Compilation des données pendant la phase intermédiaire en préparation du prochain atelier
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Cette présentation introduit le volet Politique et programmes de TNWA et les approches de recherche pour les politiques et programmes actuels/en cours axés sur la nutrition au niveau national pour le Nigeria et le Burkina Faso Elle présente par ailleurs l'activité Récits de Changement: changement dans le temps des politiques et des programmes en proposant les exemples du Sénégal et de la Zambie.
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Compilation des données pendant la phase intermédiaire en préparation du prochain atelier
- 1. Compilation des données pendant la phase intermédiaire en préparation du prochain atelier 5ème jour– Session 10 Dr. Roos Verstraeten (IFPRI) Coordinateur de Recherche Countdown to 2030 workshop | Dakar, 10-14 June 2019
- 2. Objectifs de la session 1. Politique et programmes: Introduire des approches de recherche pour les politiques et programmes actuels/en cours axés sur la nutrition au niveau national • Nigeria • Burkina Faso 2. Récits de Changement: changement dans le temps des politiques et des programmes • Contexte • Données et méthodes • Exemples: Sénégal, Zambie 2
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- 4. Politiques et programmes pertinents en matière de nutrition au Nigéria et au Burkina Faso: revue détaillée 4
- 5. Les politiques et programmes au Nigeria et au Burkina Faso qui sont Pertinent en Nutrition En vigeur (app) Multi-sectoriels Visent à traquer au moins un indicateur clé de la nutrition de mère et d’enfant. Tous les secteurs concernés, y compris la nutrition, l'agriculture, les systèmes alimentaires, EAH, la santé (CPN), la protection sociale, le DPE / l'éducation, etc. Soit en cours d'utilisation ou en état de rédaction avancée.
- 6. 6 Définir les politiques et les programmes: de quoi s’agit-il? Programmes Documents décrivant la mise en œuvre de stratégies spécifiques ou sensibles à la nutrition, y compris un plan opérationnel/de mise en œuvre, un plan stratégique, un programme ou un plan d'action et des interventions. Les programmes peuvent être mis en œuvre par n'importe quel secteur pertinent, notamment la nutrition, l'agriculture, les systèmes alimentaires, EAH, la santé (CPN), la protection sociale, le DPE / l'éducation, si le document a un objectif de nutrition déclaré. Politiques Les documents qui constituent une politique, un plan d'action, une stratégie (y compris un plan stratégique) et sont au niveau national / fédéral. Ceux-ci peuvent inclure des actions programmatiques ou des références. Les politiques peuvent concerner n'importe quel secteur mais doivent viser au moins un indicateur clé de la nutrition.
- 7. Approche de recherche Rubrique Détail Sites Internet Explorez des sites Web ciblés aux niveaux mondial, régional et national pouvant potentiellement inclure des politiques et des programmes. Pensez aux sites Web suivants: gouvernement, SUN, REACH, ONU incluant FAO, UNICEF, OMS, Agences régionales incluant OOAS, CEDEAO, les ONG actives dans la région, notamment ACF, Save the Children, Alima, IFPRI, etc. Consultations ciblées avec des experts régionaux et nationaux Pour les politiques et programmes identifiés non disponibles dans les bases de données sur Internet (gouvernements, partenaires des Nations Unies, ONG et société civile, Alive and Thrive) Citation Programmes mentionnés dans les documents de politique
- 8. Méthode de recherche: Google.com search Politiques • Nom du pays AND (policy OR policies OR “action plan” OR strategy) AND nutrition • Nom du pays AND (policy OR policies OR “action plan” OR strategy OR politique* OR “plan d’action” OR stratégie) AND nutrition Programmes • Nom du pays AND (program OR programme OR project OR plan OR strategy OR intervention OR initiative) AND nutrition • Nom du pays AND (program OR programme OR project OR projet OR plan OR strategy OR stratégie OR intervention OR initiative) AND nutrition site: site web (ex. scalingupnutritition.org)site: site web (ex. scalingupnutritition.org)
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- 12. Récits de Changement 12 Une approche avec des méthodes mixtes pour examiner les facteurs de changement de la nutrition au fil du temps
- 13. Contexte des Récits de Changement •Les Récits de Changement ont débuté en 2015 dans le cadre du consortium de recherche Transform Nutrition (TN). •Contexte à l’époque: •Attention politique croissante accordée à la nutrition •Développement de cadres d'analyse des processus politiques et des politiques •Les travaux de TN ont montré un consensus sur le Quoi faire pour augmenter l'impact, mais on en savait moins sur le Comment procéder dans différents contextes (Gillespie et al. 2015). •Les pays étaient désireux d'apprendre les uns des autres
- 14. Justification des Récits de Changement (SoC) Objectif: examiner les changements dans les résultats et les facteurs déterminants de la nutrition, ainsi que les changements dans les politiques et les pratiques au fil du temps, afin de capturer un apprentissage (par l'expérience) sur la manière de traiter les problèmes de malnutrition dans différents contextes. SoC rassemble des analyses des changements intervenus dans les actions relatives à la nutrition et les environnements favorables pour interpréter, de manière globale, comment ils conduisent à des résultats. Objectif général: améliorer la définition de l’ordre du jour, la conceptualisation et la mise en œuvre des politiques relatives à la nutrition et de la planification des programmes aux niveaux national et sous-national dans certains pays. Démarrage des Récits de Changement… • 2015-2017: premier tour dans 6 pays (TN) • Depuis lors, au moins 8 pays supplémentaires et 4 États supplémentaires en Inde.
