104. The right to nutrition: Strategies to hold multilateral and bilateral donors accountable.

Claudio Schuftan, Urban Jonsson

Most United Nations and bilateral donor agencies are not applying the human rights-based framework. This, despite the fact that this is their mandate (for the UN agencies) and the internationally expected approach to use (for bilateral donor agencies). In fact, quite a radical conversion or adjustment of their approach to aid in nutrition is indeed needed to reach that point.

Donors may be giving aid voluntarily, but in this day and age pressures have increased for them to comply with human rights tenets. Donors may be accountable in a variety of ways, e. g., through their budget allocation or through building capacity to work on realizing the right to nutrition. The accountability from donor agencies to partner governments and to the donor countries’ citizens has been historically weak at best, but –with the shift in the development paradigm now in the making– it is now legitimate to expect the donors to be accountable to work towards realizing the right to nutrition.

Accountability assesses the performance of duty bearers against established human rights principles and standards; it informs donors of such assessments in order to guide them toward changing their behavior. Accountability, as a tool, should also have the power to impose sanctions of different types; however, it first attempts to foster a constructive dialogue. While there are different mechanisms of accountability, the most crucial is that they be made available to claim holders themselves. Having rights that are enforceable means recognizing that people mobilized by civil society organizations should be empowered to stake claims. Explanation and training need to be provided on the procedures that are to be used for complaining, on the steps that will have to be taken to verify the complaints and, on the steps that are to be taken to call for corrections. Claim holders must know their rights and they must have appropriate institutional arrangements available to them for pursuing the realization of those rights. In short, where there are no effective remedies, people’s rights are not really realized.

The key right to nutrition issues that need to be assessed in donor agencies pertain to all aspects of their strategies, but mainly relate to their application of a human rights-based framework. In order to make donors comply with human rights-centred practices in their nutrition and other development aid programs, civil society organizations primarily, but also recipient governments should question donors’ compliance with such practices. We thus always need to assess the human rights training of their staff; the compliance of their aid with human right principles, their adherence to the legal obligations established by the Covenant on Economic, Social and Cultural Rights (ICESCR) and other pertinent documents; the way they conduct human rights assessments of their programs and projects; the inclusion of the most vulnerable groups, including women, in the consultation process – if the latter exists; the availability of complaints procedures for claim holders seeking redress, etc. A detailed checklist of the issues to be assessed in donors both at headquarters and at country level can be found in Box 3.

Holding donors accountable has two distinct phases: detection (i.e., determining whether they are violating the right to nutrition), and correction (i.e., doing something with the information obtained to get duty bearers to change their behavior). The assessment proposed in the preceding paragraph (as supplemented in footnote 3) is instrumental for the detection phase. The correction phase challenge calls for a caveat:

Indeed, accountability will only work if and when there is commitment to a change in behavior. Having outsiders telling donors what they ought to do, i.e., chastising them for not using the human rights-based (HRB) framework – when maybe they have never even heard of it – may not be productive. Active advocacy may have to start with an educational effort.

To get from the above assessment to a plan of action, the human rights-based framework prescribes going through:
• a causal analysis of what explains the reasons why donors have been reluctant to comply with the different processes that are key in applying the HRB framework (which can be assessed looking at what is proposed in the CD attached to this Watch as per footnote 3),
• a pattern analysis that identifies specific claim holders and duty bearers and then identifies the often complex claim-duty relationships among them, and
• a capacity gap analysis that identifies the gaps each donor has to comply with in order to address the processes and issues they are not addressing, so that specific corrective actions can inform their future plans of action. (See UNDAF Guidelines 2010 http://www.undg.org/?P=232)

Since the challenge being addressed in this chapter is to get multilateral and bilateral agencies to comply with the human rights framework, all the lessons learned from the proposed assessment have to be incorporated into the most locally feasible and relevant plan of action, a plan that will include the global and national actions that are deemed necessary to have donors abide by the HRB framework. Civil society representation is essential in this exercise. The points of assessment proposed above are necessary, but not sufficient to come up with a final plan of action that is HRB and well adapted to the local context.

