Hidden Hunger: Strategies to Improve Nutrition Quality
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Hidden hunger has long been an overlooked problem. Vitamin and mineral deficiencies have to be remedied and the availability of calories needs to be increased. As a matter of fact, the number of people who do not have access to a balanced diet has multiplied in rich and poor countries, with lasting consequences for health and well-being. Hidden hunger not only affects childhood growth and cognitive development, but also reduces productivity and well-being later in life, thus keeping the affected population trapped in a circle of poverty and malnutrition. This book illustrates the global fight against hunger by national governments and international organizations. Presented at the Third Hidden Hunger Conference held at the University of Hohenheim in Stuttgart, Germany, it presents a range of strategies being implemented in various regions of the world to improve nutrition quality and combat this international crisis.



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Date de parution 17 avril 2018
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EAN13 9783318062533
Langue English
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Hidden Hunger: Strategies to Improve Nutrition Quality
Supported by an unrestricted educational grant from the
World Review of Nutrition and Dietetics
Vol. 118
Series Editor
Berthold Koletzko Munich
Hidden Hunger: Strategies to Improve Nutrition Quality
Volume Editors
Hans Konrad Biesalski Stuttgart
Regina Birner Stuttgart
47 figures, 5 in color, and 24 tables, 2018
_______________________ Prof. Hans Konrad Biesalski Institute of Biological Chemistry and Nutritional Science University of Hohenheim Stuttgart (Germany)
_______________________ Regina Birner Institute of Biological Chemistry and Nutritional Science University of Hohenheim Stuttgart (Germany)
Library of Congress Cataloging-in-Publication Data
Names: Biesalski, Hans Konrad, editor. | Birner, Regina, editor.
Title: Hidden hunger. Strategies to improve nutrition quality / volume editors, Hans Konrad Biesalski, Regina Birner.
Other titles: Strategies to improve nutrition quality
Description: Basel ; New York : Karger, 2018. | Series: World review of nutrition and dietetics, ISSN 0084-2230 ; vol. 118 | Includes bibliographical references and indexes.
Identifiers: LCCN 2017061843 (print) | LCCN 2017061499 (ebook) | ISBN 9783318062533 (eBook) | ISBN 9783318062526 (alk. paper) | ISBN 9783318062533 (e-ISBN)
Subjects: | MESH: Nutrition Policy | Nutritive Value | Malnutrition--prevention & control | Socioeconomic Factors
Classification: LCC TX359 (print) | LCC TX359 (ebook) | NLM QU 145.72 | DDC 363.8/561--dc23
LC record available at https://lccn.loc.gov/2017061843
Bibliographic Indices. This publication is listed in bibliographic services, including Current Contents ® and Index Medicus.
Disclaimer. The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publisher and the editor(s). The appearance of advertisements in the book is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
Drug Dosage. The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
© Copyright 2018 by S. Karger AG, P.O. Box, CH–4009 Basel (Switzerland)
Printed on acid-free and non-aging paper (ISO 9706)
ISSN 0084–2230
e-ISSN 1662–3975
ISBN 978–3–318–06252–6
e-ISBN 978–3–318–06253–3
Dabbert, S. (Stuttgart)
Biesalski, H.K.; Birner, R. (Stuttgart)
Economic and Political Innovation for Nutritional Improvement
von Braun, J. (Bonn)
What Does it Need to Improve Nutrition Quality? The Role of Public Partners
Eiden, H.-C. (Bonn)
The Devil is in the Detail: Understanding the Governance Challenges of Implementing Nutrition-Specific Programs on a Large Scale
Birner, R. (Stuttgart); Sekher, M. (Mumbai)
Post-2015 Agenda and Sustainable Development Goals: Where Are We Now? Global Opportunities to Address Malnutrition in all Its Forms, Including Hidden Hunger
Amoroso, L. (Rome)
Without Land, No Crops – Without Diversity, No Healthy and Sustainable Diets
Mogge, M.; Sonntag, A. (Bonn)
A Challenge for International Cooperation
Warning, C. (Berlin)
Working with Santal Villagers, West Bengal, India: Moringa and Kitchen Gardens to Combat Malnutrition, 2012–2017
Bucher, A.; Bucher, R. (Karlsruhe)
Multidimensional Nutritional Welfare of Children in Southern Africa: A Human Rights Consistent Approach
Arndt, C.; Mahrt, K. (Washington, DC); Salvucci, V.; Tarp, F. (Helsinki)
How to Accelerate the End of Hunger and Undernutrition
von Grebmer, K. (Washington, DC)
On the Link between Production Diversity and Dietary Quality in Smallholder Farm Households
Qaim, M.; Sibhatu, K.T. (Goettingen)
Reducing Mineral and Vitamin Deficiencies through Biofortification: Progress Under HarvestPlus
Bouis, H. (Washington, DC)
The Most Hidden of All the Hidden Hungers: The Global Deficiency in DHA and EPA and What to do About It
Winkler, T.J. (London)
The Nutrition Paradox in India: The Coexistence of Undernutrition and Overnutrition
Soni, R.K.; Singh, R. (Ludhiana)
Transdisciplinary Approaches and Methods in the Context of Food and Nutrition Security
Knierim, A.; Callenius, C. (Stuttgart)
Unveiling the Menace of Hidden Hunger in Refugee Camps: Nutritional Status among Refugees, States Responsibility, and Key African Strategies on Nutrition
Yankam Lemdjo, F.M. (Addis Ababa)
Combating Hidden Hunger in Agriculture Perspective
Ul-Allah, S. (Layyah)
Latin America and the Caribbean: Strategies to Fight Hidden Hunger
Miteva, P. (Mexico City); Ruano, E. (Guatemala); Jordan, I. (Giessen)
Strategies to Fight Hidden Hunger in Ethiopia, Egypt, Sudan and Tunisia
Chemeda, A. (Jimma); Zeleke, B. (Hawassa); Abdel-Azim, N. (Cairo); Kabbar, R. (Khartoum); Ksentini, I. (Sfax); Jordan, I. (Giessen)
Agricultural Assistance to Vulnerable, Food-Insecure Female-Headed Households in Kyrgyzstan
Nurgaziev, M. (Bishkek); Jordan, I. (Giessen)
Linking Agriculture and Natural Resource Management towards Nutrition Security (LANN+)
Banerjee, S.; Varshneya, N. (New Delhi)
Vitamin D deficiency: A Public Health Issue in High- and Low-Income Countries or Just Hype?
Cashman, K.D. (Cork)
Nutrition Education Cell, a Community Based Approach to Fight against Child Undernutrition and Strength Community Resilience, in Rural Area in Burkina Faso
Belem, T.; Piazza, V.; Mormile, M.; Meneghetti, F.; Porgo, B.; Midjour, R.; Traore, M.; Neya, B.J.; Millogo, M. (Verona)
Students4Kids: Winning Project, Growing the Tree against Hunger ( Ensete ventricosum ) in Zambia
Cardenas, D.; Hensel, C. (Mainz); Molla, E.L. (Addis Ababa)
Author Index
Subject Index
In 2000, the international community made a commitment to cut by half the percentage of people who suffer from hunger by the year 2015. Despite the successful achievements in this context, related public health issues have become more significant. The number of people who do not have access to a balanced diet has increased. Such “hidden hunger” affects both rich and poor countries. Those affected by nutritional deficiencies often suffer lasting consequences to their health and well-being.
Indeed, the global fight against hunger has become significantly more complex. Such complexity necessitates research that is both connected and interdisciplinary. With the Hidden Hunger Congress, the University of Hohenheim aims to provide a platform for global interactions among all the stakeholders in this debate: the scientific community, political practitioners, government officials, the media, civil society organizations, or advocacy groups as well as other private and public sector actors.
The University of Hohenheim certainly is a very appropriate place for this debate. Its history is inextricably linked with the problem of hunger and nutrition. It was in the wake of the famines of the early 19th century, after all, that the first predecessor organization of the university was established. That was in 1818, two centuries ago. Ever since, issues such as nutrition and food security have been central topics of research here at Hohenheim. 200 years ago, these efforts had only a regional scope. Today, we are addressing hunger on a global scale.
A significant number of our research departments are dedicating their efforts to solving national and international problems of hunger and malnutrition. Our researchers are collaborating with partner institutions in Africa, Asia, and Latin America on this topic. To take just one example, we are currently promoting a German-Ethiopian graduate program supported by the German Academic Exchange Service. Our research centers focus on the causes and consequences of hidden hunger as well as strategies to address these issues.
Our upcoming 200th anniversary thus serves as a poignant reminder of the significance of hunger and nutrition as topics of research. It also affords us the opportunity to strengthen and promote our research in this field. What is more is that we look forward to hosting the 4th Hidden Hunger Congress in 2019, which will take place in our acclaimed new Otto Rettenmaier Audimax. The Hidden Hunger Congress as well as this publication stood for our commitment to contribute to the goal of food security.
