Undernutrition is the single largest contributor to the global burden of disease and can be addressed through a number of highly efficacious interventions. Undernutrition generally has not received commensurate attention in policy agendas at global and national levels, however, and implementing these efficacious interventions at a national scale has proven difficult. This paper reports on the findings from studies in Bangladesh, Bolivia, Guatemala, Peru and Vietnam which sought to identify the challenges in the policy process and ways to overcome them, notably with respect to commitment, agenda setting, policy formulation and implementation. Data were collected through participant observation, documents and interviews. Data collection, analysis and synthesis were guided by published conceptual frameworks for understanding malnutrition, commitment, agenda setting and implementation capacities. The experiences in these countries provide several insights for future efforts: (a) high-level political attention to nutrition can be generated in a number of ways, but the generation of political commitment and system commitment requires sustained efforts from policy entrepreneurs and champions; (b) mid-level actors from ministries and external partners had great difficulty translating political windows of opportunity for nutrition into concrete operational plans, due to capacity constraints, differing professional views of undernutrition and disagreements over interventions, ownership, roles and responsibilities; and (c) the pace and quality of implementation was severely constrained in most cases by weaknesses in human and organizational capacities from national to frontline levels. These findings deepen our understanding of the factors that can influence commitment, agenda setting, policy formulation and implementation. They also confirm and extend upon the growing recognition that the heavy investment to identify efficacious nutrition interventions is unlikely to reduce the burden of undernutrition unless or until these systemic capacity constraints are addressed, with an emphasis initially on strategic and management capacities.
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.
A variety of nutrition interventions are needed to meet national and global goals for women and children, and scarce resources necessitate integration of those activities. Haiti's national nutrition strategy includes 3 priority intervention areas: 1) promotion of age‐appropriate infant and young child feeding (IYCF) practices 2) prevention of micronutrient deficiencies (PMD) in young children, adolescent girls and pregnant women and 3) management of severe acute malnutrition (SAM) in children under 5. Policy makers need to identify program delivery models that effectively integrate these areas at the community level. To address the question of integration, we mapped the program impact pathways for 3 large‐scale nutrition programs serving rural Haitian communities. Two programs were managed by NGOs and one by the public sector. For each program, we assessed how activities related to IYCF, PMD, and SAM were integrated at the service delivery level. Data was collected through document review and semi‐structured interviews with program staff and beneficiaries. Analyses and findings reveal ways that various community‐based nutrition activities can be most efficient and synergistic. Research support: UNICEF Haiti
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.
The Lancet Nutrition Series estimated that global nutritional stunting could reduced by 36% with full implementation of current evidence‐based interventions but little systematic research exists concerning the political and systemic factors that inhibit or enable such implementation. These factors were studied in Bolivia, Guatemala, Peru, Vietnam and Bangladesh through participant‐observation, document review and interviews. Key findings are: a) high‐level political attention to nutrition was generated through varied strategies but political commitment and system commitment remained elusive; b) mid‐level actors from ministries and external partners had difficulty translating political opportunities into concrete implementation plans due to capacity constraints, disagreements over priority interventions, delivery strategies, ownership, roles, and responsibilities; and c) field implementation was severely hampered by capacity constraints from national to front‐line levels. These findings suggest that investments to identify evidence‐based nutrition interventions are unlikely to reduce malnutrition unless there are commensurate investments to understand and address political and systemic capacity constraints that influence implementation. Supported by a grant from The World Bank.
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