Measuring political commitment and opportunities to advance food and nutrition security: piloting a rapid assessment tool

Abstract

Lack of political commitment has been identified as a primary reason for the low priority that food and nutrition interventions receive from national governments relative to the high disease burden caused by malnutrition. Researchers have identified a number of factors that contribute to food and nutrition’s ‘low-priority cycle’ on national policy agendas, but few tools exist to rapidly measure political commitment and identify opportunities to advance food and nutrition on the policy agenda. This article presents a theory-based rapid assessment approach to gauging countries’ level of political commitment to food and nutrition security and identifying opportunities to advance food and nutrition on the policy agenda. The rapid assessment tool was piloted among food and nutrition policymakers and planners in 10 low- and middle-income countries in April to June 2013. Food and nutrition commitment and policy opportunity scores were calculated for each country and strategies to advance food and nutrition on policy agendas were designed for each country. The article finds that, in a majority of countries, political leaders had verbally and symbolically committed to addressing food and nutrition, but adequate financial resources were not allocated to implement specific programmes. In addition, whereas the low cohesion of the policy community has been viewed a major underlying cause of the low-priority status of food and nutrition, the analysis finds that policy community cohesion and having a well thought-out policy alternative were present in most countries. This tool may be useful to policymakers and planners providing information that can be used to benchmark and/or evaluate advocacy efforts to advance reforms in the food and nutrition sector; furthermore, the results can help identify specific strategies that can be employed to move the food and nutrition agenda forward. This tool complements others that have been recently developed to measure national commitment to advancing food and nutrition security.

Political commitment, priority setting, food and nutrition security, rapid assessment

KEY MESSAGES

• Low political commitment has been recognized as a barrier to the scale-up of proven effective food and nutrition policies.

• We developed a theory-based tool to rapidly assess political commitment and opportunities to advance food and nutrition on government agendas and administered the tool to representatives of government and the United Nations (UN) agencies affiliated with the Millennium Development Goals Achievement Fund Joint Programmes in 10 countries.

• In a majority of countries, political leaders had verbally and symbolically committed to addressing food and nutrition, but adequate resources were not allocated to meet specific programmes.

• In most countries, there existed a cohesive policy community and policy solutions to address food and nutrition, while a majority lacked a cohesive civil society movement around food and nutrition and media reports rarely emphasized food and nutrition.

• Overall, political commitment and priority setting opportunities for food and nutrition security were found to be highest in the Philippines and Guatemala and lowest in Vietnam and Bangladesh.

Introduction

Improvements in food and nutrition are fundamental to child survival, with long-term benefits for improved health, cognitive development, educational attainment and productivity later in life (UNICEF 2013). A number of effective interventions to reduce malnutrition exist (Bhutta et al. 2013); yet, despite the cost-effectiveness of interventions to address child malnutrition, and their high benefit-cost ratios (Hoddinott et al. 2012), food and nutrition policy is often not prioritized as highly on government agendas as other health and development issues. Countries with high rates of malnutrition continue to under-invest in food and nutrition policy (Heaver 2005; SUN 2010). In facing this pattern of underinvestment, the food and nutrition community has increasingly come to agree that building political commitment is essential to furthering food and nutrition security on government agendas (Heaver 2005; Bryce et al. 2008; Natalicchio et al. 2009; Mejía-Acosta 2011; Pelletier et al. 2011; Gillespie et al. 2013).

Despite this agreement, the concept of political commitment for food and nutrition is rarely adequately defined or empirically measured (Fox et al. 2011; Goldberg et al. 2012). Existing tools to measure political commitment have been proposed previously in food and nutrition, but these efforts have typically relied on lengthy desk reviews and qualitative assessments that are cumbersome, time consuming and difficult to analyse empirically (e.g. Chopra et al. 2009; Engesveen et al. 2009), or on indices that rely primarily on secondary data, which often lack the local knowledge needed to capture policy nuances within countries (e.g. Masset 2011; Save the Children and World Vision 2012; te Lintelo et al. 2013, 2014).

How to build political commitment is even less studied than how to measure it. A small but growing body of research has described the factors associated with the low prioritization of food and nutrition policy, leading to increasing consensus over those factors most critical to advancing food and nutrition on governmental agendas and enhancing commitment to this issue (e.g. Heaver 2005; Pelletier et al. 2011). The primary reasons that food and nutrition are not prioritized include the problem’s specific issue characteristics (invisibility and irreversibility), diverse policy solutions (little agreement over the problem and appropriate policy solutions, fragmented and disparate policy solutions), low actor power (policy community dispersed due to the lack of an institutional home, low engagement of policy experts and low voice of those most affected) and political contexts (lack of donor or national ownership of the problem) (Heaver 2005; Natalicchio et al. 2009; Mejía-Acosta 2011; Pelletier et al. 2011; Reich and Balarajan 2012). Few studies, however, have endeavoured to examine the factors associated with successfully generating political commitment and attention to food and nutrition. The Mainstreaming Nutrition Initiative found only one of 12 factors explored to be crucial to building political commitment across five countries: the existence of credible indicators of the problem (Pelletier et al. 2011).

Existing commitment indices, while building global accountability, are not designed to identify strategies to overcome low levels of political commitment or take advantage of opportunities to advance food and nutrition. By contrast, the rapid assessment tool (RAT) described here is intended to assist national governments and development partners in developing more politically feasible strategies for policy reform and in doing so can improve the effectiveness of the food and nutrition agenda-setting process.

This article presents the results of a theory-based survey designed to assess national political commitment and opportunities to advance food and nutrition policy reform, completed by knowledgeable representatives from 10 countries. The survey can also be used by policymakers and planners to formulate country strategies to advance food and nutrition on governmental policy agendas. The article first presents the theoretical motivation behind the development of the questionnaire and then presents the results from a pilot test of the survey and places this work in the context of other instruments to measure political commitment to food and nutrition.

