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Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine Health Policy and Planning 2011;1–13
ß The Author 2011; all rights reserved. doi:10.1093/heapol/czr011
1
2 HEALTH POLICY AND PLANNING
KEY MESSAGES
Strengthening the full spectrum of policy activities is necessary if large-scale and sustained reductions in undernutrition
are to be achieved.
Within this policy spectrum, high priority should be given to strengthening strategic capacities because these are
fundamental for advancing commitment-building, agenda setting, policy formulation, capacity-building for operations,
and all other aspects of a long-term nutrition agenda at country level.
These conclusions are especially relevant for major global initiatives currently under development that seek to address
nutrition through country-led processes and convergence among multiple organizations.
The extensive investments in documenting the efficacy of nutrition interventions are unlikely to produce sustainable
reductions in undernutrition unless or until these weaknesses in the policy spectrum are better understood and
addressed.
expatriate staff
3/07–12/31/09
Institute of Nutrition offered the opportunity to study the
agenda-setting process in a prospective fashion. As shown in
Table 1, the varied needs and circumstances in each country
created diversity in the MNI partnerships, roles, activities, levels
and forms of engagement, and, thus, in the particular features
of the policy process most amenable for study.
Co-create and participate in partnership group
Stakeholder assessments
- Formative research
-
-
-
-
frameworks
Organization (facilitative)
MOH, PLAN International
World Bank
(multisectoral)
Peru 30%
efforts, we have emphasized all aspects of the policy process campaigns on the social conditions in the country (i.e. poverty,
under study including those that were largely under the social exclusion, gross inequity). These symbolic actions en-
influence of actors other than MNI staff. In addition, to tailed little or no political cost because, in the absence of
strengthen our interpretation of local processes and events, we sustained pressure from civil society in any of these three
employed semi-structured interviews in Bolivia, Peru, countries, there was limited accountability for producing
Guatemala and Vietnam with selected stakeholders and key nutrition results. In addition, in all three countries there were
informants, in addition to participant observation; we engaged more pressing national issues that overtook nutrition in the
several staff members in discussions of emergent findings, to symbolic agenda after the elections.
maintain some reflexivity and cross-checking of interpretations; In Vietnam and Bangladesh, there were no comparable efforts
and we held a week-long workshop with partners from Bolivia, from advocates or policy entrepreneurs to create political
Peru, Bangladesh and Vietnam during the final year of the attention to nutrition during elections, such that the symbolic
project. actions noted above are not as pronounced in these two
countries. Instead, as revealed in all the other indicators in
Table 2, a variety of actions were taken by ministry officials,
Presentation of findings
donors or non-governmental organization (NGO) actors. These
Findings and interpretations are organized according to frame-
actions reflect the interests, entrepreneurial activity, capacity
works and indicators that have proved useful in earlier work.
and bureaucratic politics of and among these actors. Thus,
Specifically, for describing commitment we adapted a set of
public campaigns and sub-national awareness-raising activities
ministries
5
exclusion President Garcia express a security and the Right to Food such, several high profile with media coverage and ad-
concern for social policy and resonated with the political international meetings hosted vocacy playing key roles
results-based governing in his climate across two in Vietnam proved very useful
campaign and administration administrations
5. Civil society mobilization Not crucial Not crucial Not crucial No role at the national level; Not crucial
lower level mobilization in the
Has not played a role in agenda Has not played a role in agenda Civil society organizations have Media coverage played a key role
future is unclear
setting or policy formulation setting or policy formulation; played an active part in na- but otherwise it was advocacy
but is envisioned as part of unclear if it will be part of tional strategy discussions and by a respected research insti-
programme implementation programme implementation have seats on high-level coor- tution (ICDDR,B) and an
dinating structures. Lower international partner
level mobilization in the (UNICEF)
future is unclear
6. National political entrepreneurship Crucial Not crucial Crucial Not crucial Crucial
A single, trusted, high-level nu- A coalition of international NGOs A prominent local businessman The partnership was the initial After learning more about an-
trition champion in the MOH and UN agencies was the with political connections led entrepreneur and collaborated aemia, the Minister of Health