Stephan Dabbert , Stuttgart
This volume of the “World Review of Nutrition and Dietetics” presents 23 papers that were presented at the Third Hidden Hunger Conference held from March 20–22, 2017, at the University of Hohenheim in Stuttgart, Germany. With this third event, the Hidden Hunger conference series has become an established meeting of scientists from different fields, policy makers, and representatives of governmental and non-governmental organizations to present new data and analyses and discuss innovative ways to overcome hidden hunger, which had long been an overlooked problem. The title of the Third Hidden Hunger Conference was “The post-2015 agenda: Where are we now? Strategies to improve nutrition quality and combat hidden hunger.” As in the case of the 2 previous conferences, the event brought together representatives from different disciplines from high- and low-income countries, who discussed the links and the gaps between science and practice in all regions of the world.
When the First Hidden Hunger Conference was launched in 2013, the term “hidden hunger” was known only within a small circle of scientists. The first conference was entitled “From Assessment to Solutions” and highlighted problems and challenges of the hidden aspects of micronutrient malnutrition. The second conference held in 2015 focused on the consequences of hidden hunger, placing special emphasis on the 1,000-days window. Thanks to Karger publisher, we were able to publish most of the presentations in the series “World Review of Nutrition and Dietetics,” which helped to raise global attention to the problem of hidden hunger.
Indeed, hidden hunger has become more visible since then. The Third Hidden Hunger Conference featured a range of strategies to improve nutrition quality and combat hidden hunger that are now implemented in different regions of the world, which were highlighted in different important lectures. The fact that nearly all presentations are now available in the series “World Reviews of Nutrition and Dietetics” documents the importance of this conference. We are particularly delighted that all 3 conferences attracted not only leading senior scientists, but also young scientists from Africa and Asia who presented exciting new field research that shows that there is movement and scientific commitment to overcome the challenge of hidden hunger.
We are profoundly grateful for the participation of international speakers who helped to uncover the problems of hidden hunger and to make them visible to all who are engaged in combating hunger on a global scale. It is unacceptable any longer to announce a reduction of hunger based on an increase of available calories only. Hidden hunger still lurks behind the scenes, which affects childhood growth and cognitive development, but becomes visible too late and reduces productivity and well-being later in life, thus keeping the affected population trapped in a circle of poverty and malnutrition. The Hidden Hunger Conference series will continue to highlight this hidden problem to rouse policy makers, scientists, and all organizations involved in the fight against hunger to place hidden hunger strongly in the focus of their action. It is not enough to feed the world, we need to nourish the world.
Our warmest thanks are due to Jana Tinz and Donatus Nohr for their immense and generous help in organizing the congress. Special thanks are also due to our students who were a great help in the organization of the conference. We would like to express our sincere thanks for to the Robert Bosch Foundation, the Fiat Panis Foundation, to the Sabri Ülker Foundation, and to the GESTE – Foundation for Development Cooperation for their support, which allowed us to fund the conference participation of students and scientists from Africa and Asia. We are also grateful for the the German Academic Exchange Service ( Deutscher Akademischer Austauschdienst , DAAD) which allowed us to organize an alumni seminar in connection with the conference, which was attended by 60 DAAD alumni from a wide range of developing countries. Consequently, the conference was able to bring together professionals from many regions of the world that are affected by hidden hunger problems and encourage a dialogue with scientists and development organizations who are working on strategies to make hidden hunger visible as a basis for its control.
The initiative “One World, No Hunger” of the German Federal Ministry for Economic Cooperation and Development ( Bundesministerium für wirtschaftliche Zusammenarbeit und Entwicklung , BMZ) is a good example of a strategy to address hunger as well as hidden hunger by focusing not only on the quantity, but also the quality of food. We are grateful for the generous financial support of the conference by the BMZ. We would also like to thank the German Federal Ministry of Food and Agriculture ( Bundesministerium für Ernährung und Landwirtschaft , BMEL) and the Food Security Center of the University Hohenheim for their support.
The speakers, the sponsors and the back-stage assistants of the Third Hidden Hunger Conference made it possible that this book could be published. The never-ending kind deadline reminders of our assistant Kornelia Kasper ensured that we could bring together all manuscripts within a short time. Peter Roth and Tanja Sebuk from Karger publishers kindly took care of the remaining organizational requirements that made it possible to have the book available now. We trust that the book will find a wide audience and will, thus, help to combat the problem of hidden hunger worldwide.
Hans K. Biesalski , Stuttgart
Regina Birner , Stuttgart
Biesalski HK, Birner R (eds): Hidden Hunger: Strategies to Improve Nutrition Quality. World Rev Nutr Diet. Basel, Karger, 2018, vol 118, pp 1–9 (DOI: 10.1159/000484513)
Economic and Political Innovation for Nutritional Improvement
Joachim von Braun
Center for Development Research, University of Bonn, Bonn, Germany
Large shares of the world population are still affected by nutrition deficiencies and undernutrition. However, the current global agriculture and food system and its international governance shows signs of serious malfunctioning, and is not equipped to cope with the current and future challenges it is facing. In view of the complex and multi-dimensional nature of nutrition problems, a framework is put forward here to improve the understanding of underlying causalities, and to identify priorities for action. In doing so, this paper focuses on economic and policy innovation. Better nutrition policy requires systematic, multi-faceted policy innovations, that is, the re-design of the current global food and nutrition governance system, and the adoption of innovative economic and political approaches. To achieve efficient and effective nutrition policy, more attention, leadership, funds, and a global organizational home for better coordination are needed. A systematic science and policy interface in the form of an International Panel on Food, Nutrition and Agriculture is proposed to provide a strong evidence base for nutrition policies.
© 2018 S. Karger AG, Basel
Nutritional deficits and undernutrition affect large shares of populations around the world. Food and nutrition security is not just a matter of increasing food production and distribution, but matters of health, sanitation, and human behavior. Systematic, multi-faceted changes, that is, innovations are needed to improve nutrition. Simplistically innovation may be defined as “getting things done better” (improved processes), and “getting better things” (improved products and services). We distinguish between technological (e.g., biological, medical, engineering), institutional/economic, and policy innovations. Innovation is an important driver for economic and social progress, including in the whole food and nutrition system, which is our focus here. Innovations must tackle the complex problems of hunger, undernutrition, and malnutrition (obesity) to find effective and efficient solutions to them. This paper focuses on economic and policy innovations for nutritional improvements. Achieving food and nutrition security will not only require policy makers to commit, but also evidence-based choices of action, and sound policy implementation. Enhancement of scientific knowledge is fundamental for innovation. Experimentation and scaling of innovations require inclusion of the public in transparent discourse on choices of actions.
Table 1 . Impact of economic growth on health and nutrition 1

Economic Growth and Nutrition
The nutrition research and practitioners community tends to focus on identification and improvement of targeted interventions; and rightly so, because complex problems need complex solutions. Yet, broad based economic changes need consideration as well. The positive impact of economic growth on health and nutrition outcomes is shown in Table 1 . Across the 3 income groups (measured by GDP per capita), countries with higher economic growth have shown bigger reductions in both stunting and child mortality compared to countries in the same group with lower growth. An only exception is in the middle-income group; here we find that countries with lower growth have been more successful in reducing the prevalence of stunting. Innovation or total factor productivity growth comes into play by driving economic growth, which then can lead to an enhanced nutrition of the population. Of course, nature of growth – inclusive rather than growth captured by the wealthy – and public spending facilitated by increased national income, may be the real forces that translate growth into improved health and nutrition. This is not captured by the broad-brush tabulation in Table 1 .
As economic growth accelerated in the past decade in Africa and South Asia, we should expect nutritional improvement in that region. In fact, there has been substantial progress in reducing undernutrition since 2000. Global Hunger Index (GHI) scores for Sub-Saharan Africa and South Asia have decreased significantly. Africa south of the Sahara has achieved the largest absolute improvement since 2000, followed by South Asia also with a sizable reduction. Among the 10 most successful countries in reducing their GHI in absolute terms from 2000 to 2016 are 8 countries from Sub-Sahara Africa [ 1 ].
Not only growth, but also good governance is positively correlated with the reduction of undernutrition. Indicators for good governance 1 plotted against the reduction in the GHI suggest that the nutritional status and prevalence of hunger benefit from a safe and accountable policy environment as well as responsible and corruption-free leadership.
Governance is not only a matter of governments, but given their global reach, multinational food companies have a powerful role to play alongside governments, international organizations, and civil society in reducing hunger and impaired nutrition. The Access to Nutrition Index is an independent benchmarking tool that measures companies’ contributions to good nutrition against international norms and standards. According to the Access to Nutrition Index report from 2016 [ 2 ], “companies have shown improvement since 2013 in:
• Assigning top-level managerial responsibility and oversight to undernutrition.
• Explicitly committing to tackling micronutrient deficiencies in developing countries through targeted fortification of products.
• Reporting on engagement with governments in developing countries on undernutrition.”