Overview: a theory-based rapid assessment approach to advancing food and nutrition policy

The primary goals of the Political Commitment and Opportunity Measurement-RAT (PCOM-RAT) are to measure a country’s level of political commitment and identify opportunities to advance food and nutrition on governmental agendas. Health policy research has been criticized for its lack of methodological focus and underuse of existing literature informed by strong theoretical and analytical frameworks (Buse 2008; Walt et al. 2008). To develop a theory-based tool, the PCOM-RAT builds on existing literature on political commitment and two influential agenda-setting frameworks: Kingdon’s (2003) agenda-setting model and Shiffman’s (2007) global initiative priority-setting framework and incorporates elements of Reich’s (1996, 2002) method of stakeholder analysis and political strategy design. Methodologically, the survey uses two major approaches: health policy ‘effort’ surveys and stakeholder analysis. The theory behind these frameworks is described below and the measurement approach is described in the Methods section.

Political commitment

The measure of political commitment employed in the PCOM-RAT draws from existing literature on political commitment. Studies from other health issues have suggested that political commitment can be measured along three dimensions (Shiffman 2007; Fox et al. 2011): ‘expressed commitment’ (verbal declarations of support for an issue by high-level, influential political leaders); ‘institutional commitment’ (specific policies and organizational infrastructure in support of an issue); and ‘budgetary commitment’ (earmarked allocations of resources towards a specific issue relative to a particular benchmark). A similar theoretical framework designed to measure hunger commitment has been proposed, based on political will, policies and programmes (Masset 2011). The PCOM-RAT framework incorporates these elements, but views policies and programmes as tangible commitments that are constitutive of commitment but separate from a leader’s stated intentions. Expressed commitment on its own without policies or budgetary allocations to back it up can be thought of as rhetorical commitment, whereas the latter more tangible commitments signal a ‘credible’ commitment from the government—one that becomes harder to disregard with time and larger investments (Fox et al. 2011).

Agenda setting

Kingdon’s (2003) well-known three streams approach suggests that for an issue to gain political priority on a governmental agenda, three independent streams need to converge: the ‘problem’ stream, where an issue becomes perceived as a public problem that needs to be and can be addressed through policy; the ‘policy’ stream, where a set of alternative policy solutions are proposed and narrowed to address the problem; and the ‘politics’ stream, where political events such as national elections or a change in leadership create a window of opportunity to advance new problems and solutions (Kingdon 2003). When these three streams converge, there exists an open ‘policy window’ in which there is political space to advance a specific issue. Even with an open policy window, conversion to results is not guaranteed, however, and requires strategic positioning of problems and policy solutions (Gillespie et al. 2013). A variety of participants can assist as active agents in bringing together these three streams and in seizing a policy window before it closes. Policy entrepreneurs are technical specialists in a given field that push for particular policy proposals or promote a particular framing of a problem, and are generally hidden from public view (Kingdon 2003). These specialists are particularly influential for the policy solutions that they generate. Policy advocates or ‘champions’ for a given issue or cause are generally visible high-level actors such as the president or other well-known figures who bring attention to a given problem, though they rely on specialists to provide specific solutions (Kingdon 2003). The agenda-setting framework has been applied, for example, to explain the heightened attention recently being paid by researchers and planners towards health systems strengthening (Hafner and Shiffman 2013).

Global health priority setting

Shiffman’s global initiative priority-setting framework has identified multiple variables that are associated with an enhanced probability that an issue will be placed high on a policy agenda, related to actor power, ideas, political context and issue characteristics (Shiffman 2007; Shiffman and Smith 2007). The variables identified from this framework were inductively derived from a study of maternal mortality across five countries (Shiffman 2007; Shiffman and Smith 2007), and this framework has been applied across other case studies of health issues including family planning (Shiffman and Quissell 2012), neonatal health (Shiffman and Sultana 2013) and newborn survival (Shiffman 2010). Pelletier et al. (2011) recently applied this framework to analyse political attention to food and nutrition in five countries. These frameworks have usually been used in conducting qualitative case studies of countries. The PCOM-RAT operationalizes these constructs to measure their presence or absence and organizes them according to where they fall in the problem, policy and political streams (see Figure 1).

Figure 1

Factors operating in the problem, policy and politics streams that shape agenda-setting. Source: Adapted from Balarajan and Reich 2012 and Shiffman, 2007.

Stakeholder analysis

The PCOM-RAT survey also contains questions permitting a rapid stakeholder analysis to assess the positions and power of major country-level actors in food and nutrition. Stakeholder analysis systematically examines the relative power, position, coalitions and perceptions of each stakeholder (Brugha and Varvasovszky 2000). Stakeholder analysis can assist in identifying strategies and opportunities to overcome roadblocks to advancing food and nutrition and engage relevant actors (Reich 1996, 2002).

Methods

Survey design

The methodology of the PCOM-RAT survey is based on global health ‘effort’ surveys, which aim to improve accountability and benchmark progress in setting the conditions necessary for improved health outcomes. Measures of a country’s effort have been developed for several conditions beginning with family planning effort scores, which have been measured since the 1970s, and more recently applied to maternal health and HIV/AIDS using a similar methodology (Jain and Ross 2012; Ross and Campbell 2001; USAID et al. 2003). These measures have been useful to show levels and trends, as well as regional differences, for different types of effort. Effort surveys typically measure commitment across different categories of indicators including several questions specifically pertaining to political support, mostly measuring expressed commitment. However, several other categories of questions such as ‘policy and planning’, ‘organizational structure’, ‘programme resources’ and ‘legal and regulatory and environment’ capture aspects of the institutional and budgetary components of political commitment (Goldberg et al. 2012).