- 15. Changement (dans le passé) Défi (présent ét future) Engagement Comment l'engagement pour la nutrition a-t-il changé (priorités, programmes politiques)? Comment l'engagement sera-t-il durable face aux défis actuels ou futurs? Cohérence Comment la cohérence institutionnelle est-elle établie et comment a-t-elle changé? • intra-secteur et intersecteurs? • À travers les niveaux administratifs? Quels sont les défis actuels et futurs pour assurer la cohérence? Communauté Comment la vie des communautés vulnérables sur le plan nutritionnel a-t- elle changé? Y a-t-il eu des changements dans la prestation des services de santé et de nutrition? Quels sont les principaux défis, actuels et futurs en matière de santé, nutrition et de bien-être au niveau de la communauté? Cadre d'étude des Récits de Changement
- 16. Approche de SoC: Méthodes mixtes Quantitative •Statistique déscriptive Analyse de decomposition des determinants de la malnutrition Qualitative •Revue de programmes/pol itiques Analyse des bailleurs Entretiens semi- structurés Triangulation Triangulation guide par les cadres conceptuelles Publication et dissémination
- 17. Etudes de cas: Sénégal et Zambie (2015-2016) 17
- 18. SoC Sénégal 2015-2016 6% 3% 1% 2% 24% 16% 14% 15% 12% 4% 43% 60% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% HAZ Stunting Mother's education Husband's education Asset index Healthcare Demographics Unexplained Source: Kampman et al. 2017 Quantitative analysis - Trends in nutrition outcomes/drivers since ‘93 - Decomposition analysis Qualitative analysis - Policy review - Stakeholder mapping - Stakeholder interviews (national/subnational, community level) 0 10 20 30 40 1993 2005 2014 Senegal nutrition trends U5 % stunting U5 % wasting U5 % underweight Child anemia % 6-59mo Female % underweight (BMI<18.5) Comment la nutrition a changé au Sénégal?
- 19. SoC Sénégal Quels ont été les principaux changements en matière d'engagements politiques et de cohérence, au niveau national / sous-national ainsi qu'au niveau communautaire? Engagement: • Meilleure prise de conscience et compréhension de la nutrition • Changements dans le contexte politique • Changements dans la politique de nutrition Cohérence: • Institutionelle • Horizontale • Verticale Communité: • Travailleurs de première ligne • Mères
- 20. 20 Engagement: Création de CLM (avec vision collective et lobbying, soutenue par des acteurs internationaux tels que la Banque mondiale) et exécution du PRN Cohérence: Cohérence institutionnelle renforcée, principalement par le biais de la CLM avec des points focaux, par exemple santé, agriculture, éducation; avec coordination à BEN qui implémente PRN Horizontalement, les secteurs commencent à assumer davantage de responsabilités pour intégrer la nutrition Flux de communication et d'action entre les niveaux politique et communautaire Community: Engagement et formation des relais. Adaptabilité et responsabilité au niveau locale du PRN. Améliorations de la prise en charge en nutrition (modifications de l'accès aux services de santé / nutrition) SoC Sénégal Quels ont été les principaux changements en matière d'engagements politiques et de cohérence, au niveau national / sous-national ainsi qu'au niveau communautaire?