The concrete plan of action is to mobilize all pertinent actors of civil society and of government to confront donor agencies to, in no uncertain terms, demand the needed changes in their aid strategies and plans. We have no doubt that this is in the best interest of all recipient countries and especially the interest of their marginalized social groups. So, to sum up, if donors do not abide by human rights principles and standards in their nutrition projects, and there are no accountability mechanisms to ensure that claim holders get that to which they have a right to, ultimately donor projects will for sure continue to miss addressing central entitlements pertaining to the right to nutrition.

As examples to illustrate the above, it is pertinent here to introduce and critique two very current international donor-based projects:

• One on the recent World Bank-proposed Scaling Up Nutrition (SUN) Road Map which very few other donor agencies have criticized and many have actually endorsed. (See Box 1)
• One on the approach being considered for adoption by some donor agencies in terms of using ready to use therapeutic foods (RUTF) for other than cases of acute malnutrition
and in emergency feeding situations. (See Box 2)

Underlying both critiques are cases of failure of donors to carry out their human rights role in an accountable manner both in relation to the rights of the child and the right to nutrition.

Box 1. The Scaling Up Nutrition (SUN) Road Map: A Critique.
The Road Map for SUN reflects the May 2010 World Health Assembly resolution 63.23 on infant and young child nutrition and is anchored in the guiding principles developed by the Standing Committee on Nutrition in 2009 in Brussels. This initiative is an attempt to coordinate the actions of all levels of actors in the field of nutrition. However, not only does the document not present any new elements for a nutrition strategy, but it is filled with empty rhetoric; it also ignores the basic concepts of a meaningful rights-based approach to nutrition interventions. For example, SUN ignores the fact that there are claim holders and duty bearers involved in the development process and that it is only the dialectical engagement of the two that will move the ‘nutrition process’ forward. Where the first section of the document claims that the SUN initiative will “ensure that nutrition policies are pro-poor, pay attention to people with specific nutritional requirements (especially children under the age of 2 years), are rights-based, offer integrated support (food, health, care and social protection), are participatory (building on local communities, engaging their institutions and are inclusive of women’s and children’s interests), and do no harm” (p.8), none of these subjects is further elaborated in the rest of the document. The different interventions that are being called for for implementation are utterly ‘top-down’ and there is absolutely no reference made to anything resembling an Assessment, Analysis and Action approach.
A HRB causality analysis would reveal that disparity in nutritional status is rooted in processes of exploitation and power imbalances. This analysis is completely disregarded in the SUN document that, instead, calls for a naïve harmony and consensus among nutrition professionals (p.10) as opposed to actively engaging with local communities.
SUN prioritizes technical interventions over social, economic and political interventions. Its monitoring and evaluation approach includes only outcome and delivery-related impact indicators, and not the process indicators recognized as critical in a HRB approach (p.10). In addition, none of the Paris Principles are mentioned as a basis for monitoring indicators.
SUN’s proposed benefit/cost estimates are unrealistic. The Bank is spending US $12 billion a year (p.12) with an extremely limited scientific argument to back up such investments (p.12).
In conclusion, this document does not propose any real solution and lacks essential accountability elements. Moreover, since SUN is already a fait-accompli, both detection and correction activities will be a great challenge for us all –beginning now. Finally, considering the level of expertise and resources at the disposal of the authors it is hard not to blame SUN for its ideological bias.

