.
Constraints (and threats):
Political instability, civil disorder;
 These figures are difficult
to obtain in many countries. If you cannot obtain such figures, then you must
turn to qualitative information, based largely on an assessment of the extent of
dependence on external resources and on the size of the nutrition unit in
comparison to the size of other units.|
 The coordinating committee may in some cases be the same as the intersectoral committee referred to in the previous sub-component. It may also be a committee charged with overseeing the Poverty Alleviation Strategy or the Rural Development Strategy. What you are seeking is a committee that brings together a substantial number of relevant international agencies, bilaterals and NGOs and that focuses on nutrition improvement as a first step in the development process.
 Some countries are too small to support a national institution. In such cases, research and training is provided at regional institutions. Examples of such regional institutions are the University of the West Indies and the University of the South Pacific. Some countries also offer programmes in nutrition that are open to other countries in the region. Kenya, the Philippines and Guatemala (INCAP) offer such regional masters level programmes.
 The availability of technical expertise at sub-national levels is especially important in countries who have either achieved full decentralization, or are moving towards it.
 In general, it is preferable to avoid treating nutrition as a welfare issue. Such an approach tends to lead to unsustainable food distribution activities, and curative rather than preventive measures.
 In some situations, it may be acceptable to draw comparisons with other countries, both in the prevalence of malnutrition and in the actions taken to address the problems. Such comparisons can spur governments to action. In this context, you can make use of UN publications (such as FAOs State of Food Insecurity reports, UNICEFs State of the Children reports, UNDPs development reports) to highlight the position of your country in relation to others.
 In general, short courses can be accommodated, but lengthy senior level training is too costly.
 Bilateral agencies are often willing to provide scholarships for training in their countries.