- 21. Sénégal: conclusions contre le méta-protocol Changements (au cours des 15 dernières années) Défis (présent et future) Engagement - Sensibilisation forte/croissante à la nutrition et une solidarité en action. - Sensibilisation croissante à la nutrition dans les secteurs connexes (agriculture, santé, éducation), ce qui se reflète en partie dans les politiques respectives. -La CLM a été créée en 2001, un an après l'élection d'un nouveau gouvernement et après la fin du précédent projet national de nutrition (PNC, 1994-2000). La CLM a fourni pour la première fois un ancrage institutionnel pour la nutrition au plus haut niveau politique, avec un conseil multisectoriel. -La CLM opérationnalise le PRN, qui utilise les leçons tirées du PNC: il prend une approche à long terme «programme» qui tire parti de l'utilisation de plusieurs agences d'exécution mettant en œuvre des services de nutrition au niveau local. -La nutrition est encore perçue comme «sans abri» et les secteurs connexes ont souvent du mal à coordonner son intégration avec leurs autres priorités. -La CLM est limitée dans son aptitude à appliquer la politique parmi les autres secteurs. -Il reste un manque d'indicateurs et de budget pour la nutrition dans de nombreuses politiques sectorielles. Cohérence -La cohérence institutionnelle est renforcée par la CLM, qui intègre les acteurs à un nouveau niveau à travers la mise en place de relations de collaboration. - Sensibilisation accentuée de tous les secteurs à la nécessité d'une coordination horizontale; la CLM a des points focaux issue de chaque secteur. - Augmentation du flux d'informations entre les experts, les décideurs et la communauté. Depuis la décentralisation de 1994, il y a un pouvoir accru aux mains de la communauté, capitalisé par le PRN. Il y a également un nombre croissant de spécialistes en nutrition hautement qualifiés. -La CLM n'a pas l'autorité nécessaire pour imposer l'intégration: l'avenir de cette cohérence institutionnelle repose dans une certaine mesure sur la volonté des acteurs. -La plupart des secteurs sont limités en raison d'un manque de budget. -Beaucoup de gouvernements locaux n’ont toujours pas une vision claire de la problématique de la nutrition, et certains prétendent qu’il existe un décalage entre les experts et les communautés qu’ils desservent. Communauté Les travailleurs de première ligne -Lorsque CRS Caritas a commencé à mettre en œuvre le PRN en tant qu'AEC en 2009, son projet a considérablement augmenté le nombre de relais. Les FLW ressentent un fort engagement à servir leur communauté en ce qui concerne la fourniture de services de nutrition. -Les travailleurs de première ligne jouent un rôle dans l’augmentation des connaissance et la sensibilisation des villageois. En outre, beaucoup ont parlé de leur rôle dans la sensibilisation aux niveaux supérieurs, faisant efficacement pression pour la nutrition auprès des détenteurs pouvoir. Les travailleurs de première ligne -Quels sont les principaux défis actuels et futurs en matière de santé nutritionnelle et de bien-être au niveau communautaire? -La prestation de services au niveau du village dépend du travail bénévole des relais, qui peut ne pas être durable. Mères -Une majorité de mères connaissent ou bénéficient directement de services de santé gratuits (MAM: suppléments, bouillie enrichie, éducation, dépistage de suivi / SAM: réduction du coût des services, évacuation / vaccination) -En ce qui concerne l'accès aux soins de santé, les mères constatent une certaine amélioration en termes d'accès aux accouchements à l'hôpital. Les relais au niveau villageois font une grande différence en termes d’accès. -Concernant les changements de comportement, peu de mères ont réellement modifié leur régime alimentaire pendant la grossesse. Les mères étaient davantage sensibilisées à la recommandation d'allaitement exclusif au cours des six premiers mois. Mothers -Les mères de villages isolés ont peu de contacts avec les services de santé. Le coût du transport reste un obstacle pour certaines mères. -Les mères n'avaient pas accès à un régime alimentaire varié. Une divergence sur le point de savoir si un nourrisson devrait ou non recevoir d'abord du colostrum ou de l'eau bénite d'un chef religieux. - Connaissance incomplète: croyance que la poussière et le vent causent un besoin en eau pendant les six premiers mois du bébé.
- 23. 0 10 20 30 40 50 60 Underweight Stunting Wasting Chld overweight Female undeweight Female overweight and obesity % 1992 1996 2002 2007 2014 SoC Zambie: changements dans la nutrition
- 24. SoC Zambie: analyse de décomposition des déterminants 6% 4% 6% 3% 7% 3% 27% 19% 29% -3% -7% -2% 3% 20% 1% 5% 3% 1% 2% 1% -1% -2% -1% 59% 57% 60% -20% 0% 20% 40% 60% 80% 100% 120% All 0-11 months 12-59 months Asset index Underweight mother Household with bednets 4 or more antenatal visits Born in a medical facility Fully vaccinated Private toilet Piped water Unexplained