The report shows that the world’s top food and beverage companies have taken some steps towards improving consumers’ diets. However, many of the companies are still lagging behind and overall greater efforts are required.
Drawing partly on recent reviews [ 3 , 4 ], key success factors for the political economy of nutrition are:
1 Three sets of factors shape enabling environments for nutrition: knowledge and evidence, politics and governance, and capacity and resources.
2 Leadership for nutrition is fundamentally important for results.
The private sector has substantial potential to contribute to improvements in nutrition, but there is scarcity of credible evidence and trust.
4 Operational research of delivery, implementation, and the scaling of interventions, and contextual analysis is essential.

Fig. 1 . Instruments and actions for improved nutrition. Source: designed by author.
5 Systematic political economy analysis should be embedded with identification of potentially improved roles of stakeholders to avoid disappointments with public-private and NGO-private partnerships.
The Principal Challenge of Mapping Nutrition Goals and Instruments
The reduction of hunger and improvement of nutrition remain key policy goals in international policy. This is reflected in the United Nation’s Sustainable Development Goals (SDGs). The “Zero Hunger” goal No. 2 of the SDGs explicitly deals with ending the problem of hunger and all forms of malnutrition, which include hidden hunger, by 2030. The international political leaders commit to providing universal access to safe, nutritious, and sufficient food, in particular for the poor and people in vulnerable situations. Furthermore, virtually all other SDGs relate to nutrition directly or indirectly as well. However, there are trade-offs between specific policy goals that have to be taken into consideration.
In order to achieve a policy goal, there is a need for proper and well-defined instruments and specific actions. A prerequisite for effective and efficient policy action is that policy makers are equipped with more instruments than goals. Figure 1 presents an illustration of this principle emphasized by Tinbergen in the early 50s [ 5 ]. The defined goal of improving nutrition requires at least 2 instruments: (1) improving nutrition services and (2) generating or transferring income to the poor. Specific actions for improving nutrition services may include (1.1) (bio-)fortification of food, that is, increasing the content of micronutrients in food during processing or in the crops through agronomic practices, conventional plant breeding, or modern biotechnology and/or (1.2) promoting behavioral change. The second instrument would require a focus on (2.1) propelling agricultural productivity and/or (2.2) cash transfers.

Fig. 2 . Framework of nutrition and food systems. Source: von Braun [ 6 ].
The multi-dimensional character of nutrition challenges requires the deployment of a combination of multiple instruments and policy actions. This means that complex problems related for instance to income, food access, and micronutrient deficiencies require context specific combinations of interventions. Better nutrition policy therefore implies more coordination in policy making across different policy domains and innovative approaches, such as the combination of conditional cash transfers, employment guarantees, fortification, sanitation programs, small farm productivity programs, or mother and child focused nutrition interventions.
Economic and Political Innovations for Better Nutrition
In view of the noted complexities, an effective policy for improved nutrition needs a framework that helps in understanding causal relations of determinants, and shaping priorities for action. An aggregate but comprehensive conceptual framework is presented in Figure 2 . The concept takes a broad perspective on the food and agricultural sector, income and employment, markets and services, and hunger and malnutrition. Institutions, information, and behavior are cross-cutting issues that influence linkages in all the domains that describe the framework. Generally, all 4 dimensions in Figure 2 and their interrelations can benefit from innovations making the food and nutrition system more effective, efficient, and resilient.
Even in a rather aggregate framework such as presented here, at least 6 critical linkages need consideration when addressing hunger and malnutrition (see arrows in Fig. 2 ). Overarching and surrounding are environmental as well as macroeconomic framework conditions. Related linkages exist at large or even global scale, such as greenhouse gas emissions through land use change, and at local scale, such as water and sanitation in the context of irrigated agriculture and waste disposal. All the links operate with diverse dynamics under short- or long-term time lags, which require attention in policies and programs. Structural problems, such as access to markets and resources including land, have to be considered and there are risks affecting the resilience of poor people and low-income countries, often eroding societal cohesion. Furthermore, a multitude of drivers far beyond agriculture can shape food security in positive or risky ways, for example, bio-energy systems, financial markets integrated with food commodity markets, novel non-land-based foods, and more. Priorities in targeting nutritional problems can be identified from this framework. Targets for economic and political innovations are to
1 Increase investment in food and nutrition research and development (R&D),
2 Provide more innovative social protection, transfer, and nutrition enhancement programs,
3 Strengthen communities’ own innovation capacities, including for improved health, sanitation, and water environment, and
4 Improve nutrition in complex emergencies.
Furthermore, policy makers should seek innovation in the implementation process [ 7 ]. Outcomes of an implementation process are different degrees of implementation, from “paper implementation,” to process implementation, to performance implementation. The outcome of an intervention process on the other hand is an established evidence base. Interventions and implementation research have different target groups. Interventions focus on groups of people such as children, women, the infected, or the undernourished. Implementation on the other hand focuses on client groups such as practitioners, managers, organizations, or communities (in systems). For accelerated success with economic and policy innovations for nutrition, a stronger focus on policy and program implementation is called for, since it is critical for impact.
Directions for Policy Innovations
In most countries, political leaders have verbally and symbolically committed to addressing food and nutrition, but adequate financial resources were not allocated [ 8 ]. Low cohesion of the policy community has been identified as a major underlying cause of the low-priority status of food and nutrition. Furthermore, there is still is a lack of structured exchange between science and policy at national and international levels. The world food and agricultural system and the governance of its international dimensions show signs of serious malfunctioning [ 9 , 10 ]. The incoherent and inadequate response to the acute food price crisis in 2008 was just one indication. What can be done about these constraints?
Nothing less than a re-design of the current global food and nutrition governance system is needed, that means policy innovation at large scale is needed. It would include 2 sets of policy innovations, nutrition getting an organizational home at global level, and science and policy on food and nutrition coming together in a well-defined institutional framework. There should be no illusion that any such policy innovations can be translated into reality in the short run. Political economy forces will prevent that.
Regarding the first, nutrition as a global problem with at least its 3 dimensions of undernutrition, micronutrient deficiencies, and obesity, currently has no well-defined organizational home. Many low-income nation states are not capable to address the nutrition problems effectively by themselves. The recently emerging Scaling Up Nutrition Movement involving more than 50 countries with the UN playing a facilitating role is a promising international effort to overcome this deficiency. Food assistance in failed states and war-affected regions remains a tremendous challenge. A more comprehensive emergency aid mechanism is called for, in which the food and nutrition element covered by WFP remains essential, and where non-governmental actors find improved ways to effectively engage in coordinated ways. The complex nature of the problem calls for an equally complex organizational arrangement at an international level, and not just one entity to handle it all.
Regarding the second, the way policy and science interact related to food, nutrition and agriculture has to be re-shaped as well. Currently, actors on the supply side of scientific information, such as universities and other public or private research organizations, show some interaction and exchange among each other. However, the different actors on the supply side interact with the demand side (e.g., governments, NGOs, or international organizations) mainly on a one-to-one basis. A structured exchange of a more inclusive nature is missing between providers and users of research in the field of food, nutrition, and agriculture. The current and future challenges of food and nutrition security justify a permanent institutional arrangement for this purpose. Re-designing the current system toward an International Panel on Food, Nutrition and Agriculture would provide decision-makers with research-based evidence and enhance the exchange between science and policy ( Fig. 3 ). The set-up of the panel would be partly following the design of the Intergovernmental Panel on Climate Change and applying the principle of separating the provision of science-based assessments from political decision-making, where the latter should be based on facts but takes value judgements on trade-offs into account. Existing organizations and mechanisms would form building blocks of the strengthened and re-designed governance system. 2
Nutritional improvement requires nutrition sciences, but also inputs from social sciences, including economics and political science. While emphasizing multi-disciplinary approaches, this article focused on economic and political innovations. It is increasingly understood that broad-based economic growth combined with social interventions reduces undernutrition, but the relationships between economic development and malnutrition and obesity are more complex [ 11 ]. To improve nutrition and reduce hunger especially in low- and middle-income emerging economies, several conclusions for economic and political innovations can be drawn:

Fig. 3 . Toward the “International Panel on Food, Nutrition and Agriculture” (IP-FNA). Source: von Braun and Kalkuhl [ 10 ].
1 Political economy analyses of nutrition policy choices need to be combined with economic and implementation research to identify feasible and best policies.
2 Efficient and effective nutrition policy needs a systematic focus on goals and instruments, with all potential instruments taken into consideration, excluding none for instance because of ideological bias.
3 Nutrition policy requires more attention, leadership, and funds, as well as a global organizational home, rather than spread across global/UN organizations.
4 The evidence base for nutrition policies must be strengthened by establishing a systematic science and policy interface, similar to what has evolved for the field of climate change with Intergovernmental Panel on Climate Change.
1 Malabo Montpellier Panel: NOURISHED: How Africa Can Build a Future Free from Hunger and Malnutrition. Dakar, Senegal, 2017.
