Nutrition-sensitive research in Ghana
By Dr Richmond Aryeetey
Dr Richmond Aryeetey is a Senior Lecturer at the University of Ghana School of Public Health, where he teaches public health nutrition. He is engaged in research on health system support for infant and young child nutrition, as well as on nutrition-sensitive interventions in Ghana. Dr Aryeetey is also actively involved with the multi-stakeholder platform for the SUN Movement in Ghana and Co-chairs the Capacity Building Working Group of the country’s SUN platform.
The author acknowledge the comments and suggestions of Grace Marquis, McGill University, Principal Investigator (PI) of the Nutrition Links Project, and Esi Colecraft, DrPH, University of Ghana, Co-PI of the Nutrition Links Project, in the development of this article.
Location: Ghana
What we know: Ghana has made significant progress in reducing malnutrition prevalence; given its stability and resources, there is potential for further improvement. Understanding the context-specific drivers of undernutrition is needed to inform policy.
What this article adds: This article describes ongoing, nutrition-sensitive research in Ghana and explores related issues around financial commitment and evidenced policy, with particular reference to the SUN Movement. The author outlines a series of nutrition-sensitive, cross-sectoral research programmes implemented across three ecological zones in Ghana: Enhancing Child Nutrition through Animal Source Food Management (ENAM), Nutrition Links, and the Ghana Nutrition Improvement Project (GNIP). Assessment of the 2014 national budget found inadequate commitment to nutrition-specific and nutrition-sensitive programming. Since then, multi-sectoral planning has contributed to a national nutrition policy that is being costed. The SUN multi-stakeholder platform aspires to coordinate local research to inform country policy.
The Republic of Ghana in West Africa is currently ranked by the World Bank as a lower middle-income country. The population is estimated at about 26 million and growing at a rate of 2.4%. (Ghana Statistical Service, 2010.) Ghana is often hailed as one of the few Millennium Development Goal (MDG) successes in sub-Saharan Africa; in the last 25 years it has reduced poverty by more than half (UNDP, 2015). In 2015 the UN Food and Agriculture Organization (FAO) awarded Ghana for halving the proportion of hungry people (FAO, 2015). Beyond these, the most recent Demographic and Health Survey has shown that Ghana has halved the proportion of underweight children, as expected by MDG Goal One on hunger indicator 1c (Ghana Statistical Survey, 2014). The evidence provided here suggests that Ghana is making progress in reducing malnutrition among vulnerable groups. Compared to other countries in the sub-region, this is largely the case. Nevertheless much more could be achieved, given that the absolute number of undernourished people in Ghana remains unacceptably high for a lower middle-income country. Furthermore, Ghana is endowed with relatively more resources to enable it to achieve even further improvements in nutrition. These resources include human resource capacity, a stable political environment and recent discovery of fossil fuel assets. It is also important to recognise that important challenges to the nutrition situation remain in Ghana, including high rates of sub-optimal child feeding, sub-optimal micronutrient status, household food insecurity (particularly among farm families), and low coverage of nutrition interventions. Another important concern regarding the nutrition of Ghanaians are the rapidly rising levels of obesity and associated diet-related non-communicable diseases, occurring in an environment that is increasingly promoting consumption of energy-dense, nutrient-poor diets, as well as inadequate physical activity.
Nutrition-sensitive research in Ghana
In order to address these challenges, multiple research programmes have been or are currently being implemented in order to understand the key drivers of improved nutrition in Ghana. Between 2004 and 2009, the ENAM project – a collaboration between University of Ghana, Iowa State University, and McGill University and supported by the Office of Agriculture and Food Security, Global Bureau, USAID (see www.glcrsp.ucdavis.edu) – was implemented across three ecological zones. The main goal was to enhance access and utilisation of animal source food among vulnerable families with children under five years. Using a community trial design, intervention communities received entrepreneurial and nutrition education plus microfinance to support the establishment of income-generation activities (IGA).
At the end of its lifecycle the ENAM project demonstrated a number of positive outcomes, including increased incomes from IGA, reduced risk of severe and moderate household-level food insecurity, improved nutrition knowledge among caregivers, increased frequency of animal source food consumption, and reduced risk of child growth faltering (African Journal of Food, Agriculture, Nutrition and Development, 2012), (Marquis et al, 2015). A key success factor of this study was the role of microfinance with education: the microfinance provided financial empowerment for the participants. A sub-study in 2007 identified credit unions and input credit among key strategies for helping caregivers to become financially empowered (Marquis et al [1]). Another key strength of the project was the use of participatory rapid assessment methods to identify the potential interventions to address nutrition (Marquis et al [2]).