- 25. Zambie : Revue de l’évolution de la politique nutritionnelle 1964- 1967 1968- 1971 1972- 1975 1976- 1979 1980- 1983 1984- 1987 1988- 1991 1992- 1995 1996- 1999 2000- 2003 2004- 2007 2008- 2011 2012- 2015 1964 Independence Legend: 1967 National Food and Nutrition Act, estabilshes NFNC in 1967 Policy or legislation 1972 Food and drugs act National event 1972 Food reserve act International event 1975 National Food and Nutrition Act amended 1972 Goitre study Sources: 1978 Salt iodation legislation [not enforced] - "History" and "policy windows" 1978 Margarine fortification legislation (Vitamin A) themes of national interveiws ANC supplementation for pregnant women - Harris and Drimie, policy review 2012 1985 Vitamin A study - Mucha, Zambia nutrition landscape 2014 1987 NFNC review (poor) - Haggblade et al, micronutrient policy review 2015 1990 Vitamin A supplementation begins - www.zambialaws.com 1991 Beginning of economic reforms 1991/2 drought 1992 Program Against Malnutrition formed 1992 international conference on nutrition 1992 Zambia plan of action on nutrition 1994-2004 [never enacted] 1992 Zambia started work on national nutrition policy 1994 Salt iodation mandatory HIV epidemic links to nutrition 1998 Sugar fortification mandatory (Vitamin A) 2003 PROFILES tool used for advocacy and awareness-raising 2003 PRSP- mentioned nutrition for poverty reduction 2003 Biofortified sweet potato released 2005-2011 National micronutrient policy 2005-2010 NFNC strategic plan 2006 National food and nutrition policy 2006 Maize fortification plan [vetoed by government] 2008 Lancet series provided key evidence 2009 National nutrition symposium 2009 Financial scandal; donor reductions 2010 Zambia signed on as an early riser SUN country 2011 National nutrition forum 2011 National election and re-ordering of the health sector 2011-15 NFNSP 2012 Biofortified maize released 2012 SUN Fund established 2013-2015 1000 MCDP (Extended and ongoing) 2013 Nutrition for Growth event, London 2014 Multi-sectoral district plans [7 districts] 2015 5 key line ministries have nutrition budget lines added 2015 Review of 1975 NFNC Act 2015 CAADP results framework includes nutrition
- 26. SoC Zambie – Cartographie du réseau de responsabilité Renforcer la capacité, l’influence et la capacité des organisations à «frontières multiples» d’exercer leur rôle peut faire progresser les politiques et les pratiques de nutrition.(Leifer and Delbecq 1978 “Boundary spanners”) Renforcer la compréhension des citoyens de leurs droits renforcerait leur voix, améliorerait la demande d’une meilleure nutrition et exigerait que les responsables concernés rendent des comptes.(Jonsson 2009 “Right to nutrition”)
- 27. Recommandations issues d'études sur le SoC Éléments de base pour améliorer la nutrition •Engagement de construction •Renforcement de la cohérence, de l’échelle et de la portée intersectorielles et verticales •Génération de données et de preuves •Renforcer la capacité •Cultiver et soutenir le leadership •Assurer un financement stable et adéquat
- 28. TNWA SoC pays et équipes SoC Ghana • University of Ghana: Richmond Aryeetey, Afua Atuobi-Yeboah • IFPRI: Lucy Billings, Mariama Touré SoC Nigeria • IFPRI: Namukolo Covic, Mariama Touré • Univ. of Ibadan: Olutayo Adeyemi (consult.) SoC Burkina Faso • IFPRI: Elodie Becquey, Mariama Touré, Ampa Diatta, Loty Diop, Emilie Buttarelli (consult.) • Institut Supérieur des Sciences de la Population (ISSP): Issa Sombié • Research partners in-country: SNV; 4 national CSOs within the Voice for Change Partnership (V4CP) Coordination/support Mara van den Bold (IFPRI): m.vandenbold@cgiar.org Nick Nisbett (IDS): n.nisbett@ids.ac.uk
- 29. Références/Résources • Garrett, J., and M. Natalicchio. 2011. Working Multisectorally in Nutrition. Washington, DC: International Food Policy Research Institute. • Gillespie, S., P. Menon, and A. Kennedy. 2015. “Scaling up impact on nutrition: what will it take and how will we get there?” Advances in Nutrition 6 (4): 440- 451 • Gillespie, S., & van den Bold, M. (2015). Stories of Change in Nutrition A Tool Pool (Vol. 01494). Washington, D.C. • Global Food Security Special Issue on Stories of Change (2017) https:/Tww.sciencedirect.com/journal/global-food-security/vol/13 • Nourishing Millions book – Stories of Change http://www.ifpri.org/publication/nourishing-millions-stories-change- nutrition • Shiffman, J., and S. Smith. 2007. “Generation of Political Priority for Global Health Initiatives: A Framework and Case Study of Maternal Mortality.” Lancet 370: 1370–1379.
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- 31. Thank you!
