Evidence to Action: Highlights From Transform Nutrition Research (2012-2017)

Abstract

Background:

The Transform Nutrition (Transform) research consortium (2012-2017), led by the International Food Policy Research Institute, sought to generate evidence to inform and inspire action to address undernutrition in 4 high-burden countries (India, Bangladesh, Kenya, and Ethiopia) and globally.

Objective:

Within the context of the literature, this synthesis article brings together core findings of Transform, highlighting priorities for future research.

Methods:

This article uses a narrative approach to synthesize diverse study findings that collectively address Transform’s three primary research questions: (1) How can nutrition-specific interventions be appropriately designed, implemented, scaled, and sustained in different settings?; (2) How can the nutritional impact of social protection and agriculture be improved?; and (3) How can enabling environments be promoted so as to use existing political and economic resources more effectively?

Results:

Highlights of Transform include (1) improved understanding of the relative effectiveness of different combinations of nutrition-specific interventions and the ways in which they can be scaled for maximal impact; (2) evidence that shows that social protection and agriculture need to be explicitly linked to nutrition in order to contribute to stunting reduction; (3) identification of key components of “enabling environments” for nutrition and how they can be cultivated/sustained; (4) research that examines ways in which leaders emerge and operate to change the political and policy landscape in different settings; and (5) “stories of change” that provide in-depth contextual knowledge of how transformative change has been driven in countries that have made inroads in reducing malnutrition. The conclusion highlights the contributions of the consortium and provides recommendations for future research.

Introduction

The past decade has seen a marked growth in evidence of the enormous human and economic costs of undernutrition, along with signs that this evidence is strengthening the commitment to act. Undernutrition is responsible for the deaths of millions of young children every year and their failure to attain their potential as adults if they survive. ¹ The rate of undernutrition reduction, however, remains slow and patchy across regions. ² Knowledge of “what works” in terms of nutrition-specific interventions has grown, ³ but scaling up is slow. ⁴ The potential for leveraging agriculture, social protection, and health systems and sectors for nutrition has not been fully exploited, ⁵ despite the recognized need for the bulk of improvements to come from outside the nutrition sector. ¹ Finally, wider political and socioeconomic structures and processes do not support nutrition as well as they could, if at all. Alan Berg’s assertion 30 years ago—that “better nutrition is in everyone’s interests, but is nobody’s responsibility” —remains apposite today. ⁶

Against this backdrop, the Transform Nutrition Research Programme Consortium (Transform) —a partnership of 5 research organizations (note 1)—was launched in 2012. Transform sought to generate and use evidence to accelerate undernutrition reduction in the 2 highest burden regions of South Asia and sub-Saharan Africa (with a special focus on India, Bangladesh, Ethiopia, and Kenya).

Following in-depth consultations with partners and wider stakeholders in focal countries during its inception phase, a research agenda was developed to better understand undernutrition’s causes at the immediate, underlying, and basic levels to generate better evidence of what works at scale and to enhance the use of this evidence to improve nutrition.

Transform’s portfolio was structured according to the following 3 themes:

Transforming delivery: How can nutrition-specific interventions be appropriately designed, combined, implemented, scaled, and sustained in different settings?

Transforming agriculture and social protection: How to maximize the impacts of investments in agriculture and social protection on nutrition?

Transforming leadership, commitment, and accountability: How can enabling environments for nutrition be cultivated and sustained (with special focus on leadership, commitment, and accountability)?

Transform thus set out to address nutrition challenges in a new and integrated way to understand the barriers and opportunities, identify potential solutions, and actively engage with key stakeholders to translate and use this evidence to scale up effective actions. This synthesis article uses the same structure to highlight our main findings, before pulling them together in the concluding section, while highlighting priorities for future research.

Transforming Delivery of Nutrition-Specific Interventions

Nutrition-specific interventions target the immediate causes of undernutrition, namely, inadequate dietary intake and ill health. ³ In 2013, the Lancet Series on Maternal and Child Nutrition recommended 10 best-bet nutrition-specific interventions (including micronutrient supplementation and fortification, community-based nutrition behavior change communication [BCC] interventions aimed at strengthening breast-feeding and complementary feeding practices, and community management of severe acute malnutrition) that, if scaled to 90% coverage, could reduce stunting by 20% for countries with high rates of undernutrition and dramatically reduce infant and child mortality. ³ Research undertaken by Transform Nutrition ⁷ for the Copenhagen Consensus has shown that every dollar invested in these interventions generates around 15 dollars in economic benefits. Transform’s first theme sought to address knowledge gaps regarding the delivery and scaling of these types of intervention, in its focal countries. We highlight some of the main activities and outputs of this theme here.