Box 2 Ready to use therapeutic foods: A warning.
‘Therapeutic foods are any appropriate nutritionally-enhanced food products made to be very energy and nutrient dense’. Ready to use therapeutic foods (RUTF) are a specific type of therapeutic foods – now almost always in the form of commercial products (e.g. Plumpy’nut®) – which in the last several years have leapt onto the nutrition scene. RUTF do play a role in the treatment of severe acute malnutrition and in emergency situations. There are, nevertheless, dangers in their inappropriate use, particularly when misused in the prevention of malnutrition. With the escalating engagement of private companies, these products are now moving onto the open market and are being aggressively promoted for direct use by parents. The promotion of these foods to the general public could be disastrous. Manufacturers will have to be held fully accountable for the consequences of such a move.
Indeed, commercially produced RUTF, bought and distributed by United Nations and bilateral agencies, as well as by NGOs, seriously risk undermining local foods and healthy feeding habits such as breastfeeding, which for children from birth and between the ages of 6 and 24 months is the best safeguard against malnutrition. In addition, RUTF policies and programs are simply ‘top-down’ (recipients have not been consulted) and designed to be ‘market-friendly’. This course of action creates chronic dependence on an expensive, currently usually imported, commercial product, and that is a totally unsustainable option for most people who live in poverty; another issue for accountability here.
It is unrealistic, and even irresponsible, to suggest that RUTF could be provided worldwide to the many millions of children identified as having mild malnutrition or chronic hunger. Therefore, global and national actors must ensure: i) that RUTF products are used only where appropriate for the medical treatment of severe acute malnutrition, especially in disaster management, ii) that RUTF are not used as a preventive measure in stable populations, iii) that these products are rather prepared from locally-produced foods and are not imported, and iv) that a universally agreed code of conduct/guidelines on the quality standards, composition and use of RUTF in all circumstances is developed.
Moreover, and most importantly, malnutrition is not just a food problem. Good child nutrition always simultaneously requires food, health and care. Leaders of countries afflicted with malnutrition need to address the underlying social determinants of child malnutrition much more comprehensively and to focus on more rational strategies.
Governments will have to be made accountable to promote a people-centered, community-based approach to nutrition in which the capacities of those who live in poverty are strengthened in such a way that they can develop themselves. No commercial product should be promoted and distributed for the prevention of infant and child malnutrition when breastfeeding is available and locally-made foods are adequate.

These two case studies are just a small window to illustrate how good intentions are not enough to eventually reach the point where the right to nutrition is realized. Too many donors, for too many reasons, circumvent (or deliberately ignore) applying the HRB framework and what it stands for in 2011. Their foreign aid projects thus run the risk of only marginally addressing the problems of malnutrition in the different recipient countries they partner with. We have already had decades of foreign aid in nutrition with marginal results. The time has come for donors to be made to change.

Box 3 Checklist
The aspects to be assessed to test donor accountability in relation to the right to nutrition should include going through the following items:

• Have donor agencies revised their development aid approach to comply with the HRB framework’? Has any human rights expert help them to comply? Has their staff been trained in the
use of the HRB framework?
• In their nutrition work, do they use General Comment 12 on the Right to Food proactively? Do they use human rights principles explicitly (non-discrimination, participation/inclusion,
transparency, accountability, equality, rule of law, empowerment)?
• Do they collect disaggregated nutrition data by gender, by socioeconomic group and by ethnicity?
• Do they use the terms ‘capacity analysis’, ‘claim or rights holders’, ‘duty bearers’ in their lexicon? Do they identify claim holders and duty bearers’ roles in their documents/projects?
Do they distinguish between inability and unwillingness of duty bearers to fulfill their human rights obligations?
• Do they prioritize their resources going for the needs of marginalized/excluded groups in the population? Do they support the organization of these groups?
• Do they combat active discrimination? Do they track discrimination claims made by claim holders? Do they make sure redress measures are available? Do they work with the national
human rights commission or ombudsperson on this?
• In their nutrition projects, do they ensure gender balance and the empowerment of women and girls?
• In the M&E of their nutrition projects, do they focus on the implementation of human rights processes and outcomes related to human rights principles and standards? Do they insist
claim holder representatives be involved in M&E?
• Do they work with civil society organizations, academicians, trade unions, members of parliament, women’s and youth organizations and with children on right to nutrition issues?
Do they engage government agencies on right to nutrition discussions?
• Do they hold human rights/right to nutrition training courses in-house, for partner agencies, for civil society…etc?
• Do they engage the media in their work on the right to nutrition?
• Does the staff receive unambiguous directives on the use of the HRB approach? If yes, do they abide by them?
• Have these agencies raised their voice with respect to free trade agreements (FTAs) and economic partnership agreements (EPAs) that have clear negative right to nutrition consequences?
• Do they openly voice their objections to the World Bank’s nutrition projects that are not human rights-based in their approach?
• Do they consider nutrition as a social determinant of health? If so, how do they address it in a human rights-based manner?
• Are UN agencies’ situation analyses based on the HRB framework?
• Are they contributing HRB nutritional assessments and proposals to the periodic United Nations Development Assistance Framework (UNDAF)?

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