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

Nutrition through the Life-Cycle

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

Examples of SuccessAt National Level

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