Scaling up impact on nutrition: A review

Despite a growing consensus on what needs to be done, much less is known about

how to operationalize the right mix of actions in different contexts, how to do so at a scale that matches the size of the problem, in an equitable manner, and how to do so in ways that link nutrition-specific and nutrition-sensitive interventions. ⁴

This crucial gap was the rationale for a Transform evidence review that cast a wide net across different sectors to try to understand more about the key preconditions, drivers, and pathways of successful scale-up, in different contexts for different purposes. Drawing on this cross-sectoral evidence base, along with experiences in scaling 4 major nutrition programs, 9 essential elements were identified: (1) a clear vision or goal for impact; (2) clarity on intervention characteristics (what exactly is to be scaled up—a technology, a process, a project, an innovation, and/or a methodology?); (3) an enabling organizational context for scaling up; (4) drivers such as catalysts, champions, system-wide ownership, and incentives; (5) choice of contextually relevant strategies and pathways for scaling up, (6) operational and strategic capacities; (7) adequacy, stability, and flexibility of financing; (8) appropriate governance systems and processes; and (9) embedded mechanisms for monitoring, learning, and accountability. ⁴ This framework was later used to structure a series of follow-up country case studies (see Box 1).

Box 1.

Transform’s Research Related to Gender and Women’s Empowerment

Gender has become an important focus in research on food security and nutrition. ^8,9 Examining how gendered power dynamics and women’s empowerment mediate nutrition outcomes was also important for Transform’s research. One of Transform’s first outputs was an evidence review on women’s empowerment and nutrition. Following an examination of definitions and measures of empowerment, it reviewed evidence of impact of agricultural interventions, cash transfer programs, and microfinance initiatives on empowerment measures, health and nutrition behaviors and practices, and on final nutrition outcomes. It found limited evidence of mixed impacts of these types of interventions on empowerment measures and behaviors and practices, and limited impacts on final nutrition outcomes such as stunting. The review highlights the gap in research on pathways of impact, which could shed more light on why impacts on final outcomes are scarce. Other factors such as sampling methods, implementation modality, and quality of services can also play a key role. ¹⁰

Transform also carried out several analyses of secondary data from large household surveys to examine the role of underlying drivers in nutrition outcomes. Headey et al ¹¹ show that parental education and wealth accumulation were two key drivers of stunting reduction in Bangladesh between 1997 and 2011; Menon et al. ¹² examine subnational trends in underweight prevalence of under-fives and find that improvements in social equity factors such as maternal education and household assets (among others) were important drivers of undernutrition reduction. In its assessment of state-level data on undernutrition determinants, the first ever India Health Report ¹³ related indicators of women’s social status (eg, education, age at marriage, exposure to violence, workforce participation, household decision-making) to differential progress among states in improving nutrition outcomes. Lastly, Smith and Haddad ¹⁴ analyze data for 116 out of 132 developing countries between 1972 and 2012 to examine drivers of child undernutrition reduction and find that women’s education and gender equity are key drivers in sub-Saharan Africa and South Asia.

Third, several studies in India examine frontline worker (FLW) power dynamics and incentives, as well as women’s empowerment as drivers of changes in nutrition. The study by Kohli et al., ¹⁵ part of the Stories of Change initiative, finds that lack of progress in women’s education, early age at marriage for girls, and women’s participation in household decisions continues to pose challenges to undernutrition reduction in Odisha, India, despite progress in coverage of key nutrition-specific interventions and in developing an enabling policy environment. Two other studies examined FLW incentives and their influence on service delivery and nutrition outcomes in Bihar, including individual, programmatic, and community factors. ^16,17 A qualitative case study by Deshpande ¹⁸ highlights the continuing caste dynamics among anganwadi workers in India that affects implementation of the Integrated Child Development Services Program.