Following the success of this intervention study the Nutrition Links project, supported by the Government of Canada, is currently extending the findings in a district-wide effectiveness study (Nutrition Links Project). The five-year project, inaugurated in 2014, is seeking to enhance health and nutrition status of vulnerable groups (households with young children and adolescents) by fostering collaborations and increased capacity for service delivery across government and non-government agencies in the Upper Manya Krobo District of the Eastern region (see Box 1 for baseline summary data).
The project focuses on service delivery related to nutrition, health, agriculture and livelihoods and aims to increase access to these services for the most vulnerable groups in the communities included in the study (see Box 2 for an outline of 2014-15 intervention activities). To achieve the outcomes indicated, specific activities include nutrition-sensitive agriculture, capacity building of health staff and community volunteers, and empowerment of households through training in nutrition, agriculture, health, and gender empowerment. This ongoing project is expected to yield evidence on the impact of service delivery enhancement on health and nutrition outcomes (the study protocol and findings will be published in full in a forthcoming peer-reviewed journal). A key strength of the project is the fostering of collaboration across both the health and nutrition-sensitive government and non-government agencies in the district.
Box 1: Baseline household agriculture and child nutrition linkages in the Nutrition Links Project (Aryeetey et al)
The Nutrition Links Project is testing the effect of integrated agriculture and nutrition strategies on livelihoods, nutrition and health status of infants in Ghana’s Eastern Region. Logistic regression was used to determine relationships between infant nutrition (exclusive breastfeeding, diet diversity, Hb <11 g/dl, anthropometry), and household agriculture resource ownership (land, livestock) and practices (farming, home gardening) in the last year, with baseline data.
Only 57% of 1,081 households owned agricultural land but 77% cultivated food, 40% had a home garden and 79% owned livestock. Mean child age was 5.8+3.5 months. Wasting, underweight and stunting prevalence rates were 6%, 11%, and 12% respectively. Exclusive breastfeeding (24 hour recall) was 86% and 52% among infants <3 months and 3-6 months respectively. Only 24% of infants > 6 months were fed diets with four plus food groups in the past 24 hours.
Infants in households with home gardens were less likely to exclusively breastfeed (OR=0.65; p=0.04), but were also less at risk of underweight (OR=0.53; p=0.01). Land ownership was associated with lower risk of wasting (OR=0.59; p=0.04). It was concluded that, although agricultural activities are associated with better infant nutritional indicators, interventions are needed to improve infant and young child feeding practices in the Eastern Region.
Box 2: Plans for 2014-2015 intervention activities, Nutrition Links Project
Infant intervention – Integrated, nutrition-based agriculture intervention
Of the 1,500 households with infants who are participating in the annual data collection, 302 are enrolled in the infant intervention activities. The nutrition-based agriculture intervention began in 2014 and offers intensive nutrition, health and agricultural training, along with provision of home gardens and small animal husbandry. As the intervention targets the household, other family members living in the household also benefit from this intervention.
Adolescent intervention – Integrated nutrition, education and finance
This intervention focuses on reducing anaemia among female school-aged children. Baseline assessment took place at the beginning of the school year in September-October 2014. Of the 1,500 households with adolescents (9-12 years) participating in the annual data collection, 750 are engaged in the adolescent intervention. The intervention benefits girls who have high rates of anaemia. In addition, since older girls (starting in primary grade 4) are less likely to stay in school and hence are disadvantaged with respect to their access to these programmes; the project is exploring options to encourage girls to complete primary grade 5. Increasing girls’ education is one of the most effective ways to decrease child mortality.
For more information on the Nutrition Links Project, click here.
Market-based interventions have been identified as important for addressing nutrition. In Ghana, a number of studies are being implemented to increase access to nutritious and safe foods through the private sector. In 2009 GNIP implemented a range of activities aimed at improving nutrition of children between six and 24 months using a market-based approach (Ghana Nutrition Improvement Project). The activities included development of a food product, assessing cultural and sensory acceptability of the product to consumers, efficacy testing to determine effects on nutrition and health and market analysis of affordability and distribution of the product. The project has only recently (October 2015) completed field activities for both the efficacy/affordability and distribution studies. It is anticipated that the findings will further advance contextual knowledge on how to utilise the potential of market-based solutions for addressing undernutrition among young children and other groups who are vulnerable to malnutrition. Beyond the GNIP, other market-based interventions on nutrition are ongoing in Ghana, but many of these have not been evaluated. For example, since 2011 the Institute of Development Studies has been engaged in research, seeking to understand the role that markets play in individuals and household access to nutritious and safe foods (Institute of Development Studies). The study has focused on the effects of markets relative to the first 1,000 days. Its findings are yet to be concluded.
