Nutrition getting the attention it deserves?

Two years after the launch of a global effort to mobilize countries in the use of scientific approaches to improve nutrition, the movement seems to be gaining momentum. More than 30 countries have signed up with the Scaling Up Nutrition Movement, better known by its acronym SUN.

But some countries are still reluctant to join amid questions and criticism over its lack of clarity and perceived relationship with companies that have controversial nutrition records, say experts.

“I don’t think anyone will deny that the movement is based on sound scientific principles and has managed to provide nutrition the profile it desperately needed, but there is still confusion around how it actually works and what it stands for,” said Purnima Menon, a nutrition expert with the International Food Policy Research Institute (IFPRI).

Studies published in The Lancet in 2008 showed that inexpensive nutrition interventions - such well-balanced meals fortified by micronutrients and breastfeeding until a child is two years old - not only reduce infant and maternal mortality but also boost economic growth in developing countries. The Framework for SUN, developed in 2010, was based in part on the Lancet series’ findings; it also recognized the need to address the underlying determinants of poor nutrition, including poor access to nutritious food, drinking water and sanitation. 

A big tent

SUN is considered a “big tent, designed to create the political space within which various nutrition initiatives can be implemented to best effect”, said David Nabarro, coordinator of the movement and Special Representative of the UN Secretary-General for Food Security and Nutrition.

The movement provides space for countries to establish their own approaches to nutrition, based on each country’s individual needs and capacity, Nabarro said. “The movement sets out to ensure that countries are in the lead and that efforts of multiple stakeholders are aligned in response to people’s needs and requests from countries.”

But this could be its undoing. “While one can understand the need to provide enough room to accommodate everyone’s needs and be acceptable, it has to draw the line somewhere and develop a sharp focus,” said a nutrition expert in South Africa, who did not want to be named.

''I don’t think anyone will deny that the movement is based on sound scientific principles and has managed to provide nutrition the profile it desperately needed, but there is still confusion around how it actually works and what it stands for''

In its attempts to be a church for all religions, SUN might lose much-needed support from champions of nutrition, who are often purists in their approach. In their view, the movement’s affiliation with private sector companies like Unilever, which are not traditionally associated with healthy foods, sits uneasily with its science-backed effort to overhaul nutrition strategies and implement low-cost nutrition interventions.

SUN is not promoting any specific affiliations, said Nabarro. All stakeholders, including businesses, commit to the movement’s principles of engagement. “If anyone is abusing the message or using our language for interests that are not in line with those of the movement, please report it to us,” he said.

Refusing to participate

South Africa has yet to join SUN, with some experts saying that it is overly focused on packaged interventions such as ready-to-use-therapeutic foods. These approaches seem to be donor-driven, and would not suit the country’s needs, said the South African nutrition official who preferred to remain anonymous.

“We don’t depend on donors, and over-nutrition rather than under-nutrition is our bigger problem, and SUN does not speak to us about that. We are under the impression that SUN is just a movement for poor countries that have under-nutrition as a problem and need funds to address that.”

Besides, the official pointed out, "it is not clear how any country can sign up. Are we invited?"

Nabarro says, “SUN Movement countries - and no one else - set their strategies for scaling up nutrition. Any country is welcome to join the movement. There are no onerous procedures: Once they have joined, countries share their experiences with developing and implementing national strategies.”

Milla McLachlan, research director at the Division of Human Nutrition at Stellenbosch University in South Africa, reckons the country has a limited capacity to engage on nutrition issues. “I think for South Africa, the question is whether devoting very limited senior nutrition capacity to a slow-to-take-off international initiative versus getting it on the National Development Plan agenda (which I believe is happening), provincial agendas, and strengthening implementation of solid…and contested existing policies is the way to go... It shouldn't have to be one or the other, but maybe [it is].”

In a recent blog post following a nutrition conference in South Africa, Lawrence Haddad, head of the Institute for Development Studies, noted, “It is interesting that not too many people here are talking about the Scaling Up Nutrition (SUN) Movement. For example, when asked why they had not signed up [for] SUN, senior nutrition representatives from the South African government said they were waiting for an invitation. Of course they don’t need an invitation - that’s the point.

“There may be political reasons for South Africa not signing up - they don’t need the money, they might think the hassle of dealing with donors is not worth it, and making yourself accountable to a wide audience is not an easy decision to make - but I found the disconnect rather stunning.”

The movement probably needs a more effective communication strategy to reach out to countries and explain what it is about, says a nutrition expert from a developing country in Asia.

Werner Schultink, chief of nutrition at the UN Children’s Fund (UNICEF), said there were several reasons why other countries had not signed up, from a lack of capacity by fragile governments to nutrition not being a priority.

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Harmonizing nutrition approaches

SUN is attempting to bring a range of stakeholders together to ensure that everyone is speaking the same language in terms of interventions and policies - and the movement provides a framework to do this, explained Nabarro.

The first step is to bring a range of people from different groups together around nutrition in each country. This is followed by establishing strategies and legislative frameworks to address issues, such as the fortification of foods like flour and salt with micronutrients, and the promotion of exclusive breastfeeding for babies under six months of age through the provision of maternity leave benefits or the restriction of commercial advertising for infant formula.

SUN countries also set their own nutrition targets or expected outcomes; targets could include getting malnutrition down by a certain percentage within a certain timeframe or eradicating micronutrient deficiencies such as anaemia or iodine deficiency. This is followed by raising the funds and building the capacity needed to achieve these targets.

Nabarro says that the SUN Secretariat monitors the progress of all the countries though six weekly conference calls with country focal points. “If they have problems, my team and I in Geneva try to address their concerns and find solutions.”

UNICEF’s Schultink said there are signs that the movement is already having an impact. He said during a recent review of SUN’s progress that Nigeria’s finance minister - not the health minister - reported to the UN. “I thought that was very telling of the kind of priority and attention nutrition was now being given in countries thanks to SUN.”

NGOs like Médecins Sans Frontières (MSF) see merit in countries using SUN as a “hub to interexchange and gather support for what they intend to do, and also to seek inspiration from South and Central American countries like Peru and Guatemala, which are implementing large nutrition programmes with much success,” said Stephane Doyon, head of the nutrition team at MSF.

Lingering disagreement

But the South African nutrition official says South American success stories like Brazil’s Zero Hunger campaign, which reduced child malnutrition by two-thirds without using packaged interventions or being driven by donors, are not highlighted enough by the SUN campaign.

“A commodity-driven campaign contradicts the current emphasis in many developing countries on home-based nutrition interventions, be it developing chickpea-based ready-to use-therapeutic food or promoting vegetable gardens,” the official said.

Nabarro says the movement does not put emphasis on “biomedical nutrition”, meaning packaged interventions, but “some countries have chosen to encourage a greater availability of such products, especially for the treatment of severe acute malnutrition, which is often lifesaving.”

The cheapest interventions are also not always the best option, an expert on nutrition aid noted. “Often there is an over-focus on cost rather than on effectiveness.”

One problem facing countries in the SUN Movement is estimating funding shortfalls for implementing their plans, Nabarro says. “We are helping them set up good financial tracking systems.”

There are 165 million stunted children and more than 2 billion suffering micronutrient deficiencies, he points out. "Watching governments give increased attention to nutrition and checking for results is very inspiring and shows how commitment is on the increase."

jk/rz