In addition to understanding what countries did to make progress, it is equally important to understand how strategies were executed to drive sustainable progress. Alongside the list of 10 intervention areas above, we identify several promising practices that many Exemplar countries have adopted to maximize efficiency and scale with each intervention (“Proven delivery approaches”). We also highlight a set of practices that are high-impact and are priorities for sustainable health and development, but where more can be done both at the global and country-level (“Emerging priorities”).
Proven delivery approaches
1. Multi-sectoral action for addressing stunting
Given that the causes of stunting is multifactorial, interventions to address it effectively must be multisectoral—that is, they must coordinate efforts among various ministries, including but not limited to agriculture, education, health, and water, to align spending and strategies. The global nutrition community has increasingly recognized this, and many countries are devising policies and programs accordingly.
- Ethiopia’s 2016 Seqota Declaration, designed to strengthen the National Nutrition Program, encompassing seven different ministries,, is still in the pilot phase and will be scaled up nationwide in 2020.
- In Peru, in 2007, the president tasked the Prime Minister’s Interministerial Committee—a body with the power to compel cooperation among competing ministries—to design a national strategy for poverty reduction focused on stunting, known as Crecer; the committee consolidated approximately 80 programs into 25 initiatives.
- In Senegal, as far back as the mid-1990s, the president set up the Commission Nationale de Lutte contre la Malnutrition (National Committee for the Fight Against Malnutrition; CNLM) not in the Ministry of Health but in the president’s office, to bring more stakeholders together; in the early 2000s, the CNLM was replaced by the CLM, located in the prime minister’s office. Importantly, he created an implementing arm for the organization, which meant that, whereas CNLM only provided oversight, the CLM itself would administer future nutrition programs.
2. Civil society movements/SUN effort
- Successes from several countries have shown that strong civil society leadership including ownership and commitment from NGOs and communities has been central to addressing undernutrition and child stunting challenges.
- Peru, Senegal and Brazil each have had innovative and high-impact solutions in this space.
3. Effective donor coordination and financial support
- Many countries that have managed to achieve or make significant progress towards attaining health-related MDG goals, broad health system improvement and gains in reducing undernutrition have been able to effectively harness donor investments and strategically direct funds/investments.
- Procuring and ensuring efficiency spending of domestic and donor financial commitments are the crux of improvements in health, nutrition and development agendas.
4. Poverty reduction and social protection efforts
Efforts to scale high-impact interventions depend largely on reaching the most disadvantaged and marginalized communities. Countries that have managed to reduce child stunting undertook strategic moves to increase purchasing power and livelihoods of the poorest and to protect the marginalized.
5. Decentralization of health services
Increasingly, countries are seeking to decentralize administrative and political authority, devolving more decision-making power to local officials and local communities closer to conditions on the ground. These changes are designed to make government more accountable and nimble. In practice, a lot depends on the details of implementation. One key challenge is ensuring that local communities and their representatives have the resources and capacity to effectively fulfill their responsibilities.
- Ethiopia’s unique brand of decentralization puts spending decisions as well as accountability mechanisms at the local level, but keeps bigger strategic decisions as the responsibility of the central government. Local officials in Ethiopia enact centrally devised policies and programs and are held accountable for the quality of their service.
- In Nepal, where extremely rugged terrain makes it especially challenging to govern from the center, local organizations such as Village Development Committees and Mothers’ Groups help manage development programs based on the needs of the community.
- Senegal’s 1996 Local Government Law gave local governments responsibility in nine areas: planning, land planning, public land administration, urbanization, health, education, environment, youth, and sports and culture. The funding to fulfill these responsibilities was not always available, which has resulted in the need to charge fees for key services such as health care and education.
6. Targeting universal healthcare
Recently, the World Health Organization and its member states have focused on the goal of universal healthcare. Countries have pursued a variety of strategies to meet this goal, and their success or failure will have considerable impact on stunting and nutrition.
- The Kyrgyz Republic created the Mandatory Health Insurance Fund (MHIF), which collects health insurance premiums through a 2 percent payroll deduction from all formally employed people, although this does not come close to funding the health system. Co-payments, donor funding, and general government revenue fill the gap.
- Peru’s SIS gradually expanded to cover all poor people, not just pregnant women and children, and to cover more services. The coverage rate also doubled from 35 percent to more than 70 percent of the poor, but it has been challenging to continue increasing the budget allocation to keep up with the demand for services.
- Senegal has set its sights on creating a viable insurance option for the poor. As of 2014, however, only one-quarter of Senegalese had coverage, and most were relatively wealthy people participating in mandatory contribution plans through their work. Mutuelles, community-based insurance funds for the poor that have existed since the early 1990s, have scaled slowly, with only approximately 5 percent of the population covered.
7. Engagement of private sector
One way to achieve scale and sustainability is to engage the private sector in service provision, not only within the food and beverage industry, but across industries and businesses. The role of the private sector changes depending on each country’s context, but under the right circumstances the private sector can potentially fill important gaps, providing affordable and high-quality services to a wide range of customers.
- The underlying principle of Senegal’s ongoing reforms is privatization. The government contracted with private companies to provide water and sanitation services to the Senegalese population. With user fees, these private companies were able to vastly improve the quality of services while promoting equity by subsidizing water and sewer connections for those who could not afford to pay.
- In Bangladesh, the limited budget on health expenditure helps explain historically low levels of antenatal, neonatal and postnatal care in public hospitals and clinics. However, private providers and NGOs have stepped into this breach, and this evolution is part of the reason for improvements in ante-natal and newborn care that has been linked to stunting reduction.
- Careful attention is also required to the role of local businesses and markets in distributing low-nutrient, high-salt/sugar and processed foods and making them easily accessible in communities. Nepal has struggled with families replacing nutritious complementary food for children less than 24 months, with cheaper and nutritionally detrimental alternatives. Tighter government regulations on distribution chains and marketing may be key solutions to food quality assurance.