Country effort surveys are typically overseen by a knowledgeable in-country consultant, who selects experts from the government and from the private sector, civil society and other non-governmental sectors, who are considered appropriate to respond to each component of the questionnaire. Questions are primarily of a factual nature (yes/no responses) with a few requiring subjective, scalar judgements. Results are tallied and a single, standardized score assigned to each category and country. The main difference between effort surveys and other metrics gathered through secondary data is the use of primary data collection through expert interviews to generate country-specific scores.

The PCOM-RAT questionnaire consists of close-ended factual and subjective (requiring judgement) questions, similar to the design of effort surveys, regarding expressed, institutional and budgetary commitment to food and nutrition policies, and questions that capture the presence or absence of openings in the problem, policy and political streams (see Figure 2 and Table 1). The full rapid assessment questionnaire, score sheets and summary can be found in the online appendices.

Figure 2

Major components of PCOM-RAT

Table 1

List of questions in PCOM-RAT and country responses

	Number of countries with positive response
Political commitment
Expressed commitment
Head of the government has spoken publicly about food and nutrition problems at least twice (if yes, assign 1)	8/10
First lady/spouse has spoken publicly about food and nutrition problems at least twice (if yes, assign 1)	9/10
Other high officials, has spoken publicly about food and nutrition problems at least twice (if yes, assign 1)	5/10
Public campaigns have been waged in the past year to raise awareness about food and nutrition related issues (if yes, assign 1)	9/10
Attention of high-level officials to food and nutrition problems has increased in the past year (if yes, assign 1)	10/10
Overall rating of current political support of the head of government for food and nutrition programmes (if 7 or greater, assign 1)	9/10
Speak about less often: HIV/AIDS (if yes, assign 1)	7/10
Speak about less often: water and sanitation (if yes, assign 1)	6/10
Speak about less often: maternal mortality (if yes, assign 1)	7/10
Speak about less often: child health (e.g. vaccinations) (if yes, assign 1)	5/10
Institutional commitment
An intersectoral mechanism that co-ordinates multisectoral food and nutrition programming exists (if yes, assign 1)	8/10
The country has adopted a national food and nutrition policy (if yes, assign 1)	9/10
The country has adopted a national food and nutrition plan of action (if yes, assign 1)	8/10
There is a multisectoral food and nutrition programme currently operational in the country (if yes, assign 1)	6/10
There is a national nutrition plan or strategy that is part of a national development plan (if yes, assign 1)	10/10
There are published national dietary guidelines (if yes, assign 1)	9/10
SUN (Scaling up nutrition) country	3/10
Budgetary commitment
Overall rating of resources available for food and nutrition programmes (if 3, assign 1)	10/10
Rating of 3 for specific food and nutrition initiatives that the government has specifically prioritized (50%+ rated 3, assign 1)	0/10
There is a budget line for nutrition in the budget (if yes, assign 1)	7/10
If the government had an extra 5 million dollars for health initiatives, which of the following categories would it be most likely to allocate the resources to first? (If nutrition, assign 1)	5/10
Agenda setting and policy windows of opportunity
Problem stream
Credible indicators of food and nutrition status have been cited in media reports in the last 12 months? (if yes, assign 1)	1/10
Have policy advocates and/or high-level officials cited indicators showing the extent of food and nutrition problems to advance food and nutrition policy in the last 12 months? (if yes, assign 1)	9/10
Have there been any major events in the last year that have drawn particular attention to food and nutritional problems in the country? (if yes, assign 1)	9/10
Thinking about public attention to the topic of food and nutrition problems, how much attention would you say this topic has received in the past year in the official [state] media? (if substantial, assign 1)	4/10
How much attention would you say topic of food and nutrition problems has received in the past year through other forms of public discourse (e.g. protest, social media)? (if substantial, assign 1)	1/10
How often do proponents of food and nutrition initiatives invoke each of the following in their advocacy efforts:
Centrality of food and nutrition to poverty reduction (if sometimes or frequently, assign 1)	9/10
Cost effectiveness of food and nutrition initiatives (if sometimes or frequently, assign 1)	6/10
Unfavourable comparisons with other countries on food and nutrition progress (if sometimes or frequently, assign 1)	2/10
Human rights (e.g. the right to food) (if sometimes or frequently, assign 1)	7/10
Quantitative evidence highlighting the extent of the problem (if sometimes or frequently, assign 1)	6/10
Qualitative experiences with food and nutrition related health problems. (if sometimes or frequently, assign 1)	3/10
Is there a high-level ‘champion’ or influential individual who has taken on food and nutrition as a cause that he/she is currently (or within the past year) promoting? (if yes, assign 1; if the champion is the president, assign 2)	7/10
Are there civil society groups that promote food and nutrition issues? (if yes, assign 1)	10/10
In your estimation, how cohesive would you say are advocates of food and nutrition in this country? (if very cohesive, assign 1)	1/10
Policy stream
Current status of policy alternatives (if a well thought-out, coherent policy proposal has been put forward, assign 1)	7/10
In your estimation, how technically feasible is policy X to implement (technical feasibility refers to the practical feasibility given existing infrastructure, capacity and the need to co-ordinate across different sectors)? (if very, assign 1)	6/10
In you estimation how acceptable would policy X be to the public at large? (if very, assign 1)	5/10
In your estimation how financially sustainable would policy X be? (if very, assign 1)	3/10
Is there an influential individual within the policy community who has been especially influential in promoting a particular food and nutrition policy (or set of policies) in the past year? (if yes, assign 1)	6/10
Cohesiveness of policy community (if very cohesive, assign 1)	5/10
Food and nutrition policy experts agree on a single framing issue to advance food and nutrition policy (e.g. women’s empowerment, stunting, food insecurity and right to food) (if frequently, assign 1)	6/10
Food and nutrition policy experts agree on a common set of indicators to advance the food and nutrition cause (if frequently, assign 1)	4/10
Food and nutrition policy experts diverge in their support for multisectoral vs focused approaches (if frequently, assign 1)	3/10
Food and nutrition policy experts agree on the responsibilities of various ministries and organizations (if frequently, assign 1)	10/10
Politics stream (including stakeholder analysis)
Major executive elections happened within the past year or will happen within a year (if within next year, assign 1)	6/10
Major legislative elections happened within the past year or will happen within a year (if within next year, assign 1)	5/10
When is the next budget scheduled? ___________ (if within next year, assign 1)	8/10
How much financial and technical support has the country received from international agencies to address food and nutrition problems? (if a lot, assign 1)	3/10
Number of supporters outweighs number of opponents (if yes, assign 1)	10/10
Power of supporters outweighs power of opponents (if yes, assign 1)	10/10

