Mid-level actors and their operating environments for implementing nutrition-sensitive programming in Ethiopia

Evaluating the coverage and quality of nutrition programs via a bottom-up approach: A secondary analysis of real-time data from an end-user monitoring system in Ethiopia

Over the last two decades, great efforts and investments have been made in Ethiopia to ensure that all children have equal access to nutrition services in health facilities. While quality health systems are a prerequisite for quality nutrition services, little attention has been given to the evaluation of the supply and delivery services. The purpose of the study was to evaluate the coverage and quality of the nutrition-specific interventions delivered through the health system. Using an end-user monitoring (EUM) system, we monitored the delivery of nutrition-specific interventions in 500 districts, having 2514 health facilities distributed throughout Ethiopia. Data were collected through third-party monitors between August 2020 and 2021. Roughly 90% of health facilities were performing severe acute malnutrition management in line with the national guideline/protocol, and 2/3 of the assessed facilities were delivering iron and folic acid, vitamin A supplementation and deworming. A third of the messages on AMIYCN were retained by beneficiaries. Warehouse conditions were good in 64.3% of the facilities, but only 22% had good recording practices and about half had problems related to the quality and availability of nutrition supplies. Most beneficiaries were satisfied with the nutrition supplies and service delivered at the health facility level. This study also suggests the relevance of an EUM system to assess the quality of nutrition service delivery and its related supply management, as well as to improve the implementation of nutrition interventions as a decision-making tool.

Understanding differential reductions in undernutrition among districts in Rwanda through the perspectives of mid-level and community actors on policy commitment and policy coherence

Understanding the drivers of improvements in child undernutrition at only the national level can mask subnational differences. This paper aimed to understand the contributions of factors in the enabling environment to observed differences in stunting reduction between districts in Rwanda. In 2017, we conducted 58 semi-structured interviews with mid-level actors (n = 38) and frontline workers (n = 20) implementing Rwanda's multi-sectoral nutrition policy in five districts in which stunting decreased (reduced districts) and five where it increased or stagnated (non-reduced districts) based on Rwanda's 2010 and 2014/15 Demographic and Health Surveys. Mid-level actors are government officials and service providers at the subnational level who represent the frontline of government policy. Interviews focused on political commitment to and policy coherence in nutrition, and contributors to nutrition changes. Responses were coded to capture themes on the changes and challenges of these topics and compared between reduced and non-reduced districts. Descriptive statistics described district characteristics. Political commitment to nutrition was high in both reduced and non-reduced districts. Respondents from reduced districts were more likely to define commitment to nutrition as an optimal implementation of policy, whereas those from non-reduced districts focused more on financial commitment. Regarding coherence, respondents from reduced compared to non-reduced districts were more likely to report the optimal implementation of multi-sectoral nutrition planning meetings, using data to assess plans and progress in nutrition outcomes and integration of nutrition into the agriculture sector. In contrast, respondents from non-reduced districts more often reported challenges in their relationships with national-level stakeholders and nutrition and/or monitoring and evaluation capacities. Enhancing the integration of nutrition in different sectors and improving mid-level actors' capacity to plan and advocate for nutrition programming may contribute to reductions in stunting.

Translation of policy for reducing undernutrition from national to sub-national levels in Rwanda

Understanding how countries improve children’s nutrition can inform policies and contribute to further improvements. We examined the relationship between improvements in nutrition in Rwanda (1992–2017) and political commitment to- and policy coherence in- nutrition. We reviewed nutrition-relevant Rwandan policies and programs (2000–2018) and conducted 90 semi-structured interviews with national (n = 32), mid-level (n = 38), and community (n = 20) nutrition stakeholders and 40 community-level focus group discussions (FGDs). FGDs and sub-national interviews were conducted in ten purposefully selected districts, five each in which stunting decreased (reduced) and increased or stagnated (non-reduced) between the 2010 and 2014/15 Rwanda Demographic and Health Surveys. Analysis consisted of thematic analysis and the assessment of events, policy developments, and strategies that influenced nutrition in Rwanda, including operationalization of political commitment and policy coherence for nutrition. Political and institutional commitment to nutrition increased in Rwanda as evidenced by the adoption of a multisectoral nutrition policy that was reinforced with national and subnational horizontal coordination platforms. These platforms strengthened multisectoral strategies to address nutrition and supported operational and institutional commitment. The role of mid-level actors in nutrition governance increased as responsibilities for planning, implementing, and monitoring nutrition programs were increasingly delegated to sub-national administrative levels. Variations in policy implementation existed between reduced and non-reduced districts. Despite improvements, challenges remained in coordination, financial commitment, and capacity to address, monitor, and evaluate nutrition. Political commitment to- and policy coherence in- nutrition at the national level are important for improving nutrition, and when reinforced institutionally, can be translated to sub-national levels where implementation occurs.

Challenges to joint planning, monitoring, and evaluation for nutrition-sensitive agriculture in Ethiopia: an exploratory qualitative study

Background

Nutrition-sensitive agriculture is an effective multi-sectoral approach to address the underlying causes of malnutrition. However, successful implementation requires the involvement of different sectors to jointly plan, monitor, and evaluate key activities, which is often challenged by contextual barriers. Previous studies in Ethiopia have not adequately explored these contextual barriers. Hence, the current study aimed to qualitatively explore the challenges to joint planning, monitoring, and evaluation for nutrition-sensitive agriculture among sectors in Ethiopia.