Notes de l'éditeur
- Introduction and discussion of a framework for nutrition measurements: core list of nutrition indicators, definitions, overview of available data sources for obtaining nutrition data, methodological issues and gaps:
- This is the framework published in the 2013 Lancet nutrition series. It builds upon the 1990 UNICEF nutrition framework on the determinants of nutrition, but essentially adds in benefits during the life course and interventions that address each of the different levels of determinants with nutrition-specific and nutrition-sensitive interventions, and with actions that would fall into the enabling environment. Nutrition-specific interventions (left) are those that address the immediate determinants of nutrition, such as disease and dietary intake. Nutrition-sensitive interventions (right) are those that address what are referred to as underlying determinants of nutrition, such as household food insecurity, inadequate healthcare, and inadequate care and feeding resources, which in turn affect feeding and care practices and disease burden. Those that fall under ‘enabling environment’ address mostly ‘basic’ determinants, which are those that relate to governance, capacity, leadership, financial resources, and the socio-economic context. Which in turn affect underlying determinants (food sec, health services/healthy environment, feeding/caregiving resources)
- Stories of Change started in 2015 as part of the Transform Nutrition (TN) research consortium (2011-2017), which aimed to improve nutrition-relevant evidence to accelerate undernutrition reduction in sub-Saharan Africa and South Asia (specific focus on Ethiopia, Zambia, Senegal, Nepal, Bangladesh, and Odisha (India)). During this time, global political attention to nutrition had gained momentum. For example, the 2008 and 2013 Lancet nutrition series had been published, which presented evidence on the importance of nutrition for growth and development, the cost of interventions and what works, as well as the importance of nutrition-sensitive drivers and enabling environments. Further, 2010 saw the launch of the SUN movement; and in 2013 the Nutrition for Growth Summit took place (which resulted in a compact on nutrition funding of over 4 billion USD by a wide variety of development partners, business, scientific and civil society groups). In addition, by this time many frameworks and tools had been developed to analyze not only nutrition outcomes and immediate drivers, but also political and policy processes and broader enabling environments for nutrition (e.g. the SoC Tool Pool by Gillespie and van den Bold 2015 provides an overview of these various methods). As part of TN, an evidence review by Gillespie et al. (2015) [Gillespie, S., P. Menon, and A. Kennedy. 2015. “Scaling up impact on nutrition: what will it take and how will we get there?” Advances in Nutrition 6 (4): 440-451] synthesized what is known about scaling up from nutrition and other disciplines to guide action for scaling up impact on nutrition. The review found that while there is consensus on what needs to be done to improve nutrition outcomes, a lot less is known about how to do it – i.e. how to turn political momentum into effective implementation; how to effectively implement nutrition-relevant interventions in different contexts, at scale, addressing multiple determinants in an equitable manner. Hence, while there was a lot of evidence on what was needed, the ‘how’ and ‘why’ of improvements in nutrition in different contexts over time had not really been holistically analyzed, i.e. the ‘story of change’ in nutrition – e.g.: What changed in a particular country in the long-term in terms of nutrition outcomes? What have been the drivers of this change? E.g. in terms of changes in political commitment to nutrition, resources, improvements in drivers of nutrition, etc. How is nutrition policy made and implemented at different administrative levels? Who is involved? Which sectors, at what levels? How do they coordinate? What can be learned from the experiences of policy makers, implementers, and others regarding how to address nutrition in different contexts? How can countries learn from each other and share approaches and ideas? There was demand from countries, especially those that had joined SUN, to learn from each other..
- The purpose of SoC was/is to examine changes in outcomes and drivers of nutrition, as well as in changes in policy and practice over time, to capture (experiential) learning on how to address malnutrition challenges in different contexts. SoC brings together analyses of changes in nutrition-relevant actions and enabling environments to, holistically, interpret how they drive outcomes. The overall objective was/is to: improve agenda setting, conceptualization and implementation of nutrition-relevant policies and program planning at national/subnational levels in selected countries. The first round of SoC studies took place as part of TN during 2015-2017 in 5 countries and 1 state in India. Since then, the SoC approach has been used in at least an additional 8 countries and an additional 4 states in India, by a variety of institutions. Initial studies specifically focused on learning about contexts in which nutrition improved. Now another round of studies looking at particular contexts in which there are consistent challenges in improving nutrition and why this is (Stories of Challenge). TN (2015-2017): Bangladesh, Nepal, Odisha (India), Ethiopia, Senegal, Zambia A4NH: Vietnam, Tanzania, Rwanda TNWA: Ghana, Nigeria, Burkina Faso POSHAN: Odisha, Chhatisgarh, Gujarat, Tamil Nadu Gates Ventures: Nepal, Senegal Others: Maharashtra (this was pre-2015 actually) Stories of Challenge: Vietnam, South Africa, Ghana, Brighton (UK) (2017-2021)
- In Jan 2015, a workshop was held with TN partners to establish consensus on the scope of SoC work, the approach and methods to be used, expected outputs, timeline, as well as to further develop approaches for dissemination of findings, research uptake, and cross-country learning. One of the outputs from the workshop was a suggested “meta-protocol” or framework that reflects the questions discussed during the workshop and which has since served as an overarching structure to guide country studies. The framework reflects that SoC aims to look at what has changed over the past 20 or so years, and what are some of the outstanding challenges in each country across 3 domains: Commitment – how has political commitment been generated in the past, and how can it be sustained in the future? Coherence (vertical and horizontal) – how has coordination across sectors and between multiple administrative levels been developed in the past and how can it be improved/sustained in the future? Community – how have lives of people changed and what do they think will be the most significant challenges for the future regarding nutrition and health? The use of the framework is flexible and can expand depending on what country study teams deem the most appropriate analysis for the context; so the framework permits both cross-country comparisons, as well as local adaptation to context. It also aims to guide thinking about change across the different countries. For TN SoC, 5/6 countries ended up using this matrix to think through the changes in the past and potential challenges in the future).
