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Innovations in the Delivery and Scaling-up
of Nutrition Interventions
Marie T. Ruel,Director,
Food Consumption and Nutrition Division
IFPRI
Scaling-up
• Scaling-up: « A combination of strategies and technologies
designed to help expand programs with greater rapidity and larger scale »
« Strategies to bring more quality benefitsto more peopleover a wider range of geographical areamore quickymore equitablymore lastingly »
1: Develop a Scaling-up Plan
2: Establish Preconditions for Scaling up
3. Implement Scaling-up Process
Legitimize Change Build Constituency
Realign/MobilizeResources
Modify/StrengthenOrganizations
Coordinate Action Plans & Budgets
Track PerformanceMaintain Momentum
An Overview of the Scaling-up ProcessCreate VisionAssess Scalability
Fill in info gaps
Source: Cooley and Kahl 2005; MSI
Achieving « Scale »
• Achieving Scale:« Widespread achievement of IMPACT at affordable cost
Impact is a function of:- Coverage- Program effectiveness (impact resulting from
quality implementation and efficacy of intervention)
- Efficiency (cost/beneficiary)- Sustainability – continuity/ownership- Equity – reaching the hardest to reach
Nutrition is not about 1 intervention/1 outcome: Determinants of child nutrition are complex
Vitamin A
BF Water/San
Diarrheacontrol
Agriculture Education Healthsystems
UNICEF,1992
Improving Nutrition is Best Achieved through Cross-Sectoral Initiatives
• So, best results are achieved when you are able to address multiple causes of malnutrition and life-cycle approach
• This involves working across sectors –
Scaling up nutrition as part of cross-sectoral initiatives
Thailand
0
10
20
30
40
50
60
1982 1983 1984 1985 1986 1988 1990 1992 1994 1996
Mild Moderate Severe
% underweight
Thailand
0
10
20
30
40
50
60
1982 1983 1984 1985 1986 1988 1990 1992 1994 1996
Mild Moderate Severe
% u
nd
erw
eig
ht
1st NHNP (1977-81): low ( 30% coverage), focus on PEM, MN, Food
2nd NHNP (1982-86) Focus on behavior change + preventionFocus on community-based PHCMassive scale-up + training health volunteersHigh coverageNutrition within poverty alleviation strategyLinked to agriculture production
Lessons Learned from Thailand
• Rapid improvements in child nutrition when nutrition interventions were:– Community-based integrated PHC (from 1982) – Included in National Economic & Social Development
Plan (converged with poverty alleviation strategy) – Linked with agriculture-based strategies
• Success factors:– Planning– Integration– Social mobilization– Local action-oriented surveillance
China
0
5
10
15
20
25
1990 1995 1998 2000 2002 2005
Urban Rural Total
% underweight
Source: Dr. Chen Chunming, Forman Lecture 2006
China reached the MDG1 by 2002(Svedberg 2007)
China: Lessons Learned
• Successful poverty alleviation strategy• Effective nutrition/health/family planning
interventions• Complementary interventions:
– Water/sanitation– Education (92-05: 32 to 57% moms with middle school; 22.5 to
7% illiterate)
• Partnerships: Chinese Gov’t, UNICEF, WB, NGOs
• Commitment/ownership• Regular data collection; use of data for policy
But China has an Emerging Problem of Overweight/Obesity and NCDs
0
5
10
15
20
25
30
Overall Urban Rural
Overweight Obesity
Source: Dr. Chen Chunming (Forman Lecture, 2006)
% Calorie intake
Fat content of diet (oil, meat)
Physical activity (work, transport)
What is China doing about these New Challenges?
• Dietary Guidelines: (Food Guide Pagoda)– Focuses on BOTH under- and over-nutrition (e.g. limit
amount of fatty meat)
• National Plan of Action for Nutrition (1997)– Interventions to alleviate hunger/malnutrition– Prevent diet-relatd NCDs, promote healthy lifestyles
• National Surveys/Food & Nutrition Surveillance System
• Health sector activities• Plant breeding + subsidisation of vegetables• Physical activity promotion/smoking cessation• « Healthy Lifestyles for All » launched in 2007
Conclusion
• More complex and challenging to scale-up and integrate nutrition interventions across different sectors
• But pay-off is well worth it• Successful experiences do exist (other
examples from Latin America: conditional cash transfer programs
• Main challenges are NOT what to scale up, how much to scale up, but rather:
How to strengthen countries commitment & capacity to scale-up and achieve scale
Types of Scaling up Processes
• Quantitative: increase coverage• Functional: increase breath and depth• Political: address national level barriers to
effective programs and services• Organizational: increase organization’s ability to
support initiative/program in effective and sustainable way (building alliances, capacity building, etc.)
10 issues in Scaling Up
• Change
• Capacity (financial, leadership, management, technical, community, logistical)
• Strategies: replication, integration, paradigm shift
• Impact: social, financial
• Sustainability: of process, of program
• Access
• Suppy/demand
• Cost of scaling up, maintaining scale, scaling down
• Resources: financing scaling up: how much/how long?
• Timing: when is right time? Re-assessing scale