Integration of nutrition within a national program

Transforming delivery of nutrition-specific interventions will usually require reform of government policy and practice. In 2011, the Government of Bangladesh, in an effort to optimize nation-wide nutritional outcomes, integrated key nutrition-specific interventions in their existing health system delivery platform—the National Nutrition Service (NNS). Two years after this rollout, Transform undertook an evaluation ¹⁹ commissioned by the World Bank to identify what was being done right, but perhaps more importantly, where mainstreaming fell short. Somewhat overwhelmed by the myriad nutrition-specific interventions, NNS was hampered by frequent changes in leadership, weak coordination, and capacity gaps at all levels—national and subnational. The evaluation also found that the NNS started with too many interventions for its existing implementation capacity, and there were critical mismatches in choice of platforms to deliver the preventive interventions. The study did nonetheless highlight potential solutions to achieve sustained improvement in the quality of nutrition services. Carefully selecting outreach-based platforms for delivering core preventive services, particularly through collaborations with existing nongovernmental organizations, can increase coverage of preventive nutrition interventions through community platforms, optimize workload, and benefit from the years of experience in community engagement. Strategic investments to ensure capacity development, nationally and at the frontline, transparency, and effective planning, monitoring, and accountability mechanisms are key to sustainability.

Supply- and demand-side constraints to delivering nutrition programs at community level

Among the factors identified in our scaling-up review, ⁴ issues of barriers and capacity directly relate to the delivery and approaches to increasing coverage of nutrition-specific interventions. Translating upstream policies to downstream health and nutrition services effectively requires an understanding of how various grassroot-level factors might influence uptake at the population level. ²⁰ Embedding core interventions into appropriate platforms, maintaining an uninterrupted supply of quality services, and promoting community demand for their use are critical.

The delivery and uptake of health and nutritional services, both product-oriented (eg, immunization) and information-based (eg, counseling), are influenced by several factors. At the community level, the success of health and nutrition programs can be affected by practical constraints relating to the performance of frontline health workers (FLWs) and/or the characteristics of beneficiary households. These influences are highly contextual, necessitating study at a fairly granular level.

In India, for example, despite specific program guidelines for FLWs, the coverage of information-based services has generally been low in rural areas. Our study, ¹⁶ conducted in 1 district of the state of Bihar, found that beneficiaries (eg, pregnant women) are more likely to receive counseling if the FLWs maintain a registry of recipients and have a lower work load in terms of the number of pregnant women in their catchment areas requiring a visit. Incentives for FLWs were important for service delivery, and product-oriented services such as immunization had a spillover effect on the delivery of information-based ones like general nutrition counseling. On the demand side, household education and socioeconomic status disproportionately influenced receipt of certain services that should be universal. We found that educated household heads were more likely to be aware of and receive immunization services than their less educated counterparts suggesting that, in the short term at least, outreach efforts should prioritize less educated households to raise awareness about the available services.

In Bangladesh, delivery of nutrition-specific interventions was mainstreamed into the health systems with the introduction of the third health sector program in 2011. ²¹ Routine health system platforms including antenatal care (ANC), postnatal care, and management of childhood illnesses at health facilities were chosen as key contact opportunities for nutrition services. After more than 2 years, the quality of nutrition counseling during ANC services was better than that offered at health facilities during child illness, which tended to be brief with inadequate provision of counseling. Poor training of FLWs and a lack of systematic supervision and oversight, combined with weak accountability processes, impeded the delivery of quality nutrition services at the community level.

Public–private partnerships to improve nutrition: A review

Addressing the multisectorality of the nutrition problem necessitates different stakeholders working together, an example of which is a public–private partnership (PPP). While the Scaling up Nutrition (SUN) Movement, which seeks to provide space (“a big tent”) for such partnerships among others, has been growing in momentum, its 2015 Independent Comprehensive Evaluation suggested the process has not solved the multiple COI [conflict of interest] challenges facing the move"ment (p62). ²² There remains a lack of consensus on promising approaches for developing and implementing PPP arrangements.