2 Access to Nutrition Foundation (2016), Access to Nutrition Index Report 2016, Access to Nutrition Foundation, Utrecht. https://www.accesstonutrition.org/sites/in16.atnindex.org/files/resources/atni-global-index-2016.pdf .
3 Reich MR, Balarajan Y: Political economy analysis for nutrition policy. Lancet Glob Health 2016;2:e681–e682.
4 Gillespie S, et al: The politics of reducing malnutrition: building commitment and accelerating progress. Lancet 2013;382:552–569.
5 Tinbergen J: On the Theory of Economic Policy. Amsterdam, North-Holland, 1952.
6 von Braun J: Agricultural Change and Health and Nutrition in Emerging Economies. Agriculture and Rural Development in a Globalizing World, edited by Prabhu Pingali and Gershon Feder, Chapter 14. Earthscan Food and Agriculture Series. London, Routledge, 2017, pp 273–291.
7 Fixsen DL, Naoom SF, Blase KA, Friedman RM, Wallace F: Implementation Research: A Synthesis of the Literature. Tanpa, FL, University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network (FMHI Publication #231), 2005.
8 Fox AM, Balarajan Y, Cheng C, Reich MR: Measuring political commitment and opportunities to advance food and nutrition security: piloting a rapid assessment tool. Health Policy Plan 2015;30:566–578.
9 von Braun J, Birner R: Designing Global Governance for Agricultural Development and Food and Nutrition Security, Review of Development Economics, 2016. http://onlinelibrary.wiley.com/doi/10.1111/rode.12261/abstract .
10 von Braun J, Kalkuhl M: International Science and Policy Interaction for Improved Food and Nutrition Security: Toward an International Panel on Food and Nutrition (IPFN), (ZEF Working Papers No. 142), 2015. http://www.zef.de/uploads/tx_zefportal/Publications/WP142_final.pdf .
11 IFPRI: Global Nutrition Report 2015: Actions and Accountability to Advance Nutrition and Sustainable Development, Washington, DC, 2015. http://dx.doi.org/10.2499/9780896298835 .
Prof. Joachim von Braun Center for Development Research, University of Bonn Genscheralle 3 DE–53113 Bonn (Germany) E-Mail jvonbruan@uni-bonn.de
3rd International Congress Hidden Hunger, March 20–22, 2017 in Hohenheim, Germany.
1 Good Governance indicators include, for example, “Control of Corruption,” “Voice and Accountability” or “Political Stability and Absence of Violence,” taken from Worldwide Governance Indicators (WGI), World Bank, http://data.worldbank.org/data-catalog/worldwide-governance-indicators .
2 For more details on the proposed panel see: von Braun and Kalkuhl [ 10 ] and von Braun and Birner [ 9 ].
Biesalski HK, Birner R (eds): Hidden Hunger: Strategies to Improve Nutrition Quality. World Rev Nutr Diet. Basel, Karger, 2018, vol 118, pp 10–16 (DOI: 10.1159/000484397)
What Does it Need to Improve Nutrition Quality? The Role of Public Partners
Hanns-Christoph Eiden
Federal Office for Agriculture and Food, Bonn, Germany
Public partners play a key role when we want to improve nutrition quality. They will not succeed, when they try to achieve the goal alone or tend to dominate other players. In their responsibility for common interests it is up to public partners to moderate and facilitate the multi-stakeholder and multi-sectorial dialogue to improve nutrition quality. It is up to public partners to establish clear legal and structural guidelines aiming to bring all partners together, to avoid conflicts of interests and, above all, establish conditions, in which consumers are sufficiently informed about food and nutrition, so that they are motivated, empowered, and adequately protected to take their own responsible decisions.
© 2018 S. Karger AG, Basel
When preparing my presentation for this opening lecture, I thought about how to best embed it in the context of this congress. Let me start with 3 introductory remarks. First, you are attending the 3rd International Congress on Hidden Hunger. We gathered for the first time exactly 4 years ago, just a few kilometers away. While 4 years ago the headline was “From Assessment to Solutions!” today we are discussing strategies to improve nutrition quality and combat hidden hunger. We have made progress since then [ 1 ].
Second, therefore, with my second introductory remark, I would like to stress that we are talking about action, about the roadmap to success. With the adoption of the sustainable development goals (SDGs) [ 2 ], the world has defined this roadmap. Improved nutrition is explicitly mentioned in SDG 2. Goal 2 calls for action to end all forms of malnutrition by 2030, for attaining the internationally agreed targets on stunting and wasting in children under 5 years and, for addressing the specific nutritional needs of adolescent girls, pregnant, and lactating women.
Moreover, at least 12 of the 17 goals also contain indicators that are highly relevant for nutrition. This leads me to my third remark. None of the different SDGs can be achieved by treating each goal separately. Aiming at improved nutrition, achieving nutrition security as well as nutrition quality urges us to consider a wide range of aspects – from diversified and sustainable agriculture to food systems that care for the transportation and processing of food while preserving its quality. We need to consider the availability of good food for consumers at affordable prices throughout the year. And, of course, we need to consider issues such as health, sanitation, education, environmental challenges, gender issues, cultural issues, and rights issues. Improved nutrition is a truly multi-sector issue.
Nutrition Quality
What does talking about nutrition and nutrition quality mean? It means that we talk about the food we eat, about calories, the energy we need and take in every day, about safe food and about quality standards, about labelling and information on content and origin, about diet, a diet more or less diverse, a diet which is good or bad for us. So, when we are talking about nutrition, it is not just about what we eat. It is about how we eat and why we eat this way or that and how we think about our nutrition [ 3 – 5 ]. We are talking about us, about ourselves, about our lifestyles, our skills to handle food and meals, our behaviors in general and our nutritional behaviors in particular, and also about the conditions we live in.
This means that the quality of our nutrition, whether our diet is healthy or not, whether “it is health promoting” or not, significantly depends on how we live, how we learn, what we know about ourselves and about nutrition, whether we are able and motivated to act in a way that is appropriate for us, and whether we develop a lifestyle which fits our needs and allows us to nourish ourselves accordingly.
Physical activity is an important issue in that context [ 6 ]. Yet, knowledge and motivation are not sufficient. It is equally important to create both the physical and the social opportunity, which enable me to actually do what I am motivated to do. In fact, behavior emerges from the interaction between 3 necessary conditions: knowledge, motivation, and opportunity.
The Role of Public Partners
It is a complex task. Therefore, you need partners to move forward. Before describing more concretely the role of public partners, let me discuss a bit more in detail, who the partners are and what talking about a multi-actor approach actually means. It does not mean that all the partners have to do everything together. The roadmap to success rather asks us to identify different tasks and to attribute specific responsibilities to different partners. And at the same time – and this is the essence of a multi-actor approach – the roadmap to success asks us to create platforms which encourage dialogue and stimulate innovative energies that derive from this exchange among different actors at equal levels.
The actors are manifold. Among them are producers, processors, and trading companies acting individually or as a group, each of them looking at the issue from their point of view and following their own interests. There are consumers, too, also acting either as individuals or as a group. There are scientists from different academic sectors. And there are extension and field services, teachers, social and medical services.
All these actors must be committed to a continued, coherent, and sustainable action on local, regional, country, and/or global level. Of course, public partners are also involved as well as states, regions and their administrations, supranational and international organizations. However, they are not just another part of this big puzzle of actors involved. Their task is different. It is up to them to lay down the basic legal rules, aiming at a level playing field for the fruitful cooperation of all actors.
It is up to countries and regions to establish the rules to comply with and which solve conflicts of interest, establish standards for cooperation and conduct, ensure the transparency of processes, as well as equal treatment and representation and look for the appropriate discussion of the various different aspects. It is up to the public partners to stimulate and moderate the trans-sectorial and multi-disciplinary action to improve the nutritional standard of people in a given area.
This does not mean that the public partners should dominate the process in a top-down manner. Public partners will never be suited to do so, as they will never know better and already ex ante what needs to be done. Public partners need input from other actors. They need to understand and they need to get the large picture, empowering them to play this stimulating, moderating, and facilitating role with the necessary authority.
Empowering and Protecting People
However, the task of public partners goes beyond that, as the process has a goal. An individual person takes a responsible decision regarding the kind of nutrition that is appropriate for his or her needs. So we are talking about empowering and protecting people [ 7 ]. Only when people know more about their needs can they decide which quality of nutrition suits them. People must also be protected against misleading advertising and baseless product disclosures. Only then will they be less dependent on claims and will rely more on their knowledge and their capacity to take decisions. Only then can they assess the effects of their nutritional habits on the food chain as well as on the environment, health, and social structures.
