Implementing multi-sector nutrition programmes in Ethiopia and Nepal: Stakeholder perspectives

Location: Ethiopia and Nepal

What we know: Successful implementation of multi-sector nutrition programmes is challenging on numerous levels and there is much to learn about best practice.

What this article adds:  A total of 50 semi-structured interviews were conducted with key stakeholders in Ethiopia and Nepal involved in national level discussions on multi-sector nutrition policy design and subsequent programme implementation. The top three issues to be tackled via multi-sector programming by both countries were food insecurity, undernutrition/malnutrition and widespread and/or severe micronutrient deficiencies. More than 60% of respondents identified child stunting as the biggest problem of concern. In Ethiopia, broad engagement of all sectors in developing the National Nutrition Plan and technical/civil society engagement of international NGOs were identified as critical to decision-making and ownership. Nepal’s experience was similar, with much greater credit given to the National Planning Commission in reaching out to ministries to develop the MSNP. Both countries saw the need for strong coordination; this was flagged as a greater challenge in Nepal. Composite responses identified a demand for clear leadership that includes a work plan with a defined budget and responsibilities for specific tasks by sectors.

In this article, results are presented from interviews with key stakeholders in Ethiopia and Nepal involved in national level discussions on multi-sector nutrition policy design and subsequent programme implementation. A total of 50 semi-structured interviews (Ethiopia and Nepal combined) provide insights into the way national governments and their development partners approached the creation, formal ratification and implementation of these complex policy instruments aimed at improving nutrition.

Interviewees were identified by government and other partners involved in the development of the multi-sector nutrition plans. Interviews were conducted at national and sub-national levels; this article focuses on national-level results. A total of 24 interviews were conducted at the national level in Ethiopia and 26 in Nepal. The sectors in which interviewees work included, but were not limited to, health, agriculture, education, finance and economic development, gender, child nutrition, youth affairs and social protection. People were selected based largely on seniority of position and active engagement in the process leading up to government endorsement and implementation of multi-sector nutrition policies and plans. As such, interviewees included stakeholders from the government, academic institutions, United Nations (UN) agencies, bilateral donors and non-governmental bodies or programmes.

The questions asked were arranged by four domains: (1) The nature of the nutrition problems to be addressed by multi-sector action; (2) Decision-making and ownership of the process; (3) Policy and programme design; and (4) Challenges in implementing multi-sector actions.

Findings

Nature of the nutrition problem

Respondents in both Ethiopia and Nepal identified the same set of three major problems to be tackled via multi-sector programming. In Ethiopia, these were (in order of priority) food insecurity (27%), undernutrition/malnutrition (30%), widespread and/or severe micronutrient deficiencies (20%). In Nepal, the problems identified were malnutrition (45%), micronutrient deficiencies (33%) and food insecurity (22%). When pushed to specify the highest nutrition problem of concern to policy-makers, a majority (>60%) of respondents in both countries identified child stunting.

Decision-making and ownership

Two answers dominated the discussions in Ethiopia. First, 32% of respondents indicated that the involvement of many different parts of government was instrumental in developing and launching the 2013 National Nutrition Plan (NNP); that is, the plan was widely deemed to be legitimate because of broad consultation and engagement of all sectors having a role to play in nutrition. Second, 26% of those interviewed emphasised that the role of international non-governmental organisations (INGOs) was essential, both in terms of securing buy-in from civil society and in ensuring adequate technical input into decision-making. Once again, Nepal’s experience was similar, but the magnitude of responses differed. In Nepal, 92% of individuals stated that the National Planning Commission (NPC) was an effective champion for nutrition and reached out to all line ministries to play a role in formulating and implementing the Multi-Sector Nutrition Plan (MSNP). A number of respondents identified the chair of the NPC as a key player in the whole process, using his or her authority and charisma in equal measure to promote a cause in which he or she strongly believed. The second main response in Nepal also related to the role of civil society. Roughly 32% of respondents credited INGOs with having played an important role in supporting the NPC to generate multi-sector buy-in and in rallying civil society around the government’s plan.