Within this context, another Transform evidence review ²³ sought to bring more rigor to the discussion of private sector engagement in nutrition, summarizing the evidence base and outlining potential ways forward. The review generated three main findings. First, there are not enough high-quality, independent evaluations of the impact of private-sector engagement in nutrition. Second, the pervasive environment of mistrust needs to be proactively addressed by both public and private sectors. This may take time (the review found no examples of successful PPPs that took less than 2 years to establish). Third, PPPs are most likely to succeed where the nutritional benefits are significant and where public-sector solutions are not readily available, effective, or sustainable. There is a considerable untapped potential for private sector-driven, pro-nutrition innovations and financing. Open and transparent bilateral discussions of objectives, roles, expectations, and potential conflicts of interest are needed, along with adequate monitoring and independent evaluations of the initiatives that emerge.

On-time data for action

Frontline service delivery requires timely and actionable data, and this is particularly evident with regard to severe acute malnutrition, which affects around 17 million children younger than 5 years and is responsible for 1 to 2 million preventable deaths every year. Transform supported Save the Children to evaluate the development and pilot of a mobile health (mHealth) application in 5 countries by World Vision, Dimagi, Save the Children, and International Medical Corps to help health workers follow treatment protocols for Community Management of Acute Malnutrition and generate accurate and timely data to respond to changes in caseloads. The experience documented by the project reveals some of the challenges faced in rolling out a mobile app in some of the most remote health facilities in the world—such as software bugs, time for FLWs to adopt and adapt the technology, and insufficient budget and staff time for piloting. ²⁴

Transforming Agriculture and Social Protection

The limited impact of nutrition-specific interventions on stunting has catalyzed a growing interest in the potential for nutrition-sensitive interventions—complementary programs deriving from other sectors that address the underlying determinants of malnutrition. ⁵ Against this backdrop, Transform explored the potential of two sectors—social protection and agriculture—in two countries (Bangladesh and Ethiopia) to reduce chronic undernutrition. The following main findings emerged from this work:

First, in and of itself, social protection has little effect on improving children’s nutritional status. ²⁵ In both Bangladesh and Ethiopia, although providing food and/or cash improved household food security, it had no effect on chronic child undernutrition. Our work in Bangladesh ²⁶ highlights the importance of linking social protection to intensive nutrition BCC activities. These improved women’s nutrition knowledge ²⁷ and enhanced their status within their homes ²⁸ and communities ²⁹ ; combined with a cash transfer, they resulted in preschool children consuming a more diverse set of foods, including animal source foods. ²⁶

Second, food is needed for children to grow; hence, agricultural interventions that increase food supply should improve children’s nutritional status. Transform’s work suggests that this simplistic narrative—still prominent in many policy circles—is misleading. Our work in Bangladesh ³⁰ finds little evidence that rising rice yields reduced chronic undernutrition. Nor is simply providing nutrition BCC in rural communities sufficient. In Ethiopia, we find that even when mothers are knowledgeable about good child nutrition practices, this has little effect on the quality of children’s diets when children live in households with poor market access. ^31,32 Looking beyond Transform, this suggests that agricultural development may drive improvements in children’s nutritional status when it includes market-integration activities, such as enhanced value chains that generate a wider range of foods (especially animal source foods), when it links with nutrition BCC activities, and efforts to promote sanitation and hygiene.

There are two common threads linking our social protection and agriculture work: (1) by themselves, each sector appears to have limited impacts on chronic child undernutrition; both need to be explicitly linked to the nutrition sector in order to be effective; and (2) the importance of animal source foods. In Bangladesh, children in households where mothers received both cash and intensive nutrition BCC were more likely to consume flesh foods, eggs, and dairy; these children were the only ones who saw their nutritional status improve. ²⁶ In Ethiopia, we find that children with access to dairy products were less likely to be stunted. ³³ These results are consistent with recent work in nutritional sciences that emphasize the importance of essential amino acids ³⁴ and choline ³⁵ found in animal source foods and eggs, respectively, for child growth.

Cultivating Enabling Environments for Nutrition

That enabling policy and political environments play a central role in transforming nutrition is a central proposition at the heart of the Transform Nutrition consortium. The consortium was able to ^36,37 systematically consider these broader policy and political processes underpinning basic and underlying determinants and actions in these fields. These reviews were joined by primary research considering the centrality of capacity, leadership in nutritional performance, and broader indicators of governance in predicting nutrition outcomes. ^17,38,39 The ways in which nutrition commitment can be built and measured at country and subnational levels were also a key area of methodological development and research, alongside other related fields such as real-time monitoring of nutrition outcomes via mobile phones and the role of social accountability in health and nutrition services. ^{40 -42}

What is an enabling environment?

