A growing literature highlights complexity of policy implementation and governance in global health and argues that the processes and outcomes of policies could be improved by explicitly taking this complexity into account. Yet there is a paucity of studies exploring how this can be achieved in everyday practice. This study documents the strategies, tactics, and challenges of boundary‐spanning actors working in 4 Sub‐Saharan Africa countries who supported the implementation of multisectoral nutrition as part of the African Nutrition Security Partnership in Burkina Faso, Mali, Ethiopia, and Uganda. Three action researchers were posted to these countries during the final 2 years of the project to help the government and its partners implement multisectoral nutrition and document the lessons. Prospective data were collected through participant observation, end‐line semistructured interviews, and document analysis. All 4 countries made significant progress despite a wide range of challenges at the individual, organizational, and system levels. The boundary‐spanning actors and their collaborators deployed a wide range of strategies but faced significant challenges in playing these unconventional roles. The study concludes that, under the right conditions, intentional boundary spanning can be a feasible and acceptable practice within a multisectoral, complex adaptive system in low‐ and middle‐income countries.

Undernutrition has received unprecedented attention, financing and policy focus in recent years. One example is the Scaling Up Nutrition (SUN) movement, with over fifty countries engaged and pursuing a multisectoral nutrition (MSN) approach. This presentation describes the extraordinarily high requirements for MSN to achieve impact and assesses the likelihood of countries achieving impact under current conditions. It is based on the results of a two‐year, prospective study of the challenges, strategies and accomplishments in implementing a multisectoral approach to stunting reduction in four of the African SUN countries: Burkina Faso, Ethiopia, Mali and Uganda. The requirements for effective MSN include various forms of commitment, coordination and capacity at individual, organizational and system levels, involving multiple government organizations, donors, implementing agencies, civil society organizations and the private sector, extending from national to community levels. Few of these requirements were met in the four study countries, yet each of them made significant progress in four major areas: Strengthening the enabling environment, cascading MSN to sub‐national levels, aligning stakeholders and the practice of adaptive management and learning. While this progress is encouraging, these countries remain at fairly early stages of building the MSN system and continue to face many challenges. Most of these challenges can be addressed by placing a high priority on three high leverage system investments: strengthening human resources in the MSN coordinating unit, creating a small but full‐time implementation team and ensuring that accurate information on critical bottlenecks is conveyed and acted upon in a timely fashion by high level decision makers in government and partner organizations. In the absence of such investments it is uncertain whether or how MSN can become effective or sustainable within a time frame that is acceptable to politicians and international donors.Support or Funding InformationUNICEF Regional Offices in Western/Central Africa and Eastern/Southern Africa.

Undernutrition has received significant attention at global and national levels in recent years, as evidenced by the Scaling Up Nutrition (SUN) movement with 43 participating countries and a G8 commitment of $4.2 billion to the Nutrition for Growth initiative, among others. The translation of this attention into effective action at the country level poses many challenges, as documented previously. Here we describe the results of an on‐going action research effort to address these challenges by strengthening strategic capacity in four Africa countries: Burkina Faso, Mali, Ethiopia and Uganda. All four of these countries have developed multisectoral national nutrition policies and/or plans of action, created coordinating committees and identified SUN focal points. Further multisectoral progress faces challenges seen elsewhere, such as the dominance of sectoral goals and incentives, uneven understanding of multisectoral roles, responsibilities and leadership; uneven participation and ownership; weak human and institutional capacities; lack of effective sub‐national multisectoral platforms; and the persistence of unaligned donor‐ and NGO‐driven approaches. Initial efforts to address these challenges by facilitating informal strategic and adaptive management approaches reveals second order constraints such as high turnover of key staff in and out of government, heavy workloads, rigidity and risk avoidance. Ongoing work focuses on formation of strategic alliances, leadership development, the strengthening of sub‐national experiences to inform the design of multisectoral strategies at the national level and strengthening linkages with global initiatives. Grant Funding Source: Supported by UNICEF

Fifty‐four countries have signed up for the Scaling Up Nutrition (SUN) movement and committed to using a multisectoral approach, one with many challenges. Here we describe the results of action research to identify and address the challenges, in four of the African SUN countries: Burkina Faso, Ethiopia, Mali and Uganda. Our theoretical orientation is to view the many multisectoral actors and organizations as complex adaptive systems; our role and mandate is to identify the multisectoral system requirements and bottlenecks, stimulate reflection among key stakeholders and help initiate appropriate actions; our data is derived from participant‐observations. Three key findings are discussed: 1) System level requirements for a multisectoral approach consist of twelve components, in addition to the coordinating committees; 2) All four countries face challenges in all twelve components; 3) Boundary‐crossing actors have helped address these challenges in all four countries through sensitizing concepts, knowledge and alliance brokering, consensus and conflict management and participation in operational tasks for reciprocity and relationship building. Further research to clarify the roles,strategies and skills of boundary‐crossing actors is needed in order to help stakeholders work effectively within complex adaptive systems.