Therefore, public partners need to ensure legislation, where needed, especially on labelling to ensure transparency and to avoid that consumers are being misled. They need to ensure that nutrition education and nutrition information [ 8 , 9 ] start in the family, continue in childcare facilities at school, and accompany an individual throughout his/her lifetime [ 10 ] in order to help take the “right” decision under different circumstances. Eventually and depending on the specific situation in a country or region, preventive actions or emergency measures in order to fight malnutrition or micronutrient deficiencies and to improve or stabilize the nutritional status of people or specific vulnerable groups, such as small children and their mothers, adolescent girls, elderly people, minority groups, may also be necessary. The role of public partners in this aspect is to steer the process, set priorities, take the final decisions, establish the framework of action, and supervise the implementation of steps to be taken by different actors.
How Do We Interpret the Role of Public Partners in Germany?
Adequate nutrition is an issue of high political importance in Germany. There are growing concerns about the production conditions, leading to a strong public interest in information about the composition of foodstuffs. There is a strong demand for clear indications at the point of sale and/or on the packaging [ 11 – 13 ]. Simultaneously, changing lifestyle habits lead to an increasing level of overweight and obesity while, on the other hand, concerns also grow regarding insufficient nutrition especially among elderly people and specific social groups [ 14 – 22 ].
At the national level, since 2008, the Federal Government and the Federal States are active to improve the quality of food in schools and kindergartens, to establish quality standards for food in community catering and to establish networks to better reach specific groups of the population. As a national strategy for better nutrition and more physical activity, these activities are jointly led by the Federal Ministries for Agriculture and Food and for Health. It is implemented in close cooperation with the Federal States and local authorities, who are responsible in first hand. It broadly takes on board research institutions and works as a multi-stakeholder initiative, linking nutrition, health, education, public information, and agriculture [ 23 – 26 ].
In 2017, the Federal Minister for Agriculture and Food, Christian Schmidt, has significantly pushed forward these activities by establishing the Federal Centre for Nutrition as a branch of the Federal Office for Agriculture and Food [ 27 ]. The Centre will not only continue the networking activities of the previously mentioned national strategy for better nutrition and more physical activity. It will expand and intensify them, for example regarding the quality of food in schools and kindergartens, the culture of having a meal together, as well as regards improved nutrition for mothers and their children, during pregnancy and the first 2 years after a child’s birth [ 28 ]. These are core objectives of Germany’s nutrition policy.
Furthermore, the Centre supports the Scientific Committee on the Composition of Foodstuffs in its task to ensure transparent consumer information, and it deals with the reduction of food losses along the value chain from the farm up to the final consumer. Communication is the Centre’s second pillar. Extensive information about nutritional issues and influence on the environment where people eat and make food choices will help empower consumers to make the appropriate choice about nutrition and to make the healthy choice the easy choice.
A comprehensive strategy will be set up to reach the general public directly, and via multipliers and through all appropriate media under the headline “From Knowledge to Action.” Together with the new Federal Institute for Research on Child Nutrition, these activities illustrate that Germany indeed places a high priority on improved nutrition quality. Federal Minister, Schmidt, did so in view of Germany´s obligation to reach the SDGs and the Commitments deriving from the Rome Declaration by the International Conference on Nutrition-2 in 2014 [ 29 , 30 ]. Consequently, Germany will not focus on activities at the national level only.
On the contrary, we are deeply convinced that we can achieve our goals in Germany only in an intense exchange and cooperation with sister institutions in other countries. Nutrition is an issue for all of us. Malnutrition is a global issue, we may be differently affected, but the task remains the same. Consequently, Germany has given specific attention to nutritional issues already in the past in its support of the work of FAO and WHO. Scaling up nutrition is also a characterizing element of Germany’s development activities. Improving the nutritional situation in partner countries is a prime objective for German development cooperation projects in the framework of the German initiative “One World – No Hunger” [ 31 ].
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13 Federal Ministry of Food and Agriculture: Nationale Strategie zur Reduktion von Zucker, Fetten und Salz in Fertigprodukten. 2017. http://www.bmel.de/DE/Ernaehrung/_Texte/Reformulierung_Hintergrund.html (accessed June 20, 2017).
14 German Nutrition Society eV: 13. Ernährungsbericht. German Nutrition Society e.V. (Hrsg). Bonn, German Nutrition Society eV, 2016.
15 Lobstein T, Brinsden H: Symposium report: the prevention of obesity and NCDs: challenges and opportunities for governments. Obes Rev 2014;15(8):630–639.
16 Wang Y, Lobstein T: Worldwide trends in childhood overweight and obesity, Int J Pediatr Obes 2006;1:11–25.
17 James T P, Rigby N, International Obesity Task Force: The obesity epidemic, metabolic syndrome and future prevention strategies. European Journal of Preventive Cardiology, 2004, vol 11. http://journals.sagepub.com/doi/pdf/10.1097/01.hjr.0000114707.27531.48 ).
18 Kaiser MJ, Bauer JM, Rämsch C, Uter W, Guigoz Y, Cederholm T, Thomas DR, Anthony PS, Charlton KE, Maggio M, Tsai AC, Vellas B, Sieber CC; Mini Nutritional Assessment (MNA) International Group: Frequency of malnutrition in older adults: a multinational perspective using the mini nutritional assessment. https://www.ncbi.nlm.nih.gov/pubmed/20863332 . J Am Geriatr Soc 2010;58:1734–1738.
19 World Health Organization: Global Status Report on Noncommunicable Diseases 2014. Geneva, World Health Organization, 2014.
20 Studie zur Gesundheit Erwachsener in Deutschland; in Bundesgesundheitsblatt – Gesundheitsforschung – Gesundheitsschutz. Springer-Verlag, 2013. https://www.degs-studie.de/deutsch/ergebnisse/degs1/degs1-basispublikation.html (accessed July 17, 2017).
21 Studie zur Gesundheit von Kindern und Jugendlichen in Deutschland; in Bundesgesundheitsblatt – Gesundheitsforschung – Gesundheitsschutz. Springer-Verlag, 2014. https://www.kiggs-studie.de/deutsch/ergebnisse/kiggs-welle-1/basispublikation.html (accessed July 17, 2017).
22 Robert-Koch-Institut: Journal of Health Monitoring 2016/2: Ernährung in Deutschland. http://www.rki.de/DE/Content/Gesundheitsmonitoring/Gesundheitsberichterstattung/GBEDownloadsJ/JoHM_2016_02_ernaehrung.html (accessed July 17, 2017).
23 Federal Ministry of Food and Agriculture: IN FORM: The National Action Plan for the Prevention of Poor Dietary Habits, Lack of Physical Activity, Overweight and Related Diseases. Bonn, 2008.
24 Koletzko B, Bauer CP, Cierpka M, Cremer M, Flothkötter M, Graf C, Heindl I, Hellmers C, Kersting M, Krawinkel M, Przyrembel H, Vetter K, Weissenborn A, Wöckel A: Nutrition and physical activity of infants and breastfeeding women. Updated recommendations by “Healthy Start – Young Family Network” an initiative from IN FORM. Monatsschr Kinderheilkd 2016;164:771.
25 Koletzko B, Bauer CP, Bung P, Cremer M, Flothkötter M, Hellmers C, Kersting M, Krawinkel M, Przyrembel H, Rasenack R, Schäfer T, Vetter K, Wahn U, Weissenborn A, Wöckel A: German national consensus recommendations on nutrition and lifestyle in pregnancy by the “Healthy Start – Young Family Network.” Ann Nutr Metab 2013;63:311–322.
26 Koletzko B, Armbruster M, Bauer CP, Bös K, Cierpka M, Cremer M, Dieminger B, Flothkötter M, Graf C, Heindl I, Hellmers C, Kersting M, Krawinkel M, Plöger A, Przyrembel H, Reichert-Garschhammer E, Schäfer T, Wahn U, Vetter K, Wabitsch M, Weissenborn A, Wiegand S: Nutrition and physical activity in children from 1–3 years old. Recommendations by the network “Healthy Start – Young Family Network.” Monatsschr Kinderheilkd 2013;161:1187–1120.
27 Sondernewsletter des aid: “Bundeszentrum für Ernährung geht an den Start: Ernährungskommunikation national gedacht.” https://www.bzfe.de/inhalt/bundeszentrum-fuer-ernaehrung-geht-an-den-start-29489.html , Bonn 19. Januar 2017 (accessed 17 July 2017).
28 Bundesministerium für Ernährung und Landwirtschaft: Internetportal von Gesund ins Leben. Netzwerk junge Familie: https://www.gesund-ins-leben.de/ (accessed July 17, 2017).
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30 UN General Assembly: A-RES-69–310: Follow-Up to the Second International Conference on Nutrition. Resolution adopted by the General Assembly. New York, United Nations Organization, 2015.
31 The Federal Ministry for Economic Cooperation and Development: Special Initiative: One World, No Hunger. http://www.bmz.de/de/themen/ernaehrung/hunger/loesungsansaetze/index.html , Bonn, 2014 (accessed July 14, 2017).