Transform’s research, which formed part of the second Lancet Series on Maternal and Child Nutrition, summarized the wider institutional, governance, and political factors behind successful nutrition-relevant action. “Enabling environments for nutrition” were defined as the wider political and policy processes which build and sustain momentum for the effective implementation of actions that reduce undernutrition (p553). ³⁶ Three core domains were found to underpin and shape such environments: (1) framing, knowledge, and evidence; (2) politics and governance; and (3) capacity and resources. All 3 of these domains, in turn, apply to two distinct stages—first, building political commitment to address malnutrition, and second, translating this commitment into specific actions that are implemented. A second article ³⁷ widened such considerations to themes common in critical development studies including power, social accountability, and the role of political narrative. Complementary work at a country level ⁴³ has shown how such factors operate in context at both national and community levels. ^11,20

Demographic and Health Surveys were also used in another study ¹⁴ in a unique way to consider how nutrition outcomes are driven by indicators of governance and government effectiveness. The research underlined the way in which past drivers of stunting reductions have been fundamentally multisectoral—including distributed income growth, food quality/quantity, women’s education and empowerment, and safe water and sanitation.

Building political commitment

Getting governments and others to step up to the nutrition challenge requires concerted efforts to build commitment, responsiveness, and accountability for progress. For the past 6 years, Transform has been at the forefront of research in this new frontier. The program was catalytic in the development of the Hunger and Nutrition Commitment Index (HANCI), which measures commitment in terms of government expenditure, programs, and legal frameworks in areas directly targeting improved nutrition. ^40,44,45 Published as an annual global index and as a special African Index in 2016, the HANCI has usefully unpacked the notion of commitment and enabled countries to track their relative progress, regionally and over time, often triggering national debates on nutrition in the process. Accompanying research ⁴⁵ has considered broader drivers of commitment in a 5-country comparison, which found by statistically comparing the results of the expert surveys in the 5 countries (note 2) that hunger and nutrition commitment does not necessarily go hand in hand. Undernutrition tends to be invisible until the need to act becomes a political necessity, but this often occurs too late to be effective for those most at risk.

Major progress has been made in recent years in terms of generating political attention and in many cases political and policy commitment to nutrition as a development issue. But for high-level promises and pledges to be progressively translated into changes in incentives, new decisions, and actions, we need new forms of commitment. In our “Stories of Change” work (Box 2), we found that countries are struggling to grapple with the challenges of turning high-level political attention into institutional and financial commitments and ultimately into large-scale implementation of effective actions.

Box 2.

Stories of Change

After several years of growing political commitment, with more and more pledges and declarations and an increasing focus on data and evidence, the international nutrition community has come to recognize the power of narrative. Knowledge that is useful practically needs to encompass a lot more than data and evidence—it needs to include experience. To contribute to such experiential learning, Transform developed an innovative multi-method approach to documenting change, entitled “Stories of Change” (SoC). The goal was to systematically assess and analyze drivers of change in 6 high-burden countries—Bangladesh, India (Odisha), Ethiopia, Nepal, Senegal, and Zambia—where improvements in child nutrition had accelerated in recent years. ⁴³

The Stories of Change methodology combines quantitative analysis of drivers of change (using statistical decomposition of DHS datasets) with a mixed-methods approach to understand perceptions of change—as well as future challenges—on the part of national and subnational stakeholders and, crucially, community members themselves. In also placing a strong emphasis on cross-country sharing and experiential learning, the initiative has been welcomed by nutrition stakeholders, especially the SUN Movement, as a complement to other methods of understanding and facilitating change, and provides the basis for a future stream of work.

The devil is in the national- and subnational-level detail but overall, SoC shone a light on a core set of interlinked factors that underpin, enable, and drive change in nutrition. The main recommendations that emerged ⁴³ are summarized here.

Build commitment

Catalyze and support multisectoral/multistakeholder engagement, and political leadership and commitment at all levels; disaggregate “government” with regard to commitment (commit to what, by whom); improve community commitment and awareness of nutrition problems, programs, rights and government promises to strengthen demand and accountability.