In Ethiopia, 47% of those interviewed argued that the creation of a formal, multi-institution technical working group was critical to marshalling necessary evidence and ensuring adherence to a defined timeline. This technical group was created specifically to provide input to the multi-sector plan. Another 29% stressed that a large, government-sponsored workshop in 2010 was important in raising political awareness of the problems associated with stunting and the 1,000-day agenda (promoting a multi-sector focus on preventing stunting from conception to second birthday and to the evidence base relating to possible solutions). The workshop had wide participation of stakeholders, leading to an important constituency of support from across government and its many partners. It also promoted a sense that nutrition was no longer being owned solely by the Ministry of Health (MoH). The process of developing the nutrition plan in 2013 was seen to be more collaborative than the previous iteration in 2008; 39% of respondents pointed to a spirit of common ownership of both the problem and the responsibility for action as the NNP was developed. Another 25% of Ethiopian respondents commented that a high-level government meeting in 2013 included all ministers, resulting in cross-ministry support for the draft nutrition plan.

However, some ownership issues needed to be addressed in the context of plan implementation. First, although enthusiastic about the NNP and the way in which it was developed, roughly a third of Ethiopian respondents said there was a need for more direct involvement of the Ministry of Agriculture (MoA) in fleshing out what a plan on paper needs to look like on the ground. Indeed, 36% of respondents suggested that MoA is inadequately equipped to tackle nutrition and still needs to be convinced that it is the role of agriculture to support nutrition goals. Additionally, 42% of those interviewed still felt that rollout of the plan would have to be led by the MoH and that there was a danger that the earlier, collaborative, multi-sector approach to plan formulation would drop away during implementation.

In Nepal, 44% of respondents stated that the MoH was unlikely to launch multi-sector activities for nutrition without the sustained involvement of other stakeholders, including numerous other parts of government. This was seen to be due to MoH’s fairly narrow focus on targeted nutrition-specific actions, such as vitamin supplement distribution and breastfeeding promotion. Another 36% observed that the MSNP was not a top-down initiative; there are critical roles at the district and village levels in discussing priority actions and in making local commitments to nutrition goals. The roles of the many actors involved in implementation vary by agency and job category, creating a challenge in identifying the specific roles of individuals, which can also vary by district and village.

Programme design, implementation and challenges

In Nepal, a majority (56%) flagged the need for strong coordination at all levels: national, regional, district and village. Without it, they argued, plan implementation would be in jeopardy. An additional 36% stressed that cross-sector coordination was crucial at the national policy-maker level, in part to sustain commitment and to change business practices. Here again, both Ethiopia and Nepal are on a sharp learning curve to clarify the specific responsibilities of sectors and actors in the successful implementation of the multi-sector strategies.

Although the need for coordination was also noted in Ethiopia, only 9% saw this as a main challenge. A further challenge to implementation identified in Nepal (by 36% of respondents) was the need for concrete action strategies outlining the steps for each sector, whereas 52% highlighted the need for clear guidance regarding responsibilities, given the complexity of the MSNP. In essence, respondents were asking for a formulaic, step-by-step approach for translating the multi-sector plans into action. Finally, 31% of respondents expressed the desire to have nutrition as a focus of all agencies. It was clear from the composite of responses that a work plan with a defined budget and responsibilities for specific tasks for individuals/agencies was being sought. The essence of these concerns related to a need for leadership for the NNP, not just multi-stakeholder buy-in.

At the time of writing, the NNPs in both Ethiopia and Nepal are in the early stages of rollout. It is therefore too soon to determine how effectively the plans will be scaled up, their impacts and their sustainability. Respondents were asked about the main challenges going forward. These were identified as: (1) Calls for a clearer mechanism through which all sectors can continue to be part of the process (27%); (2) The need for defined line items for nutrition in the budget for each ministry (27%); and (3) A specific plan for how to implement the multi-sector approach within each agency (17%). Three issues also dominated responses in Nepal: (1) The need for continued involvement of high-level officials (56%) and sustained political engagement; (2) Active, district-level involvement in designing local nutrition actions and overseeing their implementation (40%); and (3) The need for advocacy relating to nutrition (40%). Here again, the focus on high-level officials and need for advocacy reflect the concern that leadership and broad support are both needed to keep nutrition high on the agenda. This plea for continuity in implementation is further complicated by the regular turnover of individuals in senior political posts.

The new nutrition agenda presents some particular challenges in the governance arena in that the multi-sector approach requires some untested approaches. What data in this article highlight is that a “business as usual” model is unlikely to ensure success without bold, new directions to translate plans into action.