Dr. Hanns-Christoph Eiden Federal Office for Agriculture and Food Deichmanns Aue 29 DE–53179 Bonn (Germany) E-Mail hanns-christoph.eiden@ble.de
Biesalski HK, Birner R (eds): Hidden Hunger: Strategies to Improve Nutrition Quality. World Rev Nutr Diet. Basel, Karger, 2018, vol 118, pp 17–44 (DOI: 10.1159/000484341)
The Devil is in the Detail: Understanding the Governance Challenges of Implementing Nutrition-Specific Programs on a Large Scale
Regina Birner a · Madushree Sekher b
a Hans-Ruthenberg-Institute, University of Hohenheim, Stuttgart, Germany; b Centre for Studies in Social Exclusion and Inclusive Policies, Tata Institute of Social Studies (TISS), Mumbai, India
Nutrition interventions can play a key role in combatting hidden hunger in developing countries. However, when malnutrition is affecting a large share of the population, such programs need to be implemented on a large scale, which involves major governance challenges, such as absenteeism of staff, elite capture, and leakage of funds or food. This paper discusses the underlying reasons of these governance challenges from a theoretical perspective and proposes a participatory research tool called “Process Net-Map” to analyze these challenges empirically. A case study of India’s Integrated Child Development Services Scheme was conducted in Bihar to provide a proof-of-concept of Process Net-Map as a qualitative research tool that is suitable to identify governance challenges in the implementation of large-scale nutrition programs. Applying the Process Net-Map tool made it clear that the “devil is in the detail” when it comes to the implementation of large-scale nutrition interventions. The case study also shows that an understanding of the details of the implementation mechanisms of nutrition programs is essential for designing governance reform options that have good prospects to increase the effectiveness of large-scale nutrition programs in developing countries.
© 2018 S. Karger AG, Basel
1 Introduction
Hunger and malnutrition remain among the most important challenges facing humanity. As the latest report on the “State of Food Insecurity in the World” shows, world hunger appears to be on the rise again after a prolonged period of decline. The estimated number of people with chronic calorie deficiency increased from 777 million in 2015 to 815 million in 2016 [[ 1 ], p ii]. An even more widespread problem is micronutrient deficiency, also known as hidden hunger, which affects more than 2 billion people worldwide [[ 2 ], p 21]. These figures underline that it is still a major challenge to reach the second sustainable development goal (SDG 2) on the post-2015 agenda, which is to “end hunger, achieve food security and improved nutrition, and promote sustainable agriculture.” One of the sub-goals of SDG 2 is to end all forms of malnutrition by 2030. 1
Nutrition programs have a high potential to address this problem, but in order to reach SDG 2, they need to be implemented on a large scale. One can distinguish between nutrition-specific and nutrition-sensitive programs [ 3 ]. Nutrition-specific programs address “the immediate determinants of fetal and child nutrition and development – adequate food and nutrient intake, feeding, caregiving and parenting practices, and low burden of infectious diseases” [ 3 ]. A series of papers on maternal and child nutrition published in 2013 in “The Lancet” found that the upscaling of nutrition-specific interventions to a coverage of 90% could reduce the prevalence of severe wasting by more than 60% and the prevalence of stunting by more than 20% [[ 3 ], p 8]. The series also highlighted the need to scale up nutrition-sensitive interventions, such as social safety nets and women empowerment programs, which address the underlying determinants of undernutrition and, thus, enhance the effectiveness of nutrition-specific interventions [[ 4 ], p 547].
The evidence for the effectiveness of nutrition interventions is typically derived from projects that are implemented on a limited scale by dedicated project staff with the support of generous donor funds. A major challenge is the implementation of such interventions on a large scale by national and local governments, who have to rely on their public administration system. The conditions for such large-scale implementation of nutrition-specific programs are typically quite different from those of donor-funded development projects. They are affected by the well-known problems of public sector management in developing countries, which include a chronic scarcity of operational resources, relatively low payment levels and incentive for staff, and deficient management systems for both human and financial resources. These conditions result in frequent absenteeism of front-level service providers, “leakage” of funds, political interference, and elite capture (e.g., [ 5 – 8 ]).
Against this background, the question arises: how can national governments in developing countries overcome the governance challenges of implementing nutrition programs at large scale? This question has received limited attention in the literature, so far. There is a growing number of studies on the governance problems of education and health services (e.g., [ 9 , 10 ]). There is also a growing literature on large-scale interventions that can be characterized as nutrition-sensitive, such as direct cash transfers and other types of social safety nets [ 11 ]. While this literature is also relevant for large-scale nutrition-specific programs, there is a need to focus on the challenges that are particularly pertinent for the implementation of nutrition-specific interventions. The field of “implementation science” in the nutrition literature addresses this question. Our paper aims to make 2 contributions to this emerging field. One is theoretical: we use concepts of the New Institutional Economics (NIE) to identify the governance challenges that can be expected to occur in large-scale nutrition-specific programs. The second contribution is empirical: we present a qualitative research tool called “Process Net-Map” to identify the governance challenges that can be identified in practice. To provide a proof-of-concept for this research tool, we conducted a case study of the implementation of India’s Integrated Child Development Services (ICDS) Scheme in Bihar. The ICDS is a prime example of a large-scale nutrition-specific program, which is implemented by the public administration of a developing country. Bihar is particularly suited for the case study, as it is one of the states of India where child malnutrition rates are particularly high and governance conditions are particularly problematic (see [ 12 ], and the literature quoted here).
This paper is structured as follows. The next section presents a theoretical analysis of the governance problems that can be expected in large-scale nutrition-specific programs. Insights from the literature are used to illustrate these challenges. Section 3 describes the case study context and Section 4 introduces the Process Net-Map tool. The results of the case study are presented in Section 5 and discussed in Section 6. Section 7 presents some conclusions.
2 Theoretical Considerations
This section first defines the concept of a “governance challenges” and then identifies different types of governance challenges and their underlying reasons. The theoretical concepts used here mostly belong to the “NIE,” a branch of economics that deals with the institutional and governance dimensions of economic systems [ 13 ].
2.1 The Concept of a “Governance Challenge”
The term governance, which comes from the Latin word gubernare (i.e., “to steer”), has different meanings in the academic literature. It has been used by political scientists to analyze the management of common pool resources [ 14 ], by institutional economists to study vertical integration in the industrial sector [ 15 ], and by business administration and legal scholars to assess organizations that have boards of governors [ 16 ]. In the 1990s, the concept appeared on the international development agenda. “Good governance” became increasingly recognized as a precondition for the effective implementation of development projects and programs [cf. 17 ].
Drawing on the NIE literature, we define governance as the formal and informal institutions that influence human behavior. 2 In line with the literature on good governance, governance challenges are then defined as characteristics of formal and informal institutions that that jeopardize positive development outcomes. To classify such governance challenges and identify their underlying reasons, we distinguish 3 different types of governance: the market, the state and the “third sector,” which includes organizations that are referred to as non-profit organizations, non-governmental organizations (NGOs), civil society organizations and community-based organizations (CBOs). 3 Each type of governance involves its own challenges. The economic literature refers to challenges that affect the functioning of markets as “market failure.” Using the same terminology, governance challenges in the other 2 sectors can be labelled “state failure” and “community failure” [cf. 18 ].
For the analysis of governance challenges, it is useful to consider that nutrition-specific programs have often 2 components. One is an advisory or educational component: advising or educating mothers and other caregivers on maternal and child nutrition, the need for breast feeding and the role hygienic conditions. The second component typically involves the distribution of food items, such as dietary supplements for pregnant and lactating women and children. In principle, market, state, and third sector institutions can be involved in both components.
2.2 Governance Challenges Faced by the Private Sector
As will be discussed below, major governance challenges in large-scale nutrition programs arise due to the inefficiencies of large bureaucracies. Therefore, the question arises as to why market institutions, which may be more effective, do not play a larger role in addressing the problems of maternal and child malnutrition. It is essential to recognize the different types of market failures that make large-scale government involvement necessary. For the case of agricultural advisory services, these market failures have been analyzed [ 18 ] and similar arguments apply to nutritional advisory services.
Nutrition Advice as a Merit Good: In economic terms, advice on maternal and child nutrition has the character of a “merit good,” that is, a good that people undervalue because they are not aware of its benefits, especially not its long-term benefits. Therefore, there is no demand for such a good and without demand, private service providers do not emerge. If people are poor, they may not demand such services even if they were aware of the benefits, because they cannot afford them. Moreover, poor people typically have a high time discount rate, which means that they are not willing to pay for services today if the benefits arise only in the long run. Some of the benefits of improved fetal and child nutrition indeed arise in the long run (i.e., during adulthood or even in the next generation). Considering the nature of nutritional advisory services as a merit good, governments have to at least finance the provision of such services to address this market failure. This does not, however, imply that government employees need to provide nutrition advisory services because the government can contract NGOs or private service providers to deliver such advisory services. The challenges of such arrangements are further discussed in Section 2.4.1 below.