- Stories of Change uses a mixed methods approach, combining quantitative and qualitative data collection and analysis to examine nutrition-relevant change over time. Generally, the following components are included in an SoC study: Quantitative: focused on identifying drivers of change Descriptive statistics (usually using DHS or country-specific survey data) to examine change in outcomes, and nutrition-specific and -sensitive indicators over time (~20 years) [e.g. access to safe water and sanitation, access to health services; school enrolment, literacy levels – see SoC spreadsheet in the DB folder for an example] Decomposition analysis, usually using DHS data, to assess the contribution of different determinants to observed changes in stunting (based on Headey et al.’s work). Qualitative: focused on the policy process and policy-program implementation Desk reviews of nutrition-relevant policies and programs over time (~20 years) [see SoC Odisha excel in DB folder for an example] Analysis of policy and program content (e.g. what is their target population, coverage, components, nutrition-specific or –sensitive, etc.) (search strategies for policy/program documents will vary by study) Stakeholder mapping: identifying national/sub-national level actors involved/influential in nutrition-relevant policy/programs (again exact focus of mapping depends on study context) Stakeholder interviews at national/sub-national level and if possible at community level to gain an understanding of people’s perceptions of what has changed, why, and how. These various data are analyzed, generally using conceptual frameworks to guide analysis (again these vary by country, but frequently used examples include Shiffman and Smith (2007) on political priority, and Garrett and Natalicchio (2011) on multisectoral coordination.
- Summary: DHS (1993-2004): notable improvements in breastfeeding, diarrhea treatment, vitamin A supplementation, and reduction in stunting This aligns with services provided by PNC and PRN (1995-2016) Decomposition analysis: wealth accumulation largest driver of nutritional change, followed by health care and maternal education During this same period: increased political commitment to nutrition, improvements in coherence of policy and programming, and community-level changes in health and nutrition services. Senegal’s SoC (part of TN 2015-2017) Senegal viewed as a relative success story in the region for addressing child undernutrition. Between 1993 and 2014, stunting prevalence dropped from 33% to 19%; further, stated political commitment increased especially since 2000 through development of policies, institutional structures, programs Focus of the study: How to better understand how nutrition actually improved in Senegal over this time period – in terms of commitment, coherence, and changes at the community level. Key components Quantitative analysis Nutrition trends over time (based on 1992-1993, 2005, 2010-2011, and 2014 DHS data) Decomposition analysis based on same DHS data, to examine trends in stunting and height for age, and of drivers of change in undernutrition. Qualitative analysis Policy review (of national level policy documents and development plans from 2001 onwards) Interviews with 27 national (incl. 2 subnational) level stakeholders and two subnational stakeholders – focused on changes/challenges over the past 15 years regarding commitment and coherence. Interviews with mothers (n=18) and frontline workers (n=24) at community level (4 villages) in department of Tambacounda (b/c high rates of malnutrition; Tambacounda is in the southern region of Senegal which in 2014 had 30% stunting prevalence). Mothers selected according to age of children to cover the 15-year period prior. Decomposition analysis findings: In Senegal, much of the changes in stunting were due to changes in healthcare, followed by changes in asset ownership and parental education. An important finding of the decomposition analysis is that the model explains approximately half (49 percent or 0.23 standard deviations) of the actual change in HAZs and 40 percent of the actual change in stunting prevalence observed over the 1993-2004 period. Also, among the sources of predicted change, wealth accumulation is the dominant factor, explaining 24 percent of the change in HAZs, followed by healthcare (14 percent) and parental education (7 percent). Stunting exhibits similar patterns, with changes in wealth accumulation, healthcare, and parental education making considerable contributions. Overall, for both HAZ and stunting, wealth accumulation is the largest driver of nutritional change explained by our model, followed by improvements in healthcare and maternal education. Improvements healthcare and education which contributed to the reduction malnutrition from 1993 to 2014 align with the services provided by the two national nutrition programs the PNC and PRN from 1995-2016.
- Commitment to nutrition was broken down into 3 sub-categories of analysis: ideas/understanding about nutrition, political context, and nutrition policy. Coherence was evaluated in terms of Institutional coherence: clarity and consistency of communication and action within institutions Horizontal coherence: collaboration across sectors Vertical coherence: information flows between policy and practice; between policy level and the community level Community: Frontline workers: human resources (training, pay), motivation, knowledge/awareness Mothers: access to health services, food and feeding behavior
- Food Policy Special Issue on Stories of Change was published in 2017, and includes the 6 country case studies produced under Transform Nutrition, including Senegal.