The RAT is designed to be completed in a consultative process by food and nutrition specialists familiar with a specific country context. Ideally, this process should be facilitated by an in-country consultant with expertise in political analysis and PCOM-RAT. During the group session, a single survey is completed by the team. This team approach allows for discussion and agreement on both factual and subjective questions in the survey.

Group participants should represent diverse institutions both within and outside national government. In addition to generating timely information on a country’s degree of political commitment to nutrition, the process of completing the PCOM-RAT can be used as a training tool to raise awareness about the dimensions of commitment, the agenda-setting process and stakeholder analysis, and to facilitate strategic planning, which can assist in identifying gaps and opportunities in the policy environment.

Measures

Measuring commitment

Pelletier et al. (2011) distinguish between political ‘attention’ or symbolic commitment vs the translation of that attention into effective action. Here, we draw on previous frameworks (Fox et al. 2011) to distinguish between ‘expressed’ commitment, which may be rhetorical in nature, vs demonstrated ‘institutional’ and ‘budgetary’ commitment, which include the adoption of laws and policies supportive of formulating and implementing the food and nutrition agenda, and adequate resource allocations to accomplish programmatic initiatives. These questions are adapted from different sections of previous global effort surveys.

Measuring opportunities to advance food and nutrition policy

The measures of opportunities to advance food and nutrition are new questions divided across the three streams framework (problem stream, policy stream and politics stream) and are intended to capture the 12 factors identified in previous work as facilitating priority setting (Shiffman 2007; Pelletier et al. 2011). The goal of these questions is to assess whether an open policy window exists and to assist respondents in identifying strategies that can increase the likelihood of food and nutrition being advanced on the policy agenda. Results can also help shed light on which factors are correlated with food and nutrition related outputs and outcomes, though this use is not examined here.

Stakeholder analysis

The rapid assessment survey incorporates elements of the ‘PolicyMaker’ software package (www.polimap.com), which employs methods of organizational analysis and rule-based decision systems to map stakeholders’ positions, power and interests, and suggests strategies to advance the political feasibility of policy reform (Reich and Cooper 2010). Recognizing that even well-intentioned policies to improve health and nutritional status of the population can meet resistance from groups or individuals who stand to lose materially or otherwise from policy change, the goal of these questions is to assess whether the number, intensity and power of supporters of food and nutrition policy outweigh the number, intensity and power of opponents.

Pilot data collection and analysis

The rapid assessment tool was pilot tested with representatives from 10 selected countries (Bolivia, Colombia, El Salvador, Guatemala, Nicaragua, Bangladesh, Cambodia, Philippines, Timor-Leste and Vietnam) where the Millennium Development Goals Achievement Fund (MDG-F) had supported Joint Programmes (JPs) in Children, Food Security and Nutrition. Further details about the MDG-F and the individual JPs are available at http://www.mdgfund.org. In brief, MDG-F JPs brought together multiple United Nations (UN) agencies to work jointly with national governments on shared goals to improve food security and nutrition in order to accelerate progress towards achieving the MDGs. Importantly, each of these JPs was designed to build a supportive enabling environment for nutrition, e.g. through supporting advocacy, policy development and implementation.

In a pre-pilot phase, the rapid assessment tool was initially tested with the joint programme team in Timor-Leste, with representatives from government, United Nations (UN) agencies and national non-government organizations (n = 12). Minor modifications were made to the survey instrument based on feedback from this group. The tool was then translated into English, French and Spanish so that it could be used by the Children, Food Security and Nutrition JPs, and was made freely available to interested parties by request.

The revised PCOM-RAT was then piloted at MDG-F knowledge management workshops in 2013. This was part of a broader session on applied political analysis designed to assist JP representatives, who typically do not have training in this area, in how to better advance food and nutrition policy. Two MDG-F knowledge management workshops were held, one in Lima, Peru (attended by eight JPs in Latin America) and one in Bangkok, Thailand (attended by six JPs in Asia); no workshop took place in Africa.

The dual goal of the PCOM-RAT survey was to collect information on countries' efforts to advance food and nutrition, but also to provide country-specific feedback on ways to strengthen food and nutrition policy advocacy. At the same time, the group exercise of completing the survey provided participants with an opportunity to design political strategies to overcome resistance and build coalitions, and thereby enhance the political feasibility of proposed policies.

After receiving a short introduction to applied political analysis and the tool, representatives from each JP completed the survey for their respective countries. The country teams consisted of at least one JP Co-ordinator (from the lead agency responsible for co-ordinating the programme, typically a UN agency) and one national government agency representative. Workshop attendees were highly knowledgeable of the food security and nutrition situations in their respective countries, having been directly involved in the implementation of Children, Food Security and Nutrition JPs. Respondents were also free to ask questions and clarifications about the survey and its terms.