Information Asymmetry: The food items to be delivered by nutrition-specific programs, such as dietary supplements, can partly be considered as merit goods, as well. Hence, they are affected by the same problem of market failure as advisory services. Yet, one can observe that there is some willingness to pay for commercial baby foods, including infant formula, even among poor households. Therefore, there are private sector providers of such food items that operate not only in only in industrialized, but also in developing countries – even in remote rural areas where poverty levels are high. An important market failure that arises with regard to commercial baby food is due to information asymmetry. The customers of infant formula are often unaware that breast feeding is better for nutritional outcomes, especially under problematic hygienic conditions. Moreover, it is difficult for customers to verify the health claims that companies often use to market commercial baby foods. This market failure can be addressed by government regulation, and to some extent also by information campaigns and by self-regulation of the industry. While there is global progress in the establishment of a regulatory framework, this type of market failure still remains widespread (e.g., [ 22 ], for a recent commentary on the problem). One challenge inherent in global regulations related to commercial baby food is the fact that, at country level, they need to be implemented by the national public administration, which faces the governance challenges outlined in the next section.
2.3 Governance Challenges Faced by Government Agencies
Due to the market failures discussed in the previous section, the public sector is needed to implement nutrition-specific programs. Yet, for the government, such programs are difficult to implement, especially on a large scale. This is not only due to the limited capacity of government agencies, but also by the inherent characteristics of nutrition-specific programs, as will be explained in the following.
Transaction-Intensity and the Need for Discretion: Using a concept of transaction cost economics (one of the branches of NIE), one can identify one important underlying reason for the governance challenges that the public sector faces in implementing large-scale nutrition-specific programs. Such programs are inherently “transaction-intensive,” both in terms of time and space. They have to be implemented on a daily basis (hence, transaction-intensive in terms of time) and in different regions of the country, often even in the remotest rural areas (hence, transaction-intensive in terms of space). To meet these requirements, large-scale nutrition programs require large numbers of frontline staff who are distributed all over the country. Partly, they have to work “in the field,” that is, outside government offices, for example, for visiting mothers’ groups in remote villages. For all these reasons, a central government faces inherent problems of supervising the staff of such programs. The problem can partly be solved by decentralizing the management of such programs, but local government offices still have problems in supervising staff that is dispatched to rural areas [ 23 ]. The supervision problem is aggravated if the services to be provided require discretion, as is typically the case in nutrition-specific programs. A nutrition advisor needs to identify the specific problems that a household or village is facing and provide advice that is tailored to the situation. Programs that require such discretion cannot be easily standardized (unlike, for example, a primary school curriculum). It is the combination of transaction intensity and the need for discretion that causes inherent problems of implementing large-scale development programs [ 18 , 24 , 25 ] and this challenge is inherently pronounced in large-scale nutrition programs.
Low Government Capacity: Even for an agency with high capacity, transaction-intensive programs that require discretion are challenging to implement. In developing countries, government agencies do not typically have strong capacity, especially not those that are in charge of implementing programs in rural areas. As pointed out in the introduction, the typical capacity problems of such public administration institutions are well known: low salary levels; patronage-based rather than merit-based recruitment and promotion; low share of operational funds; bureaucratic procedures; and deficient management systems for human and financial resources. The public agencies in charge of implementing nutrition-sensitive programs are typically affected by these problems because they are part of the general public administration. Hence, is difficult to address these problems if no general public sector reform is taking place. Yet, even where such general public sector reforms have been pursued, the results have generally been disappointing (e.g., [ 26 ]).
Government agencies with limited capacity, which are in charge of implementing transaction-intensive nutrition programs that require discretion, can be expected to be confronted with the following governance challenges:
Absenteeism of Service Staff: One governance challenge of large-scale nutrition-specific programs is the problem that the front-level service providers do not show up for work, a problem referred to as “absenteeism.” This problem results from the combination of low incentives and limited possibility of supervision discussed above. One can expect this problem to affect in particular the advisory component of nutrition programs, since provision of advisory services requires more staff time, effort, and discretion than distributing food items. An empirical research method to assess the level of absenteeism are surprise visits in a random sample of field offices. This method has mostly been used in the fields of health and education. A review of such studies in 5 countries found that on the average, absenteeism rates in primary health centers were in the range of 35%. In India, the rate was even 40% [[ 5 ], p 92]. A study by Yamada et al. [ 27 ] showed that timely payment of wages and intrinsic motivation were associated with reduced absenteeism. However, these 2 factors are often neglected in studies about absenteeism of service staff in developing countries. 4
Leakage and Sub-Standard Quality of Food Items: A problem that can be expected to affect in particular the distribution of food items in nutrition-specific programs is “leakage,” a term used to describe the fact that funds and food items “disappear” in the implementation process and do not reach the intended beneficiaries. Empirical evidence suggests that leakage can be substantial. For example, an analysis of food subsidy programs in India and the Philippines showed that in both countries, illegal diversion accounted for more than 40% of the funds spent on the subsidy programs [[ 28 ], p 37–38]. This problem, essentially a form of corruption, is also well known in the health sector, where it affects the distribution of drugs [ 7 ]. One underlying reason for the leakage problem is the fact that food items are, in economic terms, “private goods,” which can be appropriated by individuals. (Projects that provide “public goods” do not face this challenge). Moreover, food items need to be procured in a public procurement process, which is well known for its own governance challenges, such as susceptibility to bribery and political interference [ 29 ]. Procurement problems for food items may not only lead to reduced levels of food that is ultimately available to the beneficiaries, but also to sub-standard quality of the food delivered, which may even result in health hazards.
Targeting Problems and Elite Capture: These governance challenges affect both the advisory component and the food distribution component of nutrition programs. Households that are in the direst need of nutrition advisory services and food items are usually among the poorest and therefore lack political connections and political voice. They may also face problems of discrimination if they belong to religious or ethnic minorities or, in the case of India, to lower castes. For these reasons, there is the concern that they are less likely to benefit from government programs than the elites, a targeting problem known as “elite capture.” Donor interventions may increase such local elite capture [ 30 ]. Targeting problems may also occur within households if food items, such as supplementary foods, are consumed by other household members than the intended ones. Due to existing intra-household power structures and socio-cultural factors, women and children are typically disadvantaged (see e.g., the review by [ 31 ]). A wide range of targeting methods has been developed to address targeting inefficiency in large-scale programs, but the evidence on their effectiveness remains mixed. Moreover, most of this literature refers to nutrition-sensitive rather than nutrition-specific programs [ 4 , 32 , 33 ].
2.4 Governance Challenges Faced by Third Sector Organizations
In view of both market and state failure, there have been intensive efforts in past decades to involve third-sector organizations in large-scale nutrition interventions. To assess the governance challenges involved in different such approaches, it appears useful to distinguish between NGOs that act as service providers and CBOs, such as mothers’ groups, that are designed to facilitate service provision and hold service providers accountable.
2.4.1 Governance Challenges Faced by NGOs
NGOs play an important role in implementing nutrition interventions. Many of them are faith-based because “feeding the hungry” is often a religious goal. Since such NGOs are, by definition, motivated by humanitarian goals rather than profit motives, they have strong incentives to avoid some of the governance challenges indicated above. For example, the staff of faith-based or humanitarian-inspired NGOs is more likely to be intrinsically motivated than the staff of government agencies. Still, NGOs also face governance challenges in implementing large-scale nutrition programs.
Limited Scale: Since NGOs require donor funding, they typically do not operate on a large scale. Quite often, they chose to operate in areas where logistic problems are limited, because they are better able to achieve results in those areas, which they need to be able to raise funds. An exception are NGOs that specialize in disaster relief operations. There are also some NGOs that do operate on a very large scale. One of them is BRAC, an NGO based in Bangladesh that operates on a large scale and also implements programs in other developing countries. Yet, if NGOs operate on a large scale, their management becomes more challenging and they are likely to face the same problems of supervising their field staff as do public sector agencies (see above).
Procurement Challenges: In view of the governance problems of public sector agencies, the large-scale contracting of NGOs for program implementation is often seen as an alternative solution. Yet, the contracting of such NGOs involves public procurement, which involves the typical governance problems of procurement, such as political interference and provision of sub-standard services [ 29 ]. Moreover, the large-scale contracting of NGOs may give rise to the establishment of NGOs that are non-profit in theory, but for profit in practice. Such NGOs can, for example, “hide” their profits in the salary rates and benefits that they pay to their staff. So far, there are few systematic comparisons of the relative efficiency of NGOs versus government organizations in implementing large-scale nutrition-specific programs, which have applied rigorous methodological approaches, such as randomized controlled trials. Existing case study evidence suggests that NGOs are not necessarily more effective than government agencies in implementing large-scale nutrition programs [ 34 ]. One would assume that they are more effective than government agencies in addressing culture- and gender-related problems of access to nutritious food, but this is not necessarily the case either [ 35 ].