Financial commitment to nutrition-sensitive programming
Another important component of the nutrition-sensitive research in Ghana is the role that government plays in facilitating access to nutrition services. One of the ways to indicate government commitment to nutrition is to assess how much funding government has budgeted for nutrition actions in public sector financial allocation. This is an important area that has attracted much attention from the Scaling up Nutrition (SUN) Movement. However in many SUN countries there is no simple process for determining government budgetary allocation and eventual expenditure on nutrition. This is partly because nutrition actions often occur across multiple government agencies. Currently there are no established approaches to determining government national-level nutrition budget allocation and expenditure on nutrition-sensitive programmes such as water and sanitation, social protection, food and agriculture, etc. The SUN Movement has therefore supported the multi-stakeholder group in Ghana to use a simple and uncomplicated three-step approach (see Box 2). This exercise was initiated in Ghana in February 2015 and is ongoing. Prior to the assessment of budget allocation using the SUN three-step approach, the SUN Academic Platform assessed the national budget for fiscal year 2014 (the method used is as per SUN Movement Step 3, see Box 1) and reported that there was inadequate commitment to nutrition based on the provisions in the budget statement (Laar, Aryeetey, Akparibo & Zotor). In Ghana, nutrition-specific services are administered by the Nutrition Department, a sub-unit of the Ghana Health Service. Because the Nutrition Department has a low level of power within the Ghana Health Service, it does not receive adequate budgetary allocation. Nutrition-sensitive spending is distributed through other agencies (local government and rural development; water, works and housing; food and agriculture; and gender and social protection ministries; etc). The actual spending on nutrition by these sectors to increase the nutrition sensitivity of their programming is almost negligible. A key outcome of this study is that nutrition budgets should not be embedded in the total health budget as this diminishes their priority.
Box 3: The three-step approach to budget analysis (SUN Movement)
A three-step approach was identified by the SUN Movement Secretariat as a way to report on nutrition-relevant allocations in national budgets. The process includes:
Step one – identifying nutrition-relevant budget allocations through a key word search.
Step two – clearly assessing which budget allocations are specific to nutrition, which allocations are related to nutrition, and those which are unrelated to nutrition.
Step three – attributing a weighting of the allocated budget to programs that are specific to nutrition (100%), such as a national nutrition programme in the budget; and a reasonable allocation to programmes that are related to nutrition (e.g. 25%), such as social safety net and early child development programmes.
For more information, including tools, click here.
Research influencing policy-makers
The research activities described above are expected to feed into the national plan to address malnutrition through the SUN multi-stakeholder platform. In Ghana, this platform – the Cross Sectoral Planning Group (CSPG) – has been in existence since 2012 following Ghana’s commitment in 2011 to scale up effective nutrition interventions towards reducing stunting among young children. The CSPG is coordinated by the national development planning commission and convenes working groups that include government (health and non-health sectors), UN agencies, business sector, bilateral development partners, academia and civil society. All these partners are contributing to implementing a national nutrition policy; this has been prepared and awaits completion of a costed budget prior to government endorsement. The working groups include resource mobilisation, policy development and review, capacity-building and research, monitoring and evaluation, and advocacy and communication. The plans of the CSPG are intended to be operationalised through the support of the National Nutrition Partner Coordination (NaNuPac), another multi-stakeholder platform that predates the CSPG. The NaNuPAC is focused on implementation aspects of nutrition service delivery, while the CSPG concerns policy and strategic planning. The NaNuPac is convened by the Ghana Health Service.
The findings of the various studies indicated above need to be contextualised in the implementation of the national nutrition policy. The ENAM project has demonstrated the role of community mobilisation and the use of non-formal systems to enhance nutrition of families and particularly young children. The Nutrition Links project in the Eastern region is seeking to improve nutrition and livelihoods of poor and vulnerable families in the Upper Manya Krobo district using improved agriculture, business and health services. The current study will provide insight and useful lessons on how different government and non-government agencies can work together with traditional leaders and communities to improve nutrition. The findings from the market-based initiatives are likely to identify the roles and pathways by which private sector participation in nutrition can be maximised. All these findings, however, need to be plugged into a national nutrition evidence system that allows for reviewing not only the quality of the studies but the strength of the evidence from the studies. The University of Ghana is currently engaged in an international network seeking to support national efforts to set up a mechanism for evidence-informed priority-setting and decision-making (see Box 3). The aspiration of the CSPG is ultimately to coordinate local research so that it meets the needs of decision-makers. Ideally, the research should be relevant to ongoing programmes and eventually, when pulled together, should guide decision-making at the CSPG and NaNuPAC levels.