Strengthen cross-sectoral (horizontal) coherence

Develop cross-sectoral vision and shared nutrition goals, including civil society and private sector; integrate nutrition (as both an outcome and a contributor) into other sectoral policies; advocate for high-level institutionalization (eg, prime minister’s office) for better coordination and political clout.

Improve vertical coherence (national to grassroots), scale, and reach

Align national commitments with ground-level implementation realities; build nutritional literacy of local leaders; strengthen vertical (2-way) communication level from national to community; proactively identify and address challenges in implementation (eg, ownership, responsibility, accountability). Learn and apply lessons from successful scaling, within and outside nutrition.

Generate data and evidence

Catalyze a data revolution in nutrition; evaluate implementation of national plans and publish results; disaggregate data to surface disparities in outcomes and intervention coverage; build library of experience, for example, from other SoC case studies.

Strengthen leadership and capacity

Develop a network of connected nutrition leaders; enhance cross-sectoral/lateral leadership on nutrition; balance praise and blame in cultivating leadership.

Assess capacity strengths and gaps (individual, community, organizational, systemic); build on existing technical and systemic capacities; strengthen frontline worker capacity, power and incentives, including appropriate salaries, adequate worker numbers, and an exploration of innovative nonfinancial motivations.

Secure and sustain financing

Develop sustainable funding mechanisms/flows to ensure adequate worker remuneration; enhance flexibility of international donor funding; explore innovative financing for nutrition.

The findings of these 6 country case studies and an overview were published as a special issue in Global Food Security in June 2017, along with three other papers (quantitative analysis of drivers, community-level perceptions of change, and reflections on the SoC approach from global and national nutrition leaders). ⁴³

Strengthening accountability

Within the challenging multisectoral arena of nutrition, accountability relates to clarity and cross-sectoral consensus on roles and responsibilities for different actions. It requires transparency and an understanding of whose job is under threat if they consistently fail to deliver on agreed targets. Global and national accountability is key, but accountability is relevant at all levels and ultimately should be channeled to the grassroots, where nutritionally vulnerable communities live.

Accountability needs data on trends in different forms of malnutrition and on the outcomes of actions and programs (from different sectors, at various levels). Data need to be timely, accessible, actionable, and acted upon. In addition to our work on mobile applications (in Kenya, see above), Transform has developed evidence reviews on nutrition surveillance systems ^46,47 and real-time monitoring. ⁴¹ The effectiveness of nutrition surveillance depends on context and purpose—whether for early warning, for program decision-making, advocacy, monitoring and evaluation, or media awareness. Our India Health Report (IHR) was transformative in bringing together state-level, nutrition-relevant data in India for the first time. ¹³

Social accountability initiatives have been trialed successfully in many public sectors including education and health, but there is still little evidence on their use directly benefiting nutrition. Research published by Transform ⁴² in collaboration with the Making All Voices Count Programme has reviewed the evidence in South Asia and pointed to a number of innovative ways in which social accountability tools are now being applied to health, nutrition, and related sectors. Transform concluded that the nutrition sector now stands virtually alone, however, in lacking a rigorous evidence base on the application of social accountability approaches to improving community-level outcomes. We hypothesize that such approaches could be similarly transformative at a community level.

Identifying and supporting nutrition leadership

Although earlier studies have long highlighted the role of leadership in driving nutritional change, ³⁶ there has been little empirical work on the nature and role of such leadership. In one Transform study, ³⁹ 89 individuals were identified via stakeholder mapping exercises across the 4 focus countries and subsequently interviewed. The results showed that there was no one type of individual associated with nutrition leadership or champions but a range of individuals with different backgrounds and motivations. What was important is that they were boundary spanners (between sectors and disciplines), strategic at adapting politically and ensuring that others followed in their stead, particularly as their knowledge and understanding of nutrition developed.

Accompanying this research, the consortium invested further in ways to identify, nurture, and support nutrition leaders. This included highlighting the work of nutrition champions ⁴⁸ and running an annual training course focusing on the latest research and evidence. Many leaders reported substantial benefits of being involved in terms of their influence in policy and practice (note 3).