- 1. Ideas and understanding: Growing awareness of multisectorality of nutrition in various sectors e.g. health, education, agriculture [quote] 2. Political context: Major policy windows opened in Senegal in the early 2000s (‘policy windows’ a la Shiffman and Smith 2007): 1. Creation of the CLM, Cellule de Lutte contre la Malnutrition), in 2001 following election of President Wade. CLM was funded by the World Bank and lead by a motivated group of nutrition leaders. It was housed in the office of the Prime Minister and its role was to coordinate all nutrition relevant projects. CLM galvanised collaborative engagement promoting government funding for nutrition…allowed nutrition leaders to centralize and coordinate their efforts with a high level of political support, with a long-term commitment. Interviewee: “Government funding to all nutrition programs and activities the CLM coordinated matched that of the World Bank in 2014 and has since then exceeded it.” (NS1) However, persistent financial resourcing challenges Only 6 out of 14 policy documents reviewed had a budget for nutrition 2. Creation in 2001 of the PRN (shaped by lessons learned from the previous PNC); executed by community agencies, local government, NGOs; supported by the CLM. With a 15-year agenda, it was active throughout the country and aimed to improve nutritional status of U5s, and pregnant and breastfeeding women. Presented a significant policy change that made a difference on a number of fronts. 3. Integration of nutrition into national policies Letter of nutrition policy (2001-2014): to ensure satisfactory nutrition for the population especially WRA, U5s, and adolescents; as well as improving access to/quality of health services, adoption of adequate nutrition practices, increased research, finance, coordination, multisectorality etc. National Nutrition Development Policy (2015-2025), with same objectives as the 2001 Letter, but with new and clearer focus on multisectoral action including clear roles for each sector.
- This slide shows the relationship between the CLM and other partners, and the different types of relationships e.g. hierarchical relationships vis a vis nutrition; nutrition-related laws, policies, and regulations; and nutrition-related program implementation. The CLM is the coordinating body for nutrition, housed in the PM’s office. Before this, there existed no group/agency with the capacity for an institutionalized long-term commitment to nutrition. The CLM is a centralized political and administrative hub that coordinates nutrition across sectors, supporting e.g. agriculture, health, and education to incorporate nutrition into their agendas (although the CLM can’t enforce coordination). The CLM is supported by the BEN (Bureau Executif National/National Executive Bureau), which acts as the secretary and operational arm. BEN: 1) assists the CLM to define the national nutrition policy, design appropriate strategies, and manage the implementation of national nutrition programs, 2) develops annual action plan and budget 3) prepares quarterly progress report for CLM. A major role of the BEN is the implementation of the national nutrition program: “Programme de Renforcement de la Nutrition” (PRN / nutrition enhancement program) (primarily funded by the World Bank). The BEN is divided into a ministerial arm and a local government arm. Through the ministerial arm, the BEN leads the dialogue among national actors regarding the coordination of programs through the CLM. Through the local arm the BEN implements the PRN through the “Bureau Exécutif Régional” (BER/ regional executive bureau). (Thus, the CLM provides tools for the operationalization fo the PRN, and provided it with a home). The PRN in turn is structured to engage the community by incoporating a broader network of implementers (already existing community agencies, NGOs, local government, etc.). (I)NGOs play an important role in the implementation of the PRN; these are community executing agents or Agence d’Execution Communautaire (AEC), such as CRS Caritas (who then impelement e.g. screening, provision of therapeutic care for MAM children, etc.).
- I. Institutional coherence: clarity and consistency of communication and action within institutions. CLM coordinates overall agenda for nutrition; facilitates sharing of data, results, works to prevent overlap in intervention. “...there can be links, but really we are not working on the links. It’s the glue, the cement, that we need to put between the bricks. It’s that we are looking for at the CLM.” (NS 2) Future challenges for CLM: CLM lacks technical authority to implement changes in other sectors. Further, CLM needs to separate itself from BEN, which is the implementer of the PRN (p51 report). II. Horizontal coherence: clarity/consistency of links between and within sectors. Interviewees confirmed this is important but remains a major challenge due to lack of budget for sectors to integrate nutrition into their mandates. “I think that sectors are more aware of the fact that there are transformations happening. Two years ago I sat with a multisectoral group and I said to agriculture, you must include nutrition indicators: they said ‘no that's not our affair’. But now when you talk to agriculture, they say, ‘can you help us to integrate nutrition in our affairs?’” (NS3). Key challenges: Inadequate financial resourcing across the board. Not always knowing what to do within a given context. III. Vertical coherence: clarity/consistence of coordination between policy and community level Increased collaboration between policy and community level over the past 20 years Renewed focus on community level approaches thanks to decentralization reform of 1994 which transferred competences to local governments, giving them more power in decisionmaking, e.g. in PRN, local governments play a leading role Policymakers becoming increasingly aware of importance to make nutrition understandable to populations Growth in quality of Senegalese nutritionists (MA and PhD programs) Challenges: lack of clear vision by local governments on how to incorporate nutrition into their local development plans; lack of proper budget allocation for nutrition.