Box 4: EVIDENT partnership
The Evidence-informed Decision-making in Nutrition and Health (EVIDENT) partnership is a global hub of North-South partners aiming to enhance evidence-informed decision-making and policy-driven research in health and nutrition. The network addresses the priority concerns and questions of decision-makers from low- and middle-income countries by providing reviews of evidence, health technology assessments and locally-appropriate guidance, and by facilitating the translation of evidence into policy. It aims to meet local needs and to avoid unnecessary duplication of research.
EVIDENT encompasses all issues that are at the forefront of global nutrition and health policy: stunting, underweight, maternal and child health, micronutrient deficiencies, obesity and non-communicable diseases (e.g. heart disease, cancer, diabetes, hypertension, etc.).
EVIDENT runs courses on evidence-informed decision-making (e.g International Course in Evidence-Informed Nutrition, South Africa, 2015; and Translation of Evidence into Country based Recommendations, Ethiopia, 2015), is developing a series of guidelines (Stakeholder Mapping and Engagement, Identifying and Prioritising Questions), and shares key relevant resources.
Partners include: Ethiopian Institute of Public Health; Ethiopia Institute of Tropical Medicine; Belgium (coordinating body); Makarere University, Uganda; National School of Public Health, Morocco; NICE International, UK; North-West University, South Africa; University of Abomey-Calavi, Benin; University of Ghana, Ghana; University of Ghent, Belgium; University of Sheffield, UK; Sokoine University of Agriculture, Tanzania; and Royal Tropical Institute, the Netherlands. EVIDENT is supported by a number of external scientific experts in knowledge management and health technology assessment.
For more details, include course locations and dates, visit www.evident-network.org
In conclusion, the nutrition-sensitive research activities indicated above make important contributions towards nutrition outcomes. It is important to actively engage with other sectors beyond those in health as part of efforts to improve nutrition. It is essential that nationally-driven research is coordinated and applied to enable evidenced country policy.
For more information, email Richmond Aryeetey
References
African Journal of Food, Agriculture, Nutrition and Development, Volume 12 No. 1 (2012) ENAM Supplement. www.ajfand.net/Volume12/No1/index1.html?
Aryeetey, R et al. Baseline Household Agriculture and Child Nutrition Linkages in the Nutrition Links Project. April 2015 The FASEB Journal vol. 29 no. 1 Supplement 585.17. www.fasebj.org/content/29/1_Supplement/585.17. See also: Nutrition Links – Building Capacity for Sustainable Lives in Ghana, April 2015 The FASEB Journal vol. 29 no. 1 Supplement 898.18.
FAO, 2015. State of food insecurity in the world. www.fao.org/hunger/en/
Ghana Nutrition Improvement Project (GNIP). www.ajinomoto.com/en/activity/csr/ghana/?
Ghana Statistical Service, 2010. Population and housing census. www.statsghana.gov.gh/docfiles/2010phc/Census2010_Summary_report_of_final_results.pdf?
Ghana Statistical Survey, 2014. Demographic and Health Survey 2014. www.dhsprogram.com/publications/publication-FR307-DHS-Final-Reports.cfm?
Institute of Development Studies. www.ids.ac.uk/publication/markets-for-nutrient-rich-foods-policy-synthesis-from-three-country-studies?
Laar A, Aryeetey RN, Akparibo R, Zotor F. Ghana SUN Academic Platform. Nutrition sensitivity of the 2014 budget statement of Republic of Ghana. Proc Nutr Soc. 2015 Nov;74(4):526-32. Epub 2015 Aug 5.
Marquis et al, 2015. Journal of Nutrition. www.jn.nutrition.org/content/early/2014/12/10/jn.114.194498?
Marquis et al [1]. Global Livestock CRSP. Research Brief 08-01-ENAM.
Marquis et al [2]. Global Livestock CRSP. Research Brief 08-03-ENAM.
The Nutrition Links Project is a collaboration between University of Ghana, McGill University and World Vision International with funding from the Department of Foreign Affairs, Trade and Development (DFATD), Canada. www.mcgill.ca/cine/research/building-capacity-sustainable-livelihoods-and-health-ghana?
UNDP, 2015. MDG report for Ghana. www.gh.undp.org/content/dam/ghana/docs/Doc/Inclgro/UNDP_GH_2015 Ghana MDGs Report.pdf?