(with support from a second entrepreneur at first, then the consensus process and with committed government and Director General of
MOH ally) succeeded in con- followed by the Prime high-level advocacy officials to advance the issue, Family Planning (DGFP)
vincing the incoming presi- Minister with World Bank with a government champion played key roles in advancing
dent and overcoming encouragement emerging in the process the issue
resistance from senior officials
in the ministry of planning
and other officials in the MOH
7. Credible indicators Crucial Crucial Crucial Crucial Crucial
Indicators revealed stunting as Indicators showed 10-year stag- Indicators revealed Guatemala as Indicators revealed high burden The finding of anaemia in 92% of
the major problem and heavi- nation in stunting after years one of the most heavily af- of stunting, out of line with infants, 68% of preschoolers
est burden in the highlands of decline, despite rapid eco- fected countries in the world Vietnam’s social and economic and half of pregnant women
nomic growth progress immediately captured
attention
8. Internal frame and policy com- Not crucial Crucial Crucial Crucial Crucial
munity cohesion for agenda
Attention was generated by one The coalition of international The development of a formal A small but tight-knit partner- The Minister of Health chaired a
setting
senior MOH official and sup- NGOs and UN agencies sup- policy and law required gain- ship of international organ- meeting of nutrition and
port from a few others in the ported common advocacy ing consensus at a general level izations helped government health experts, government
MOH but otherwise with little messages among major government and identify stunting as a major officials, NGOs and develop-
input from the broader policy non- government actors problem ment partners, moving the
community issue further into an action
agenda
(continued)
and evaluation.
distinctions noted in the previous section between the political
Bangladesh
ICDDR,B.
and bureaucratic sphere, electoral versus non-electoral contexts,
Promising
and MOH versus multisectoral settings. This distinction reveals
different dynamics in the two sets of countries. In Bolivia, Peru
and Guatemala, political transitions, credible indicators and an
effective external frame all were universally crucial, while norm
sectoral structures.
the existence of a problem and connecting it to broader political
Unclear as yet
themes (poverty, inequity, etc.) without the need to offer clear
solutions, appeal to international norms, or make use of (or
Vietnam
a multisectoral strategy
policy discourse.
governance structures
preventive intervention strategy. In Peru, there was disagree- or districts) do provide insight into the range of factors likely to
ment over central leadership for the President’s new nutrition influence the implementation process and the types of
initiative, with some actors favouring the ministry that was capacities required to manage them effectively.
historically responsible for the politically popular but The Potter and Brough framework provides a useful way to
poorly-targeted food distribution programmes and others fa- summarize the implementation and capacity issues observed in
vouring the MOH. Policy formulation in Peru was further these countries by recognizing a four-tiered hierarchy of needs
complicated when a major donor agency that was not part of (tools; skills; staff and infrastructure; and structures, systems
the original advocacy coalition entered the policy dialogue at a and roles) and nine component capacities (material supplies
high political level, marginalized the advocacy coalition and and resources, personal capacities, workload and supervisory
promoted a different intervention strategy. capacities, facilities and support services, administrative sys-
In all three Latin American countries, a major source of tems, coordination and decision-making capacities, and au-
disagreement or ambiguity related to the focus on broad, thoritative role definition) (Potter and Brough 2004). These
multisectoral strategies (and defining the precise role of each four tiers and nine components are relevant at each adminis-
sector) versus more narrow, often health-sector-based inter- trative level, from national, to regional, municipal/district and
ventions. These examples illustrate that the disagreements local.
often could not be resolved through appeals to technical The strengths and weaknesses of these capacities vary widely
evidence, and more often were related to questions of institu- according to sector (MOH and BRAC vs. others) and interven-
tional leadership, expertise, agenda control, the promotion of tion type (e.g. micronutrient powders vs. growth promotion vs.
Bangladesh
Intervention: Counselling of mothers concerning appropriate infant and young child feeding (IYCF).
Policy intent: BRAC will integrate IYCF counselling within its existing maternal, newborn and child health (MNCH) programme, with a
focus on exclusive breastfeeding for 6 months and appropriate complementary feeding from 6–23 months.