- Based on interviews with frontline workers (n=24) and mothers (n=18) in4 villages in Tambacounda Overall: enhanced knowledge and improved service delivery Frontline workers: to examine changes in frontline worker human resources and effects on service delivery, frontline worker motivation, influencing community member nutrition knowledge Increase in number of relays (community health workers) following implementation of PRN Relays key in raising awareness about nutrition at the community level + lobby for nutrition at higher levels e.g. village chiefs and policy makers. Substantial commitment/motivation of relays when given the required tools and responsibility But concerns about number of trainings and pay Budget 2001 - 2015? Funding 90% world bank 10% Government 2016 - Funding 50% World Bank 50% Government Still a challenge limiting implementation intensity and staffing levels Mothers: How have lives of nutritionally vulnerable people changed? What are changes in mothers’ access to health care? What kinds of behavioral changes have resulted? What are current and future challenges for these populations? Mothers mentioned: Improved access to health services e.g. screenings, vaccinations, MAM/SAM care, changes in where women give birth Mixed responses to food/feeding practices (due to dependence on income, agricultural yields, cultural practices) Challenges: less changes observed in more remote villages; cultural/religious practices impeded optimal breastfeeding practices
- Namukolo’s slide
- Major trends in Zambia are a reduction in stunting over the past 12 years, but a concurrent increase in overweight and obesity in women. Not going into it here, but the major drivers of stunting reduction were increased bednet use for malaria reduction, and improved sanitation. A potential driver of increased overweight is changing diets, and this shows calories available from different food groups in Zambia using FAO national data, with analysis over time showing the nutrient-dense foods being less available over time, and the calorie-dense ones being more available.
- This is a timeline showing nutrition-relevant policies and events from Zambia’s independence in 1964 to present day Zambia appears to have followed most of the main international paradigms in its policy and program approach, and there was a sense in the interviews of Zambia’s nutrition community to some extent being buffeted by international priorities, and the subsequent funding and support for certain issues Recently, the focus swung towards current international narratives of stunting, and nutrition-specific/sensitive interventions, and therefore multisectorality. On one particular issue, that of nutrition-related chronic disease, there is frustration that this can't be comprehensively addressed because donors are not interested in funding overnutrition projects.
- This is a social network map using the Netmap method, showing key actors in national nutrition policy; their influence shown by the size of their bubble; and any links of ‘accountability’ between them. The network map can approximately be seen in two halves: National in the top-left, and international in the bottom-right. Only seven actors are linked to both ‘sides’ of the network: In the center are NFNC and CSOSUN, clear hubs for nutrition, but all of their accountability connections are outwards, meaning they must try to please multiple different actors. They were not assigned high influence by respondents, and their control over the issue clearly does not match the multiple and central roles assigned to them. They can be seen as ‘boundary spanning’ organizations, with many masters and little power. Another key observation is that the network map appears to be capturing several forms of accountability, including financial accountability through funding contracts; institutional accountability in terms of management authority; and political accountability through the processes of democracy . Conclusions (2)…
- The diagrams show the ‘collaboration’ links from the local NetMaps in Mumbwa in 2011 and 2015. The figures have captured visually the changes we know have happened- in 2011 MAL and to some extent MOH and MCD were considered the hubs for nutrition, but interaction was not consistent among the ministries and other partners- and in fact from the interviews we did at the time, we know that people were not really even sure what the other sectors were doing or what it meant to be ‘working for nutrition’. Fast forward to 2015 and we have a map shape that is considered a much stronger network, with the DNCC now as the hub, but also consistent interactions between the network members even outside of the DNCC- and the interviews reveal a very strong understanding of what it means for each sector to be involved in nutrition.
- [See synthesis report p44.] SoC studies show that commitment, coherence, accountability, data, leadership, capacity and finance are some of the key building blocks needed to improve nutrition – although context matters. Key aspects of commitment: Political attention (stated intent) Political commitment (intent reflected in policy) System/institutional commitment (actual change in institutional procedures, incentives, decisions and actions) Budgetary or financial commitment (new actions backed by new funds) Coherence Occurs when commitment is embedded/reflected in institutional structures and processes – horizontal and vertical Important because nutrition requires actions from several sectors and because it requires engagement by a range of actors at different levels Accountability Who is responsible for what type of action, where and when? Important to have clarity and cross-sectoral consensus on roles and responsibilities, backed by authority and capacity and resources to act at all levels. Data Available/accessible data on outcomes, drivers, as well as nutrition-relevant policies and programs key. More data needed at sub-national level, as well as better evaluations to understand why, how, and where programs work or do not work. Capacity – required at individual, community, organizational, and systemic levels Leadership – to work across sectors, catalyze change; SoC demonstrate champions are key. Need to develop next generation of nutrition leaders. Financing – across studies, stable and adequate funding for nutrition seen to continue to be an issue. Need for nutrition plans to be costed, and finance ministries involved in budgeting discussions across sectors. SUN has contributed to this but more work is needed.
- 4 TNWA focal countries Taken out for now: SoC Senegal (update) IFPRI: Elodie Becquey, Ampa Diatta Previous: Halie Kampman (consult.), Rahul Rawat, Amanda Zongrone, Elodie Becquey