Some simple but neglected truths
When it comes to nutrition, the typical mother in a low- or middle-income country is more instinctively multisectoral than any government planner can hope to be. She has a more personal stake in the well-being of her children than the most well-intentioned official, and has a more holistic, real-time view of the different services her household receives from each sector.
These are simple truths, but it is worth making them explicit because they are too often ignored in our efforts to improve nutrition outcomes. In many sectors critical to nutrition, experience shows that when citizens are placed in a position to monitor services and hold officials accountable, performance improves. It’s time for the nutrition community to bring a stronger citizen engagement perspective to tackling the stubborn and multifaceted determinants of malnutrition.
Current approaches are not fit for purpose
It is well-accepted that tackling malnutrition requires sustained contributions from many actors across many sectors. Without agricultural services, farmers will lag in productivity and nutrient-rich foods will be less available. Without access to safe, clean water, children will lose nutrients to diarrheal diseases. Without good antenatal health services, mothers and children alike will have worse birth outcomes, and children are likely to start life at a nutritional disadvantage.
In response to this, experts recommend multisectoral nutrition plans and multisectoral coordinating bodies at the highest levels of government to oversee them. It sounds good in theory, but these coordinating bodies are sometimes de jure or de facto led by a lead ministry, which can cause friction with other line ministries and reduce cooperation. In other cases, the coordinating bodies may sit above line ministries (e.g., in the office of the prime minister), but often then suffer with limited resources and low visibility into service delivery. These coordination mechanisms are often then replicated at multiple different levels of government before reaching the actual point of service delivery. In countries with a large donor presence, donors may also be invited into coordination forums at multiple levels. This leads to complicated coordination efforts across and between levels of government — and, ultimately, to limited accountability for improving comprehensive nutrition services and nutrition outcomes. While genuine success stories for this type of approach exist, the track record is spotty, raising the question of whether there are different tools or actors that should be tapped to complement and strengthen these efforts.
A complementary approach: empowering the multisectoral citizen
What is often missing from these multistakeholder and multisectoral approaches to improving nutrition is the voice of those with the strongest incentive to improve nutrition outcomes — the voice of citizens themselves. The potential for citizen participation to increase the impact of the fight against malnutrition is incredible. First, the root problems that underlie malnutrition are numerous and vary country to country, village to village, and even household to household. The best placed individuals to identify the problems that may be contributing to malnutrition in a particular place are those people who live and participate in public life in that place every day.
Second, the actions best suited to ensure the responsiveness of government and other actors — regardless of the sector that they represent — is also likely to be dependent on local context. As such, supporting a bottom-up approach to improving nutrition, driven by citizens who know local context better than those sitting in the capital or beyond, has great potential to complement and enhance traditional top-down efforts to improve nutrition.
This type of citizen-led effort has proven successful time and time again in the health, education and water, sanitation and hygiene (WASH) sectors. Rigorous impact evaluations have provided solid evidence that citizen engagement in decision-making, planning and monitoring of service delivery can lead to significant improvements in service quality, utilization and outcomes. In perhaps the most famous example, citizens in Uganda were enabled to play a more active role in the oversight of health care services, leading to substantial improvements in health workers’ performance — which in turn resulted in increases in infant weight and reductions in under-5 mortality in those communities with more empowered citizens.
In our own work, we have seen similar impressive examples of the roles that citizens can play in strengthening services that improve the lives of those most in need. In another case from Uganda, Results for Development supported a local education-focused civil society organization (ANPPCAN) to provide training to students to monitor teacher absenteeism and tools to report problems that they observed to government officials who were then pressured to take action. The result was a drastic drop in the absenteeism rates in the targeted schools, from 44 percent at the start of the program to 10 percent after several months.
Effective accountability and participation efforts in these sectors were driven by people who wanted to improve big outcomes rather than specific sectors. This bodes well for how such an approach could work in a multisectoral space like nutrition. Citizens have critical information on whether health, agriculture, education and WASH services are meeting their needs: The key is to ensure that this information gets into the hands of relevant officials and stakeholders — and that there is accountability for acting upon it. In some cases, this accountability might lead particular sectors to improve the performance of their existing programs. In other cases, we might see the emergence or evolution of cross-sectoral solutions, with a continued focus on the outcome of fighting malnutrition.
Coordination remains important, but does not need to flow from top down
To be clear, it is not the role of the multisectoral citizen to do the job of government and to design programs that maximize synergies between sectors at the point of service delivery. The citizen can identify where more is needed and play an important role in accountability, but cannot and should not play the role of technocrat. Government coordination and collaboration is required.
It is also important to note that empowering citizens is not something that can be completed in a one-day workshop. We need to continue to support civil society organizations and other stakeholders who view empowering and engaging people in government decisions and actions as a worthy investment.
However, with the private citizen at the heart of nutrition services, public services can be coordinated from the bottom up, starting with the point of service delivery. Coordination at higher levels of government can continue to reflect top-down policy goals, but can also reflect more clearly the realized needs of lower-level program delivery.
A call for empowerment
It is time to rebalance the paradigm for comprehensive nutrition programming. Relying exclusively on a cascade of complex policies and coordination mechanisms — from national governments down to villages via several intermediate layers of bureaucracy — is tying one hand behind our backs in the fight against malnutrition.
Citizen-led approaches have proven successful in improving service delivery and outcomes in many countries across many sectors. It is time to start empowering new generations of multisectoral citizens to demand and monitor comprehensive nutrition programming — and to make predominantly top-down approaches to multisectoral nutrition a thing of the past.
Photo © Transparency for Development/Jessica Creighton