how progress has and has not been achieved, to identify bottlenecks, to guide further action, and to inform and inspire related efforts in other countries. These should be led by researchers from the case study countries, should include countries from all parts of the world, and should be completed to agreed-upon standards of quality.
MESSAGE 4: Dealing with different, overlapping forms of malnutrition is the “new normal.”
Single-issue malnutrition is on the wane, and the days of sepa- rating undernutrition from overweight and obesity are num- bered, if not over. Countries are increasingly facing complex combinations of malnutrition. For example, of 122 countries with data on stunting among children under age five, anemia in women of reproductive age, and obesity in adults, fewer than 20 experience only one type of malnutrition. This com- plexity should not be an excuse for inaction, but an urgent call for more effort to strategize, prioritize, and sequence actions. Complexity must focus action, not stifle it.
All nutrition actors need to be more aware of the risks— nutritional, financial, and political—of addressing each burden in isolation. Given these multiple burdens as well as the trend toward decentralization of nutrition programming, it is more important than ever to produce subnational and other disaggre- gated analyses of nutrition outcomes.
Recommendations
• Nutrition-related institutions—national and international, public and private—need to better align their capacity and expertise with the evolving nature of malnutrition. Groups that work on undernutrition issues need to reach out to groups within their organizations that work on overweight, obesity, and noncommunicable diseases.
• International partners who work on only one dimension of malnutrition should consider whether their approach reflects a deliberate strategic focus or simply an easy default.
• In the disbursement of awards, funders should encourage the development of simple tools to help develop and refresh country and subnational plans for improving nutrition status, focusing on prioritization, sequencing, and trade-offs.
MESSAGE 5: We need to extend coverage of nutrition-specific
programs to more of the people who need them. Only three nutrition-specific programs—vitamin A supplemen- tation, universal salt iodization, and zinc treatment during diarrhea—have comparable national coverage data for many countries. This is in part because few nutrition-specific inter- ventions have been scaled up. The poor data on coverage of interventions to treat moderate and severe acute malnutrition are a particular concern because levels of moderate and severe child wasting are high and persistent.
Expanded program coverage is valuable only if it leads to expanded impact. It is thus important to focus on maintaining
72 GLOBAL NUTRITION REPORT 2014
and improving effectiveness. Research on implementation has an important role to play in improving the quality of programming.
Recommendations
• The 2015 Global Nutrition Report will help the relevant agen- cies do more to document and analyze the stock of available data on program coverage. We aim to expand the report’s focus on programs to address overweight and obesity.
• As programs scale up to national levels, data on coverage must be scaled up in ways that promote international com- parisons.
• In future research calls, a greater emphasis should be placed on implementation research.
MESSAGE 6: A greater share of investments to improve the underlying determinants of nutrition should be designed to
have a larger impact on nutritional outcomes. This report has highlighted the stable long-term relationship between improvements in the underlying drivers of stunting (such as food supply, clean water and sanitation coverage, and women’s secondary education enrollment) and decreases in stunting rates. Given the relatively large national budget expen- ditures for agriculture, social protection, health, and education, there is a clear rationale for increasing the proportion of those expenditures that are nutrition sensitive. Moreover the need to do so seems urgent. For example, the nutrition-sensitive disbursements of the donors cited in the report were only twice that of their nutrition-specific disbursements. The evidence base on how to increase nutrition sensitivity is growing stronger in agriculture and social protection but less so in other sectors.
Recommendations
• As difficult as it may be, nutrition investors—whether gov- ernments, civil society organizations, businesses, or interna- tional partners—need to persist with their efforts to assess nutrition-sensitive spending.
• A review of evidence on how to make health systems and interventions on water, sanitation, and hygiene more nutri- tion sensitive needs to be commissioned.
• The relative absence of evidence on the nutrition impacts of nutrition-sensitive programs and approaches means that efforts to improve nutrition sensitivity should be evaluated in a rigorous way.
MESSAGE 7: More must be done to hold countries, donors, and agencies accountable for meeting their commitments to improve nutrition.
In most fields of human endeavor, accountability is a constant spur to action. But the key features of nutrition status—the need to work in alliances to improve it, the long-term benefits derived from improving it, and the invisibility of the consequences of failing to do so—all work against accountability. An increased
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