Respondents completed the questionnaire jointly, allowing for discussion of both subjective and factual questions. Verbal consent was obtained before the time of completion of the survey, and this study was reviewed and approved by the Institutional Review Board of the Harvard School of Public Health. Copies of completed surveys were made available to the country teams as well as a summary of the findings. In this way, the PCOM-RAT was used to collect information on countries' efforts to advance food and nutrition and then provide country-specific feedback on ways to strengthen food and nutrition policy advocacy. Ten countries (out of the 14 countries that attended workshops) representing Latin America and Asia completed the full questionnaire: Bolivia, Colombia, El Salvador, Guatemala, Nicaragua, Bangladesh, Cambodia, Philippines, Timor-Leste and Vietnam. In this pilot, most country teams consisted of two country experts. It is envisioned that in the future, the tool will be used with a broader set of nutrition policy experts from diverse sectors, moderated by a facilitator familiar with the tool’s approach and political analysis.

The results of this pilot are presented in three ways. First, results for each question were summarized for each question (Table 1). Second, the results were analysed according to the scoring algorithm summarized in Table 1, but which takes a subset of questions targeted at directly measuring political commitment to food and nutrition, and opportunities to advance food and nutrition according to the three streams model (problem, policy and political opportunities) (see Table 2). Each selected question was assigned a score of 1 or 0. For factual yes/no questions, a yes was assigned a 1. For questions presented on a scale of 1–10, a response of 7 or higher was assigned a 1 and for budgetary questions with a 0–3 scale, a 3 was assigned a 1 signifying adequate resources. Total scores were computed for political commitment and opportunities, assigning one point for each question. These points were then tallied to provide a picture of how many countries had different elements present and to compare countries on a common scale. In this current version, questions are unweighted and each assigned a score of 1 based on specific coding criteria.

Third, individual radar plots for each country were prepared to display the results along six different domains (expressed, institutional and budgetary commitment, problem, policy and politics stream) (Supplementary data) to give an overview of the results of the piloting of this tool. We present next a general summary of the overall findings.

RESULTS

Political commitment to food and nutrition in 10 countries

Expressed commitment

Nutrition received a high level of expressed attention in most countries in the survey. In all countries except El Salvador, at least one high-ranking ‘visible participant’ had spoken publicly about food and nutrition at least twice in the past year. In 8 out of 10 countries, this was the head of the government and in every country except El Salvador the First Lady (or first spouse) was reported to have spoken about food and nutrition at least twice in the past year. In every country, attention to food and nutrition was reported to be on the rise. In every country except Bangladesh, respondents gave an overall rating of current political support for food and nutrition programmes of seven or higher. Colombia, Guatemala and Timor-Leste scored the highest in terms of their overall expressed commitment to food and nutrition (see Table 2).

Table 2

Total points per section in PCOM-RAT, by country^a

	Political commitment				Agenda setting
	Expressed commitment	Institutional commitment	Budgetary commitment	Total	Problem stream	Policy stream	Politics stream	Total
Bangladesh	5	5	1	11	4	3	6	13
Bolivia	9	5.5	1	15.5	8	8	7	23
Cambodia	8	4.5	1	13.5	4	7	4	15
Colombia	10	5.5	1	16.5	6	7	7	20
El Salvador	2	6	0	8	8	5	6	19
Guatemala	10	6	0	16	8	9	6	23
Nicaragua	8	6	1	15	7	4	3	14
Philippines	7	6	2	15	11	9	7	27
Timor-Leste	10	2	1	13	11	2	6	19
Vietnam	6	6	0	12	8	1	5	14
Total possible points	10	6	3	19	15	10	7	32

^aPoints for each section are totalled from the questions outlined in Table 1.

Institutional commitment

Most countries had in place fundamental legal and institutional provisions. These included a national food and nutrition policy (9/10), national nutrition guidelines (9/10), an intersectoral mechanism that co-ordinates multisectoral food and nutrition programming (8/10) and national food and nutrition plan of action (8/10). All countries had a national nutrition plan or strategy that is part of a national development plan. In some cases these policies were proposed but not yet in effect. Half of the countries reported having all of the institutions asked about.

Budgetary commitment

With regard to budgetary commitment, in most cases, there was a line for nutrition in the budget. However, only the Philippines rated the current resources available for food and nutrition programmes as adequate to meet needs, and no country rated 50% or more food and nutrition programmes as having adequate resources to meet needs. The only individual programs where resources were rated as adequate to meet needs were Vitamin A programs in one country and multisectoral nutrition programs in another. Half of the countries said that if the government had an extra 5 million dollars for health initiatives, they would put this money towards nutrition.

Agenda setting: opportunities to advance food and nutrition

Problem stream

Most countries had some activity in the problem stream, with the most commonly cited being civil society groups that actively promote food and nutrition issues (10/10), policy advocates and/or high-level officials citing indicators showing the extent of food and nutrition problems to advance food and nutrition policy (9/10), and some form of a focusing event occurring in the past year that had drawn attention to food and nutrition (9/10). Most countries (7/10) reported having a high-level ‘champion’ or influential individual who has taken on food and nutrition. Although most countries noted that high-level officials had cited indicators of the extent of food and nutrition problems, no country reported credible indicators of food and nutrition status having been cited in media reports and few reported unfavourable comparisons with other countries on food and nutrition progress. In addition, only Timor-Leste reported that the topic of food and nutrition had received substantial attention through other forms of public discourse. Furthermore, although all countries reported having civil society groups promoting food and nutrition, only one country reported that these groups were very cohesive. Bangladesh and Cambodia scored the lowest in the problem stream, both of which lacked a champion and cited low levels of media attention to food and nutrition.

Policy stream

A majority of participating countries had a well thought-out policy alternative to address food and nutrition, and a ‘policy entrepreneur’—a policy expert within the policy community who had been especially influential in promoting a particular food and nutrition policy or set of policies. Half of the countries felt that the policy community was very cohesive overall. For instance, most countries reported that food and nutrition policy experts agree on the responsibilities of various ministries and organizations, do not diverge in their support for multisectoral vs focused approaches, and agree on a single framing of the issue and on a common set of indicators. Vietnam, Timor-Leste and Bangladesh had the lowest score in the policy stream—each reporting a lack of a well thought-out, coherent policy proposal and reporting low levels of cohesion in the policy community.