Methods

A qualitative exploratory study was conducted in Tigray and Southern Nations, Nationalities, and Peoples (SNNP) of Ethiopia regional states in 2017. Ninety-four key informants were purposively selected from government agencies primarily in health and agriculture, from local (kebele) to national levels, and ranging from academic organizations, research institutions, and implementing partners. Researchers developed a semi-structured guide and conducted key informant interviews which were audiotaped, transcribed verbatim in local language, and translated to English. All transcriptions were imported into ATLAS.ti Version 7.5 software for coding and analysis. The data analysis followed an inductive approach. Transcriptions were coded line by line; then similar codes were grouped into categories. Subsequently, non-repetitive themes were identified from the categories using thematic analysis methodology.

Results

The following themes were identified as challenges that hinder joint planning, monitoring, and evaluation to link nutrition to agriculture: (1) limited capacity, (2) workload in home sector (agriculture or nutrition), (3) lack of attention to nutrition interventions, (4) inadequate supportive supervision, (5) problematic reporting system, and (6) weak technical coordinating committees.

Conclusions and recommendations

Gaps in human and technical resources, limited attention from different sectors, and absence of routine monitoring data hindered joint planning, monitoring, and evaluation activities for nutrition-sensitive agriculture in Ethiopia. Short-term and long-term training for experts and intensification of supportive supervision may address gaps in capacity. Future studies should address whether routine monitoring and surveillance in nutrition-sensitive multi-sectoral activities provides long-term improvement in outcomes.

Stories of change in nutrition from Africa and Asia: an introduction to a special series in Food Security

Malnutrition in all its forms continues to be a massive global challenge, and the past decade has seen a growing political attention to addressing malnutrition in different contexts. What has been largely missing so far, and is in growing demand from countries, is tangible, practical and rigorous insights and lessons (from other countries or contexts) on how to translate this burgeoning political momentum into effective policies and programme implementation strategies - and ultimately impact on the ground. This new climate of learning from experience and evidence led to the launch in 2015 of the Stories of Change initiative. This series presents a second wave of studies from six countries (Tanzania, Rwanda, Vietnam, Ghana, Burkina Faso, Nigeria,) and three Indian states (Chhattisgarh, Gujarat, Tamil Nadu). These provide clear evidence combined with compelling narratives on what drives success in addressing all forms of malnutrition - evidence that is necessary for turning global momentum into actual results on the ground. This introductory Opinion is published with the first set of papers. It will be followed by a thorough synthesis of papers as a conclusion of the Series. We hope that the lessons embedded in these Stories of Change will inform and inspire the deliberations and outcomes of the UN Food Systems Summit and the second Nutrition for Growth Summit to be held this year, and the actions of those in the global food and nutrition system working for positive change.

Multisectoral nutrition planning in Nepal: Evidence from an organizational network analysis

Multisectoral approaches are central to the global Scaling Up Nutrition (SUN) movement and the Sustainable Development Goals. Nepal joined SUN in 2011 and approved the first 5‐year Multisectoral Nutrition Plan (MSNP) in 2012, covering 2013–2017. This mixed methods study draws on organizational network analysis (ONA) and qualitative interviews with a sample of 22 organizations to examine (1) levels of engagement and network dynamics among government sectors and development organizations and (2) milestones and processes in the development and implementation of Nepal's MSNP. Findings suggest that the development of the MSNP was related to the high density of organizational connections; the leadership role of the Nepal's National Planning Commission and the National Nutrition and Food Security Secretariat; and the bridging roles played by a few government ministries and UN agencies that linked organizations that did not have direct relationships with each other. Specialized roles were observed for the three types of working relationships: policy dialogue, strategic planning and implementation. Partners were less connected on MSNP implementation than for policy dialogue and strategic planning, which may have constrained collaborative scale‐up efforts. The Ministry of Agricultural Development, in particular, was the conduit for connecting non‐health sectors into the broader network. Our study offers insights into the structure and dynamics of multisectoral planning in Nepal. It also contributes to a small but growing literature that illustrates how ONA can be applied to measure and use network results to elucidate the processes for strengthening multisectoral planning and implementation of nutrition‐specific and nutrition‐sensitive interventions.

The silencing of political context in health research in Ethiopia: why it should be a concern

In 2004, the Ethiopian government launched what has been called an innovative and groundbreaking solution to the country's public health challenges; the Health Extension Programme (HEP). The positive public health outcomes that have been reported following the implementation of the HEP have led researchers and global health actors to propose it as a model for other countries to emulate. In this systematic review, we point to a potential weakness and methodological bias in the existing research. Despite being implemented within a context of an increasingly authoritarian regime, research conducted following the implementation of HEP reflects a limited discussion of the political context. Following a discussion of why political context is marginalized we provide arguments for why a focus on political context is important: first, political context has an impact on health systems and actualizes questions related to good governance and ethics. While some of the studies we reviewed acknowledge the importance of political factors we contend that the one-sided focus on the positive relationship between political will, political commitment and political leadership on the one hand, and key public health outcomes on the other, reflects a narrow engagement with health system governance frameworks. This leads to a silencing of issues actualized by the authoritarian nature of the Ethiopian regime. Secondly, the political context has methodological implications. More specifically, we contend that the current political situation increases the probability of social desirability bias. In order to balance the overarching positive literature on Ethiopia's health system, research that takes the political context into account is much needed.