Accomplishments: In early 2007, BRAC’s research and evaluation division conducted a formative study and convened a stakeholders
plans, even in those cases where a rare window of opportunity (Holman 1999; Senge 2006; Innes and Booher 2010). Genuine
was created by the head of state. These difficulties arose, to knowledge or evidence gaps might sometimes benefit from
varying degrees, due to differing professional views about the consulting trusted experts, seeking guidance from authoritative
most effective or appropriate intervention strategies (e.g. sources (e.g. WHO guidelines, Lancet series), and reviewing or
whether to distribute fortified complementary food to all gathering relevant evidence (Mulrow 1994; Bowen 2005).
children 6–24 months), differing institutional positions con- However, the experience in these countries and the broader
cerning these strategies, rivalries concerning leadership or literature (Wildavsky 1979; Rogers 1988; Majone 1989; Barker
agenda control, and genuine uncertainties concerning the and Peters 1993; Rochefort and Cobb 1994; Stone 2002;
roles of various ministries other than the MOH. The net Huxham 2003; Atkins 2005) suggests that differences in
result has been significant delays in moving the nutrition professional views and interpretations of knowledge or evidence
agenda forward in most countries, and, most worrying, the risk typically are intertwined with professional and institutional
of eroding the interest, support and confidence of the political values, incentives, agendas and rivalries, i.e. they relate to
champions and donors. These difficulties and disagreements competing interests rather than purely intellectual or know-
were not as salient in the literature on multisectoral nutrition ledge constraints. As such, responses that only seek to address
planning in the 1970s, which instead stressed the importance of intellectual, knowledge or evidence issues are unlikely to
political commitment and implementation capacities (Field succeed (Black and Donald 2001; Behague et al. 2009).
1977; Pines 1982; Berg 1987; Field 1987), with one notable Similarly, the establishment of multisectoral councils or other
exception (Iverson et al. 1979). formal decision structures are unlikely to be sufficient by
These difficulties and disagreements in policy formulation themselves, as seen in these countries and earlier experiences
parallel the dynamics observed within nutrition policy commu- (Levinson 1995). One approach for overcoming these difficulties
nities in recent years at the global (Morris et al. 2008) and and disagreements in the policy-formulation process is to
national levels (Pelletier 2008; Natalicchio 2009), and in health strengthen the strategic capacity within the nutrition policy
policy and other sectors more broadly (Mills 1990; Kingdon community, referring to the individual and institutional cap-
1995; Shiffman 2007; Shiffman and Smith 2007; Walt et al. acity to broker agreements, resolve conflicts, build relationships,
2008). The appropriate response depends fundamentally on the respond to recurring challenges and opportunities, and under-
specific source of the problem and the context. For instance, take strategic communications (Mintrom 2000; Agranoff 2007;
differing professional views might sometimes be addressed Pelletier 2008). Such capacities have not yet received systematic
through various collaborative problem-solving methods attention from the global nutrition community and will be
12 HEALTH POLICY AND PLANNING
crucial as countries make greater efforts to achieve alignment attention if large-scale and sustained reductions in under-
on goals, strategies and implementation in the coming years. nutrition are to be achieved. The country experiences docu-
The above suggestions for how to resolve disagreements in mented in this study underscore the inter-connected nature of
policy formulation all accept the current institutional architec- these policy activities and the need for all of them to be
ture and governance system as a given. These consist of strengthened. Second, within this policy spectrum, high priority
ministries, donors, NGOs, coordinating councils and others is warranted to strengthening strategic capacity (Pelletier 2008)
interacting to promote their preferred problem definitions, because it is fundamental for advancing commitment-building,
interventions and delivery strategies, with no single authority agenda setting, policy formulation, capacity-building for oper-
charged with making and enforcing final decisions. When the ations, and all other aspects of a long-term nutrition agenda at
authority did exist for certain decisions, as in the case of the country level. Our conclusions are relevant for the major global
MOH for decisions on growth monitoring indicators in Bolivia initiatives currently under development that seek to reduce
and anaemia interventions in Bangladesh, the competing actors undernutrition (Bezanson and Isenman 2010). We conclude
tended to direct their advocacy towards those authorities rather that the extensive investments in intervention efficacy research
than each other, and authoritative decisions eventually were (Leroy et al. 2007; Rudan et al. 2007b; Bhutta et al. 2008) are
taken. This suggests the problem is only partly related to the unlikely to produce sustainable reductions in undernutrition
existence of competing interests and perspectives among the unless or until these constraints in the policy process are better
policy actors (though these clearly do exist) and the absence of understood and addressed.
effective fora for reconciling these in a collaborative or
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