Politics stream

Most countries reported an opening in the politics stream with presidential and/or legislative elections happening within the year or having occurred within the year (6/10). Three countries where elections were not occurring had a budget scheduled within the next year, which could open space to advance the food and nutrition agenda. In every country, the number and power of the supporters of food and nutrition security were rated as exceeding the number and power of opponents, suggesting that key food and nutrition stakeholders did not believe that they faced insurmountable opposition from powerful groups to developing food and nutrition policies.

Country commitment and open policy windows

Overall, political commitment and priority-setting opportunities were found to be highest in the Philippines and Guatemala and lowest in Vietnam and Bangladesh (Table 2). Based on the scoring of selected response items, Colombia and the Philippines were considered to have open policy windows to advance food and nutrition. These countries had a core set of factors in the problem, policy and politics streams that indicated potential to advance food and nutrition on the government’s agenda.

Discussion

This article presents a theory-based RAT that can be used to assess national political commitment and opportunities to advance food and nutrition policy reform (PCOM-RAT) and describes the results from piloting the tool in 10 countries. PCOM-RAT is designed to be completed in a consultative process by stakeholders working in food and nutrition, who are knowledgeable about the specific country context. In addition to generating timely information on a country’s degree of political commitment to nutrition, the process of completing the PCOM-RAT can be used as a training exercise to raise awareness about the political environment surrounding food and nutrition policy reform and facilitate the development of political strategies to advance the agenda-setting process in countries.

Based on our piloting of PCOM-RAT, we summarize some key findings below and place the tool in the context of the existing literature:

Political commitment

Most countries had a high degree of expressed commitment and institutional commitment but a low degree of budgetary commitment. This may reflect generally low budgetary outlays and underfunding of programs rather than a lack of prioritization per se, but it may also reflect an unwillingness of countries to ‘put their money where their mouth is’ when it comes to scaling up food and nutrition policy. Countries may be willing to put up window dressings by adopting plans of action and multisectoral programmes, but not convert these programmes into meaningful action—reflecting the profound challenges of implementation. On the other hand, half of the countries did report that if the government had an extra 5 million dollars for health initiatives, they would most likely allocate those funds to food and nutrition, suggesting that absolute resource constraints may be hindering further budgetary allocations in these instances.

Opportunities to advance food and nutrition

Most countries were found to have important elements in place to compel attention to food and nutrition policy. In the problem stream, most countries had visible, high-level champions to draw attention to food and nutrition issues, at least one focusing event (e.g. conference, food-related crisis) that drew attention to food and nutrition, and civil society groups focused on food and nutrition. However, additional opportunities were identified to improve coverage of food and nutrition in the media and advocacy groups.

In the policy stream, although the lack of cohesion within the food and nutrition policy community has frequently been cited as a challenge in the food and nutrition sector (Heaver 2005; Natalicchio et al. 2009), half of the countries in this study reported that their policy communities were very cohesive. Policy communities universally agreed on the responsibilities of various ministries and organizations, and a majority did not diverge in their support for multisectoral vs focused approaches, and agreed on a single framing issue to advance food and nutrition. Most countries also had a well thought-out policy alternative, contrasting with the findings from prior studies that the diversity of policy solutions impedes policy advocacy.

The five-country case study by Pelletier et al. (2011) found that having a coherent, evidence-based policy was not critical to garner attention to food and nutrition and instead found that policymakers could be swayed in their attention through messages regarding the extent of the problem that resonate with other political priorities they are tackling, especially during periods of political transition. Having credible indicators was the only factor that held across the five cases in the study by Pelletier et al. (2011). By contrast, although most of the 10 countries in this study did report that high-level officials had cited indicators of the extent of food and nutrition problems, no country reported credible indicators of food and nutrition status being used strategically by the media and few reported unfavourable comparisons with other countries on food and nutrition progress.

Pelletier et al. (2011) found that external resource provision and civil society mobilization were not consistently related to attention to food and nutrition. In the present study, a majority of countries reported having civil society groups that promote food and nutrition issues; however, only one country said these groups were cohesive. Thus, though it may be common to have civil society groups dedicated to food and nutrition, it is less common for them to be working in concert towards a common goal, which could hinder their effectiveness. Previous research on food and nutrition’s low-priority status has also suggested that actor power in food and nutrition has been diluted by multiple stakeholders, each with their own specific framing and agenda, vying for attention and muddying ownership for the issue (Reich and Balarajan 2012). Despite this ‘multiplicity of owners’ problem, only three countries reported receiving a great deal of financial and technical support from international agencies to address food and nutrition problems.

Qualitative case studies to date have been unable to determine whether certain combinations of the multiple variables in Shiffman’s (2007) global initiative priority-setting framework are more influential than others. In general, none of these variables on its own is considered either necessary or sufficient to explain why certain health conditions ascend in priority. If repeated across more countries over time, the PCOM-RAT has the potential to shed additional light on identifying factors that are more or less influential. However, this pilot test did not aim to accomplish this and the tool is not a substitute for in-depth case study approaches, which may be necessary to confirm the validity of the rapid assessment findings.

Stakeholder analysis

Surprisingly, the stakeholder analysis did not reveal any groups who were actively opposed to reform of food and nutrition policy. This may reflect an optimistic bias among the expert respondents who are working in this field or political caution concerning the ramifications of labelling groups as opposed. Future iterations of the survey may require further prompting to assist respondents in identifying stakeholders, who may also be on the losing end of advancing food and nutrition policy. [Alternatively, country teams could perform a more detailed stakeholder analysis using freely available tools (Reich and Cooper 2010)]. Furthermore, the lack of budgetary commitment suggests that in practice there are groups that are opposed to increasing expenditure on food and nutrition.