Assessing and strengthening nutrition-relevant capacity

Alongside individual leadership, organizational and systemic capacities have been highlighted as critical aspects of health system change that are also relevant to nutrition. Reviews by Transform focused on India and South Asia ^49,50 —undertaking situation and curriculum analyses, ¹⁵ policy analysis of Government of India programs ⁵¹ as well as wider qualitative work drawing on the opinions of public health nutritionists. Constraints in educational capacity ranged from the lack of accreditation for future professionals to the lack of journals—with the potential role accreditation might play in building a future national cadre of nutritionists being particularly highlighted.

In addition to this research on capacity, Transform and partners Public Health Foundation of India, Centre for Chronic Disease Control (CCDC), and Partnerships and Opportunities to Strengthen and Harmonize Actions for Nutrition in India (POSHAN) have also contributed to building capacity in the region, adapting the annual Transform Nutrition short course, intended to build nutrition knowledge and capacity, to the Indian context and holding national- and state-level courses in Delhi and Bihar in 2014 and 2015. Through our alumni, and subnational trainings in India and Ethiopia, we are realizing that the challenges for strengthening capacity and leadership at subnational level—to address the oft-cited “missing middle” —are different from those at national levels.

Conclusions

Over a period of 6 years, Transform Nutrition initiated a series of research studies linked to a range of communications and capacity strengthening activities, with a particular focus on eastern Africa and South Asia along with more globally relevant work. More than 90 peer-reviewed journal articles have been published and many more briefs, blogs, and newsletters targeted to relevant audiences. In the three Appendix A tables, corresponding to the three core themes discussed above, we provide more detail on the main findings emerging from a selection of the leading studies.

Highlights of Transform research include (1) enhanced understanding of the relative effectiveness of different combinations of nutrition-specific interventions and the ways in which they can be scaled for maximal impact; (2) evidence to show that, by themselves, the social protection and agriculture sectors have limited impacts on chronic undernutrition and that both need to be explicitly linked to the nutrition sector in order to be effective; (3) identification of key components of “enabling environments” for nutrition and how they can be cultivated and sustained; (4) groundbreaking research that shines a light on the ways in which leaders emerge and operate to change the political and policy landscape, in different settings; and (5) “stories of change” that provide in-depth contextual knowledge of how transformative change has been driven in countries that have made inroads in reducing malnutrition.

Main Policy and Program-Relevant Findings

With regard to the three core themes, we summarize here the key policy and program-relevant findings emerging from Transform Nutrition research.

Theme 1: Transforming delivery

The potential to reduce stunting significantly through nutrition-specific interventions alone is limited. In India, delivery of nutrition interventions via coordinated frontline implementation by workers from two ministries and stories of successful scale-up, such as Odisha, show that many of the big changes were driven by improvements across sectors. Combinations of nutrition-specific interventions with nutrition-sensitive actions are likely to be more effective in reducing stunting, and this also strengthens incentives for policy makers to act multisectorally.

For health services to work for nutrition, a good fit to platforms is needed, along with strong coordination, continuous service and demand mobilization, and role clarity, capacity, and incentives for frontline workers. Mobile technology has real potential to improve services.

Theme 2: Transforming agriculture and social protection

Combining BCC with cash transfers in Bangladesh provided a rapid reduction in stunting, while the Productive Safety Net (social protection) Programme in Ethiopia, without any nutrition intervention built-in, had no impact on stunting, wasting, or child diets even when overlaid with community nutrition actions.

In Bangladesh, it was noted that the cash transfers were effective through mothers being more likely to use them to provide animal source foods (milk and eggs) for their children.

Work on agriculture in Ethiopia and Bangladesh suggests that for child growth, what matters is access to certain food types (animal source foods) in environments which are hygienic. BCC can only be effective where the recommended food sources are available. Nutrition-sensitive agriculture interventions therefore need to focus on certain types of food, promote hygiene, and strengthen markets for these food types rather than concentrating on agricultural productivity more broadly.

Theme 3: Transforming leadership, commitment, and accountability

Evidence, governance, leadership, and capacity are critical dimensions of shaping policy processes into an enabling environment for successful scale-up of nutrition-specific or nutrition-sensitive actions.

Building leadership capacity and recognizing and supporting champions are effective mechanisms for inspiring and catalyzing national and subnational nutrition commitment, accountability, and policy change.

