Strategic evidence and insight report: community-led initiatives in health and nutrition in children under-five

Genuinely community-led health and nutrition initiatives for children under five are extremely rare. This review, commissioned by Action Against Hunger UK, examined 2,250 sources across academic and grey literature and found no initiatives that reached the level of empowerment demonstrated by AAH’s own Boolo Xeex Xibon pilot in Senegal — the only example consistent with IAP2 Level 5. The scarcity of comparable examples should not be interpreted as evidence that empowerment is impossible, but as an indication of the structural constraints that continue to shape global health programming. Child malnutrition and under-five mortality remain major public health challenges across LMICs. Despite evidence-based interventions capable of reducing wasting, stunting, and preventable mortality, millions of children continue to experience undernutrition. Global policy discussions have increasingly shifted toward localisation and locally led development, emphasising community ownership, power-sharing, and governance. However, while the language of participation is widespread, there remains limited clarity regarding how often communities genuinely control and govern health and nutrition initiatives — and terminology itself remains a barrier, with terms like “community-led” applied inconsistently across the sector.

A scoping review methodology was employed, with searches structured around three core domains: children under five, health and nutrition interventions, and community leadership or empowerment. Programmes were assessed using operationalised IAP2 criteria examining problem identification, programme design, financial control, and monitoring and evaluation. A consistent structural pattern emerged across the evidence base: programme architecture — including problem definition, intervention design, funding structures, and accountability mechanisms — was almost always determined externally before community engagement began. Communities participated within frameworks they had not created. Four structural barriers consistently prevented initiatives from reaching Level 5: NGO-originated programme architecture; financial governance structures restricting community budget control; donor accountability requirements demanding predefined indicators; and external control over decision-making boundaries.

The Hunger Project’s Epicenter Strategy represented the initiative closest to Level 5, though its broader programme pathway and governance framework remained externally defined, placing a structural ceiling on empowerment at Level 4. Boolo Xeex Xibon stands apart: communities conducted their own analysis of undernutrition determinants, designed interventions independently, controlled financial resources directly, and developed their own monitoring indicators. External actors acted as facilitators rather than implementers. The findings position Action Against Hunger at the forefront of genuinely community-led nutrition programming. Strategic opportunities include strengthening advocacy around donor flexibility, developing facilitative partnership models, contributing evidence to localisation agendas, and collaborating with Level 4 organisations to explore pathways toward full empowerment.