PCOM-RAT and comparison with other food and nutrition policy measures

The PCOM-RAT shares commonalities with other food and nutrition political commitment measures (measures that explicitly separate food and nutrition commitment from food and nutrition outcomes). Table 3 summarizes the major differences among these four approaches to measuring political commitment to food and nutrition. Engesveen et al. (2009), Chopra et al. (2009) and Nishida et al. (2009) report on the development of a comprehensive framework for determining a country’s commitment, capacity and readiness to adopt food and nutrition policy. Their framework involves different activities to generate a complete nutrition Landscape Analysis: (1) development of a Nutrition Landscape Tracking System (NLTS) to monitor nutritional outcomes from epidemiologic surveys; (2) classification of countries according to ‘political commitment’ to nutrition through desk review and (3) in-depth country assessments to identify readiness and capacity to act. The NLTS provides information on nutrition outcomes (Nishida et al. 2009). The political commitment and readiness to act measures, closest to the measures proposed in this study, uses a combination of desk review (secondary analysis of policies and legal frameworks), content analysis of a country’s Poverty Reduction Strategies and United Nations Development Assistance Framework (UNDAF) reports to assess recognition of undernutrition as a development problem, and in-depth assessments with country experts on willingness and capacity (‘readiness’) to act towards nutrition (Engesveen et al. 2009). The in-depth assessments involve qualitative interviews, focus group discussions and checks at the national and sub-national level with experts. Although the Landscape Analysis is thorough and comprehensive, data collection using this method is also lengthy and time-consuming. The PCOM-RAT, which relies on self-directed, expert opinion of in-country respondents, is rapid, but can be complemented with other measures using desk review and country case studies.

Table 3

Comparison of four measures of food and nutrition commitment

	PCOM-RAT	Nutrition barometer	HRCI/HANCI	Food and nutrition landscape and commitment analysis
Basic structure	Theoretically informed, self-administered questionnaire to be completed by a group of in-country, food and nutrition experts	Index measuring political, legal and financial commitments to food and nutrition Compares commitment levels with food and nutrition outcomes	Index measuring policies and programmes, legal frameworks and public expenditures on food and nutrition	Measures political commitment (desk review and content analysis of policy documents) Nutrition governance (secondary policy/legal data) Readiness analysis (expert interviews) Nutritional outcomes (secondary analysis of population surveys)
Goal	Generate actionable information about a countries’ current level of commitment to food and nutrition Identify opportunities and strategies to promote food and nutrition on government policy agendas	Summary measure to monitor nutrition effort vs outcome	Summary measure of the relative ranking of countries on political commitment to tackling hunger and undernutrition	Identify countries level of commitment to food and nutrition Identify readiness and capacity to prioritize food and nutrition Monitor nutrition outcomes and their association with commitment.
Data (primary, secondary, both)	Primary (can be supplemented with secondary)	Secondary	Secondary Pilot of primary data collection	Primary and secondary
Data collection	Self-administered expert questionnaire	Desk review	Desk review and in-depth expert interviews	Desk review and in-depth expert interviews
Coverage	10 countries (pilot)	36 countries	21 countries; 2 countries (in-depth, expert interviews)	36 countries (desk review); 6 countries (pilot of in-depth case studies)

The Nutrition Barometer, sponsored by Save the Children and World Vision (2012), as well as the Hunger Reduction Commitment Index (HRCI) (previously the Hunger and Nutrition Commitment Index—HANCI) from the Institute of Development Studies, are additional indices that assess country commitments to food and nutrition (te Lintelo et al. 2013, 2014). These instruments rely primarily on secondary data to provide relative ranking of country performance, although the HRCI has also implemented perception surveys of experts and communities in two countries to derive more nuanced in-country information (te Lintelo et al. 2013, 2014). A key objective of these indices is to serve as an accountability mechanism, seeking to hold governments more accountable for efforts to reduce hunger and malnutrition.

Like the PCOM-RAT, both the Nutrition Barometer and HRCI include measures of institutional and budgetary commitment, such as policies, laws and international norm adoption to fight hunger and undernutrition and government spending on nutrition. Neither of these indices, however, includes information on relevant in-country stakeholders nor on more targeted information about the expressed commitment of key leadership to food and nutrition issues.

Both the HRCI and the Nutrition Barometer make an effort to separate outcome from effort (commitment). For instance, the Nutrition Barometer identifies countries where commitments match outcomes and where commitments exceed outcomes and makes specific recommendations for addressing these cases. Likewise, the HRCI does not include nutrition outcomes to generate their ranking of countries. However, the HRCI includes some measures that might be considered an output of commitment (e.g. sanitation coverage and women’s access to agricultural land) in addition to legal and policy commitments (e.g. presence of a constitutional right to food). Outputs such as these (as opposed to measures of policies designed to increase sanitation coverage or women’s access to land) may be confounded by the capacity and general resource level of the state. The authors of the HRCI acknowledge the limitations of these measures and cite the lack of available data as reasons for the use of proxies (te Lintelo et al. 2014).

The Landscape Analysis separates measures of nutrition outcomes from its other measures of commitment and readiness to act. The use of content analysis and questions on the commitment of political leaders adds an additional dimension (stated commitment) to their commitment measures not captured in the Nutrition Barometer or HRCI, but that is captured in the PCOM-RAT. The Landscape Analysis also measures state’s capacity to act separately from verbal, policy and financial commitments. Likewise, the questions on the PCOM-RAT were designed to be neutral to a state’s overall resource levels to the extent possible, to isolate commitment apart from resource constraints and to allow for direct comparability across countries at different levels of economic development.