2.4.2 Governance Challenges Faced by CBOs
CBOs, such as mothers’ groups, can facilitate the implementation of large-scale nutrition-specific programs in several ways. The costs of providing nutrition advice can be reduced considerably if advisory services are provided to groups rather than individuals. The costs of distributing food items may also decline if food is delivered to mothers who are organized in groups. Moreover, the group members can support and coach each other, which can increase the effectiveness of nutrition interventions. Women’s groups can also play a role for empowering women, especially if gender-transformative approaches are used [ 36 ]. Importantly, CBOs can hold service providers accountable, for example, through social audits, which can help to overcome the governance challenges faced by public agencies as well as NGOs in implementing large-scale nutrition programs. For example, a randomized field experiment on community-based monitoring of health programs in Uganda found improved nutritional outcomes [ 9 ]. However, CBOs face their own governance challenges, as further detailed in the following.
Free-Rider Problem: A fundamental governance challenge of CBOs is the free-rider problem of collective action [ 37 ]. If the benefits of collective action are non-excludable, people have few incentives to join a group. This problem does not apply if group members benefit from nutritional advice or from receiving food items, but it does apply to groups that are formed to hold service providers accountable [ 38 ]. Using CBOs for accountability has been tried in various large-scale services, including basic health and education. Yet, the experience has been mixed [ 39 ]. One problem is that the staff members of the service that is to be held accountable are often the only persons who are available in the field to support the formation of such groups. Yet, their incentives to form well-functioning community groups that will effectively supervise them are obviously limited.
Social Exclusion and Local Elite Capture: CBOs in nutrition programs are typically formed by female members only, as in the case of mothers’ groups. This strategy avoids the problems that women often face in mixed groups, such socio-culturally determined restrictions to making their voices heard in such settings. Yet, other problems of social exclusion can still prevail in CBOs. Communities are typically differentiated by wealth and other characteristics, such as ethnicity, religion, or, in the case of India, caste. Such differentiations often exist even within the same village, and this poses challenges for the formation of inclusive CBOs. The problem of elite capture discussed above, therefore, also affects CBOs in the form of “local elite capture” [ 30 ]. Recent studies, including randomized field experiments, provide a mixed picture on the extent of local elite capture in community-based programs [ 40 , 41 ]. One strategy to overcome the challenge of social exclusion is the formation of CBOs that comprise only members of disadvantaged groups, such as scheduled castes. However, CBOs formed by members of disadvantaged groups may have less access to program resources than CBOs formed by members with higher social status [cf. 42 ].
2.4.3 Governance Challenges Faced within Households
Households can be considered as another type of organization of the third sector. Nutrition-specific interventions typically target specific household members, such as pregnant and lactating women and children below a certain age, who live together with other household members who are not among the target groups. In the development literature, households are often defined as the group of people who live in the same place and share a common source of food, even though this definition does not take cultural differences into account [ 43 ]. Still, it is the sharing of the food within the household that also leads to governance challenges for nutrition programs.
There is a substantial literature on the intra-household dimension of nutrition, which documents the governance challenges involved in reaching the intended target groups within the household. At the heart of these challenges are socially and culturally determined norms and perceptions, including food taboos that determine how food is distributed within the household and result in restricted access of women and children to sufficient amounts of nutritious food (e.g., [ 44 ]). Overcoming these challenges may require “whole-of-family” approaches rather than focusing on female household members only. Such approaches may also help to address the problem that interventions that aim to empower women often meet with negative reactions from male household members because they have a “zero-sum” perception of power and therefore consider efforts to empower women as negatively affecting their own position within the household [ 45 ].
2.5 From “Best Practice to Best Fit”
How can large-scale nutrition programs be designed to be effective in spite of the governance challenges described in the previous sections? This is an essential question for the emerging implementation sciences in nutrition. Since the evidence from nutrition-specific programs is still limited, it appears useful to draw on insights from the literature on governance challenges of other large-scale development programs in developing countries, such as social services or agricultural development programs. One important insight that emerges from this literature is the need to design programs that fit the specific local context. There is no “silver bullet” in resolving the governance challenges described above, and program design features that have worked well in one context do not necessarily work well in another. These findings have led various authors to conclude that there is a need to move “from best practice to best fit,” that is to identify a program design that best fits context-specific conditions [ 24 , 26 , 46 , 47 ].
The need to move from best practice to best fit involves a major challenge for implementation research: how can one analyze to what extent a nutrition program fits the specific context? Insights from NIE can be used to derive hypotheses on the comparative advantage of different institutional design options, depending on the context [ 46 , 48 ]. Empirical methods can then be used to analyze the effectiveness of different institutional design options. One promising quantitative approach are randomized controlled trials that can be used to experiment with different design elements of a large-scale nutrition program, such as community-based monitoring. The study by Björkman and Svensson [ 9 ] quoted above is an example of this approach.
Such quantitative approaches are well suited to assess in a methodologically rigorous way the impact of certain design elements in large-scale nutrition programs, such as a particular community-based monitoring mechanism. However, such quantitative survey-based research tools are less suited to understand the complex processes that are involved in the implementation of a large-scale nutrition program. As will be illustrated below, large-scale nutrition programs are inherently complex and involve different types of actors (e.g., program officers, inspectors, administrative staff, private sector contractors, and community-facilitators) who operate at different levels (state, local government, community, and household). The implementation of such programs also involves various flows of funds and material items, which offer multiple opportunities for governance challenges to occur. Against this background, there is a need to develop qualitative research approaches that can be used to understand the complexity of such programs and identify the entry points for governance challenges that result from a specific program design. Such a qualitative analysis can be a useful first step before new program design elements are introduced and evaluated on a larger scale. This paper presents a qualitative research tool that can be used for this type of analysis. It is called “Process Net-Map” and will be described in Section 4 in more detail.
3 Case Study Context: Implementation of ICDS in Bihar
To provide a proof-of-concept for applying the Process Net-Map tool, a case study was conducted on the implementation of India’s ICDS scheme in the state of Bihar. The ICDS is a program of the federal government, which was created in 1975. ICDS targets pregnant and lactating mothers and children below 6 years of age who are affected by undernutrition.
ICDS is implemented by the state-level government departments in charge of social protection, which are represented at different levels of local government (districts and blocks). At community level, ICDS services are delivered through centers referred to as anganwadis (literally, courtyards), which are located at village level. Each anganwadi is managed by a female community-based frontline honorary worker, the anganwadi worker with the assistance of an anganwadi helper. These frontline service providers are not regular staff members of the public administration, but they receive a remuneration from the government.
The main nutrition services provided under ICDS are nutrition education for the pregnant and lactating mothers and the provision of supplementary food, which is provided in 2 ways: (1) in the form of a hot cooked meal given to children from 3 to 6 years of age at the anganwadi center; (2) and a “take-home ration” that is provided for children under 3 years of age and for pregnant and lactating women, and adolescent girls. 5 The ICDS services also include growth monitoring, immunization, health checks, and referral services, which are carried out by community-based health workers.
The ICDS is one of the world’s largest nutrition programs, and as it is implemented by the government, one can expect the governance challenges identified above in Section 2.3 to occur. Both the academic literature and reports by the government provide evidence of such problems. 6 Several studies document the disincentives faced by the anganwadi workers and helpers, such as job insecurity, excessive paperwork, low payment levels, and difficulties arising from late release of funds (see [ 12 ] and the literature quoted there).
There is also ample evidence of leakage and targeting problems in ICDS. One example is a report of the Comptroller and Auditor General of India that covers the time from 2006 to 2011. The auditors found that the gap between the intended beneficiaries of the supplementary nutrition component of the ICDS and those who actually received this benefit was in the range of 33–45% [ 49 ]. A study based on random visits to nearly 200 anganwadi centers in Bihar found that 53% of funds invested in the supplementary nutrition component of the ICDS were missing due to leakages [ 50 ]. NGOs and newspapers also report frequently on the governance problems of ICDS. An example of procurement problems was published by the Times of India: Several civil society organizations claimed that the Department of Social Welfare “has been in corrupt collusion with unscrupulous contractors/manufacturers, politicians, and bureaucrats” and “siphons off about Rs. 12 crore per year by supplying substandard, unhealthy nutritional supplements to children under the Supplementary Nutrition Programme of the ICDS” [ 51 ].
There is a substantial literature on various aspects of ICDS that aim to explain why child malnutrition rates in India have remained relatively high, in spite of ICDS (e.g., [ 52 ]). Yet, there is still a lack of studies that analyze in detail the implementation processes of ICDS and specify why and where in the implementation process different governance challenges occur. The remaining sections aim to address this knowledge gap.
4 Process Net-Map: An Empirical Tool to Identify Governance Challenges in Large-Scale Nutrition Programs
4.1 Development of the Tool
Process Net-Map is a participatory mapping tool that has been derived from Net-Map, a research tool that was originally developed by Eva Schiffer to collect data on social networks of stakeholders and the influence they have on development outcomes [

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