Background: In 2010, Uganda began developing its first multisectoral nutrition plan, the Uganda Nutrition Action Plan (UNAP), to reduce malnutrition. While the UNAP signals high-level commitment to addressing nutrition, knowledge gaps remain about how to successfully implement such a plan. Objective: We tracked the UNAP's influence on the process of priority setting and funding for nutrition from 2013 to 2015. Methods: This study used a longitudinal mixed methods design to track qualitative and budgetary changes related to UNAP processes nationally as well as in 2 study districts. Qualitative changes were assessed through interviews, news content, and meeting notes. Changes in allocations and expenditures were calculated based on budget documents, work plans, and validation interviews. Results: Important enabling factors named by stakeholders included identity, human resources, sustainable structures, coordination, advocacy, and adaptation of the UNAP to local needs. Evidence suggests that the UNAP facilitated improvements in the last 3 factors. We found no systematic increases in planned nutrition activities, nor did we find increases in allocations or expenditures for nutrition between fiscal years 2013-2014 and 2014-2015. Expenditure data were not always available for all funding mechanisms. In the 2 study districts, there was little flexibility within financing structures to allow for additional nutrition activities. Conclusions: Results suggest the UNAP has played an important role in strengthening the enabling environment for nutrition action. The next UNAP will need to translate these improvements into a greater number of nutrition activities and higher levels of funding at the national and subnational levels.
Based on the data collected in Uganda, Nepal, and Ethiopia, the papers included in this supplement fill a critical gap in evidence regarding multisectoral National Nutrition Action Plans. The studies offer new data and new thinking on how and why governance, effective financial decentralization, and improved accountability all matter for nutrition actions in low-income countries. This introductory paper offers an overview of the current state of evidence and thinking on the multisectoral nutrition policy cycle, including how governance and financing support that process. It also explores the benefits of applying a systems lens to understand the dynamic, enabling processes of the policy cycle-from research to knowledge and ultimately action-and to provide more dynamic and accurate information for nutrition advocacy and evidence-based decision-making. It concludes with key findings from the 5 country-level studies included. Several important themes emerge: the egregious gap in human resources needed for effective nutrition actions in most low-income settings, the value of research on bottlenecks and successes, and the need for routine monitoring of national policies and plans to measure their effectiveness in achieving both their own stated goals and global sustainable development goals. Reviewing these studies together provides a path forward in building stronger, evidence-based multisectoral nutrition policies and supporting implementation of the nutrition activities included within them.
Background: Nepal has a long tradition of designing good multisectoral nutrition policy. However, success of policy implementation has varied. More evidence on how to successfully carry out multisector nutrition policy is needed. Objective: We tracked the influence of Nepal's multisectoral nutrition plan (MSNP) on the process of priority setting and budgeting from 2014 to 2016. Methods: This study used a mixed-method longitudinal design to track qualitative and budgetary changes related to MSNP processes nationally as well as in 3 districts. Qualitative changes in each study area were assessed through interviews, observation, news content, and meeting notes. Changes in allocations and expenditures were calculated based on budget documents, work plans, and validation interviews. Results: Improved understanding of the MSNP was documented nationally and in study districts but not in VDCs. Human resources, ownership, bottom-up planning, coordination, advocacy, and sustainable structures all emerged as important factors within the enabling environment. Evidence suggests the MSNP influenced improvements in the last 3 factors. We also found notable increases in activities and financing for nutrition-allocations increased steadily between FY 2013-2014 and FY 2015, and 28% of total nutrition allocations in the final year came from new or expanded MSNPaffiliated activities. Data from 3 districts highlight challenges linking local planning and budgeting to central-level structures. Conclusions: The MSNP appears to have strengthened the nutrition system in Nepal and increased priority and funding for nutrition. Next steps include strengthening linkages to the districts and below. Other countries can learn from the MSNP's success in increasing investment for nutrition.
Although the study showed improvements in key UNAP indicators, there is a need to invest in appropriate methods to gauge its progress because the NIL was not designed to assess UNAP. Since the quality of implementation of complex multisectoral programs can differ widely across different contexts, it is critical that effective monitoring of progress be part of such programs. National endorsement of nutrition plans doesn't in itself result in desired outcomes, hence, the allocation of scarce resources has to be based on rigorous evidence.
The dynamics of urban settings can increase health disparities. This paper explores techniques for examining urban health inequities of non-communicable disease risk, using data from the city of Indore, Madhya Pradesh, India as an example. We analyzed non-communicable disease indicators by gender, wealth, education, slum status, housing type, and location, using a 2018 city-level dataset collected in Indore with a final sample size of 3,070. Four techniques for equity analysis were used including bivariate ratios, concentration indices, geographic information system heat mapping, and multivariate regressions. We found that in Indore, behavioral risk factors such as tobacco, alcohol, and salt intake were more likely to be borne by those with low education and income, slum status and temporary housing type, while diseases such as hypertension were borne more equally over the population. This analysis has shown techniques that urban health researchers and planners can use to understand differentials of noncommunicable disease risk and where action can be taken to reduce inequities. Use by city planners will be limited by technical feasibility and production of understandable information. We discuss implications and next steps for Indore as an example for other cities.
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