Unlike the Landscape Analysis and the Nutrition Barometer, the PCOM-RAT does not collect information regarding countries’ nutritional outcomes or commitments to international norms. Nonetheless, the PCOM-RAT can be readily combined with outcome measures and measures derived from secondary data, both as a validation exercise and to add additional items to the measure. A major difference between PCOM-RAT and the indices described above is that PCOM-RAT can be used by countries themselves in addition to external researchers to rapidly and systematically analyse their food and nutrition commitment status and opportunities to advance food and nutrition on policy agendas.

During the pilot test of PCOM-RAT, each country was given a customized report with specific recommendations based on the rapid assessment for how they might strengthen the level of commitment and priority given to food and nutrition. Five overarching recommendations were proposed, given the results found across the 10 countries:

• Support existing food and nutrition champions, which most countries had in place.

• Capitalize upon focusing events that bring attention to food and nutrition as opportunities to advance agreed-upon policy proposals.

• Strengthen cohesion within civil society groups that focus on food and nutrition issues.

• Work with the mass media and social media to give food and nutrition issues greater public attention and prominence.

• Build greater consensus within policy communities on food and nutrition indicators and multisectoral approaches.

Strengths and limitations

The PCOM-RAT builds on existing efforts at measuring political commitment and prioritization to overcome problems of length and resource intensity that affect certain methods. This new RAT can be administered within a short time frame to gauge a country’s current level of political commitment to food and nutrition and to assess opportunities to advance food and nutrition policy on the governmental agenda. Importantly, the current survey is not seeking to test which of the agenda-setting variables are causally related to political commitment or associated with nutritional outcomes. However, if repeated over time and across a large set of countries, the survey has the potential to test the relationship between policy opportunities, political commitment and nutritional outcomes. The survey may also be completed by representatives at various levels of government (district, local and ministry levels) to assess political commitment and opportunities within a national system.

This study has a number of limitations. The instrument presented here is designed specifically for the agenda-setting stage of the policy cycle, and therefore, the explanatory power of the survey is limited to this initial attention phase. Other stages, such as policy formulation and implementation, may require different metrics. Our focus is also on political factors related to agenda setting and therefore does not explicitly capture certain variables related to policy formulation or the capacity to implement policies, which other frameworks assess (Pelletier et al. 2011).

The quantitative nature of the PCOM-RAT necessarily reduces a large volume of information to a summary measure, which may give a false sense of certainty about a complex and dynamic political process. Recommendations derived from the RAT will necessarily be suggestive. The rapid assessment approach can be complemented with in-depth case studies to dig deeper and produce more country-specific recommendations. The tool is also intended to be used in the context of broader political analysis training to assist food and nutrition experts and food and nutrition policymakers in formulating more systematic strategies to advance food and nutrition on government agendas and build political support for food and nutrition, rather than as a stand-alone indicator.

The PCOM-RAT is intended to be completed by a wider set of respondents representing diverse sectors within and outside the government, but in this pilot test only one governmental and non-governmental nutrition expert completed the tool per country. The results of the tool may also be influenced by the selection of participants and their own cognitive biases and frames. As food and nutrition experts, they may be more likely to view the government’s support for these issues in a more optimistic or pessimistic manner. In addition, a number of proposed questions rely on the judgement of experts. Respondents in different countries may use different frames of reference in responding to certain items, which may create difficulties in comparing scores across countries. These issues have been identified in previous effort surveys (USAID et al. 2003). Group consensus ratings such as these may be subject to group-think, power relations and other dynamics within the small groups. Therefore, future tests of this methodology should incorporate tests of inter-rater reliability of the scoring among respondents within each country. The tool should also be implemented across a wider set of countries to be able to draw inferences about how countries vary in their commitment levels.

This study does not distinguish between hunger-related policies and nutrition-related policies. Other indices have found that the relative commitment to hunger reduction does not predict the relative commitment to nutrition (te Lintelo et al. 2013). This suggests the two need to be separated, whereas in this instrument, we have combined questions pertaining to both.

Next steps include collecting more country profiles and validating results from the rapid assessment survey against more comprehensive desk reviews and secondary measures. In addition, results from the rapid assessment can be combined with other measures of political commitment such as the Nutrition Barometer and Hunger Commitment Index as well as outcome measures from the Mainstreaming Nutrition Initiative’s NLTS for a more comprehensive set of indicators.

Conclusions

The PCOM-RAT is a promising new method to benchmark country progress on advancing food and nutrition security and prospectively assess the political feasibility of policy change, so that stakeholders can engage more effectively in policy processes. This study finds that most of the 10 countries studied have a high degree of expressed and institutional commitment to food and nutrition, but a low degree of budgetary commitment. Most countries also have a more cohesive policy or set of policies proposed than previously believed, and three countries have a combination of factors that would suggest that a window of opportunity exists for reform.

Improving our understanding of the political environment around nutrition policy and developing the capacity for applied political analysis at the country level are critical to achieving the nutrition movement’s goals. This theory-based survey can be applied to both the academic questions and the practical challenges of scaling up nutrition programmes and policies in developing countries. The PCOM-RAT can be particularly useful in training food and nutrition experts who may have limited experience with policy or political analysis, so that they can work more effectively with governments in advancing food and nutrition policy in the post-2015 era.

Acknowledgements

The authors thank the government and UN agency representatives involved in the Joint Programmes of the MDG Achievement Fund (MDG-F), who participated in this study. The authors also thank the MDG-F secretariat for their continuous support of this project, and especially Regina Gallego for insightful comments that greatly enriched this work and Paloma Duran for her leadership. At UNICEF, the authors thank Mayang Sari for helpful feedback on the PCOM-RAT survey, as well as the Nutrition Section, Programme Division. This study was funded MDG-F, through the Children, Food Security and Nutrition knowledge management initiative coordinated by UNICEF. The analysis, interpretations and conclusions expressed in this article are those of the authors alone and do not necessarily reflect the policies or views of UNICEF or the MDG-F.

Conflict of interest statement. None declared.