WHAT IS MISSING? ATTENTION TO DETAILED EXPLICIT MECHANISMS GUIDES ACTION AND IMPLEMENTATION OF COMMITMENTS TOWARDS ACCOUNTABILITY
REPLY TO QUESTION 3
References to paragraph 21, Commitment VII ‘Monitoring and accountability’, action also under paragraphs 22. and 23.
The current draft political declaration fails to set out explicit mechanisms to correct the imbalance between indicators for economic growth and those that reveal progress in addressing childunder nutrition. This imbalance operates at two levels. Progress will not come about without better attention to accountability for childunder nutrition in ODA macroeconomic indicators. Progress will not come about without elevating to national policy discourse indicators for child under nutrition and co-variates that reflect inequities at subnational levels.
While MDG1 includes reducing child underweight, in policy fora, addressing chronic childunder nutrition with structured cross-sectoral action still receives little attention. The OECD Paris Declaration remarkably failed to include stunting prevalence as an indicator with which to monitor progress. International policy discourse is still fixed in tradition to consider material living standards (head-count poverty ratios), not living standards jointly with reduction of (ill) health with intergenerational transmission of poverty (Ref. Angus Deaton, ‘‘The Great Escape: Health, Wealth, and the Origins of Inequality”, 2013). Little surprise that the positive impact on future economic growth - by preventing impaired early age human capabilities (-9-24 months) – receives little attention in dominant policy discourse also in countries burdened with high stunting prevalence. Progress will remain limited without political alignments to reduce divergence between nutrition status and economic goals.
At global level, OECD DAC indicators neglect to monitor progress in reducing prevalence of stunting. Priorities in ODA traditionally emphasize addressing material poverty relative to health (child under nutrition, stunting). This has meant neglect of the pathway for longer-term inclusive growth operating via reduced stunting prevalence associated; neurocognitive impairment raises risk of intergenerational transmission of poverty.
Priorities in development aid promoted by the World Bank and OECD countries remain driven by focus on monetary poverty. These priorities influence those of national development plans; they thwart public discourse for a broader agenda. Across powerful Ministries of Finance this is associated with less attention to address child under nutrition, and co-variates, to less attention to cross-sectoral action supported by diagnosis of determinants.
At national level, district level indicators for under nutrition and determinants are either scarce or missing. Goals other than improved nutrition that are pursued by strong economic and political interests in the agricultural sector, the postharvest value chain, and extractive industry may adversely impact livelihoods. Economic agents in food systems aim to make money subject to reasonable levels of risk; governments pursue policies that are compatible with the interests of politically powerful stakeholder groups. “Malnourished populations are rarely among these interests” (Pinstrup –Andersen, The Lancet 2013)
Can political momentum be created to foster policy interventions to “remedy problems that could have been avoided”?
Nutrition indicators, that may include food diversity - routinely collected at district level - is a necessary, while not sufficient condition, to raise accountability for negative outcomes of missing food and health system policy interventions. When food-system policies and the private sector promote inexpensive calories and expensive nutrients, results extend beyond inferior nutrition and adverse population health. The current discussion in India about dominance of starch based diets over pulses, neglected in food support policies, is one reminder. There is so far little attention to that burden to respond shift to underfunded Ministries of health and social protection agencies; by default they seek to provide a costly range of interventions that include food and micronutrient supplementation: to “remedy problems that could have been avoided”.
A shift, long overdue, is use of frequent district level indicators for nutrition status, by wealth quintile, for nutritional status in high burden countries. Relevant co-variates to explore in local context include sectoral determinants for rising stunting and rising mortality trend, up to age five, after weaning from exclusive breastfeeding. Most sectoral development programmes continue being funded ‘semi-automatically’, supported by scarce evaluations with uncertain or little impact on policy. The uncertain external validity of RCTs reflects the bewildering extent of unrecognized information disconnects at subnational level. Heavy reliance on RCTs as the only pathway to scaling-up is a barrier with opportunity costs. Health and nutrition effects resulting from agricultural and other foodsystem policies and programmes are difficult to assess with RCTs; treatments cannot be randomized and the effect pathways are long. “Yet, the most promising opportunities for improvement of health and nutrition are undoubtedly found in such policies, and not in home gardens and other minor projects which are amenable to study within the framework of randomised trials” (Per Pinstrup-Andersen, Lancet, 2013).
Focus on plausibility pathways for nutrition improvements in food systems, with district data, in combination with human rights orientation, need more prominence in scaling-up for more than one reason. This means building capacity at district level in high burden regions for monitoring trends, establish covariates and plausible determinants and barriers (compare with proposal Victora et al., for ‘District Evaluation Panels’, Lancet 2010 -2011 and comments (Eklund)). This information is rarely available. If available it is not well disseminated, and explained to civil society, local populations and women groups! With more resources, rigorous evaluations with attention to counterfactual may follow to explore determinants, particularly when/where outliers emerge in these trends.
Such institutional capacity development has potential of vast improvement over dominant economic growth agendas. The latter reflect power asymmetry combined with ignorance in policy discourse about regional inequities, co-variates and determinants. Triangulation of anthropometry with qualitative data sources and information, e.g. re undersupply of local public goods for hygiene, sanitation, and eventual discrimination in services, raise precision in identifying determinants reorienting cross-sectoral interventions.
Information feed back from the field to media, to national policy makers and voters, may educate the public about mutual benefits between growth and development (reference Jean Dreze and Amartya Sen, 2013). Such information, when impacting political processes, raises probability of more balanced development priorities, incorporating child stunting, an indicator of adverse prospects for future inclusive growth.
Per A. Eklund
Fr. Sr. Evaluation Officer, IFAD