The challenges for strengthening leadership capacity for collaboration across sectors at subnational level may be different from those at national levels.

Tools to support commitment through surveillance and monitoring need to be tailored to the purpose and level—impact on nutrition requires commitment to nutrition (not just food security); national-level metrics may encourage debate, but subnational data may be more effective in generating commitment that results in impact. Institutional and financial commitments need to flow from political attention for implementation to happen.

Research priorities

Several research priorities remain. With regard to delivery of nutrition-specific interventions, we need (1) to strengthen our understanding of the drivers for uptake of interventions (in addition to improving supply-side delivery factors) using context-specific studies; (2) more rigorous assessments of impacts of engagement by the commercial sector in nutrition; and (3) further development and improvement in data management systems to ensure timely, accurate actionable data. With regard to agriculture and nutrition, future work—both research and interventions—should focus both at the household/caregiver levels (eg, increasing incomes, improving knowledge of good nutrition practices) and on improving access to animal source foods through improvements in value chains. On social protection, more operational and evaluative research is needed to test approaches to integrating nutrition behavioral change and women’s empowerment approaches within programs. And finally, on enabling environments, we need further research on (1) commitment (ie, how to build trust and generate consensus among government stakeholders, understanding why political commitment is still absent in many countries, and how to turn high-level political commitment into sustained institutional commitment); (2) clarifying roles and responsibilities to enhance collaboration across sectors and administrative levels; (3) assessing and monitoring of commitment and accountability (eg, via better surveillance systems); (4) social accountability approaches to improve outcomes at community level; and (5) approaches to developing nutrition leadership.

Contributions to change

Transform Nutrition has catalyzed and supported evidence-informed action on nutrition in its focal countries as well as contributing at a global level. Some examples are highlighted here.

At a national level, Transform evidence was consulted in the redesign of Ethiopia’s Productive Safety Net Programme (a social protection program benefitting 10 million people) to include specific nutrition elements. In Bangladesh, policy makers drew on Transform evidence to inform the nutrition section of the National Five-Year Plan. Following the NNS assessment, the Government of Bangladesh also implemented recommendations to strengthen frontline delivery through district nutrition officers, with support from UNICEF. Transform-funded analysis on the importance of BCC in improving child nutritional status of children (from the Transfer Modality Research Initiative) informed the 2016 National Nutrition Plan of Action for Bangladesh, and the Ministry of Women and Children Affairs adopted recommendations to incorporate BCC into the Vulnerable Group Development Program. In India, building on previous engagement with senior policy makers Transform hosted the launch event for the IHR and 2015 Global Nutrition Report, with the presence of senior ministers from both the Ministry of Women and Child Development and the Ministry of Health and Family Welfare. The IHR was cited in a draft “National Plan of Action for Children, 2016.”

At the global level, evidence from Transform has been used by the SUN Movement to inform the framework of their 2016 to 2020 strategy, particularly the strategic objective to expand and sustain enabling political environments and for their implementation roadmap. Transform and SUN have collaborated most closely in initiatives to build capacity through evidence and training on leadership, including the nutrition champions initiative and the codevelopment of a toolkit to guide nutrition stakeholders on how to identify, engage, and sustain nutrition champions as a key strategy for change, launched at the SUN Global Gathering in Abidjan in November 2017. Along with other sources, Transform research contributed to the inclusion of stunting reduction as a priority in the report of the High-Level Panel convened by UK Prime Minister David Cameron in 2013 to inform the development of the sustainable development goals. Evidence from Transform’s work on enabling environments, leadership, accountability, scaling up, PPPs, data, and mobile phones has featured in Global Nutrition Reports. Evidence from Transform research (especially the $1:16 cost to benefit ratio work) has contributed to the investment case for nutrition, which encouraged African heads of state and finance ministers to focus investment on nutrition, leading to the launch of the African Leaders for Nutrition Initiative. The Stories of Change initiative has generated significant traction in shining a light on critical “how” questions and given rise to a new generation of national and subnational case studies of change (in Vietnam, Tanzania, Rwanda, and several Indian states). Finally, the lessons learnt in managing a multipartner initiative on nutrition are now being brought to bear in a new regional initiative—Transform Nutrition West Africa—with support from the Bill and Melinda Gates Foundation.