Prioritising and funding the Uganda Nutrition Action Plan

Location: Uganda

What we know: The Government of Uganda (GoU) is committed to tackling high rates of malnutrition through a multi-sector approach, reflected in the Uganda Nutrition Action Plan (UNAP) 2011 to 2016.

What this article adds: A two-year study documented if and how the UNAP influenced the enabling environment for nutrition action at national and district (two sites) levels, focusing on enabling factors, prioritisation and funding. There was significant improvement in multi-sector coordination of nutrition and UNAP and advocacy increased over the two-year timeframe. Nutrition accounted for 1% of the total GoU budget for 2014 to 2015. Ninety-six per cent of nutrition funding from external development partners (the majority of total nutrition-related allocations) was provided off-budget, with no public record of expenditure. After two years, donors, UN groups and the private sector still looked to internal policies to inform national and strategic funding decisions around nutrition, rather than the UNAP.  Findings suggest the UNAP has enabled nutrition through influence on multi-sector coordination, advocacy and moderate adaptation of the plan to local needs. Improvements in prioritisation of nutrition for four of seven ministries was observed. Progress has been slow on realising a unified identity for nutrition, securing greater human resources and establishing sustainable structures, limiting development of new UNAP-related activities within the study period. Strong foundations have been laid for scale-up; a longer timeframe (five-plus years) may be needed to see change.

The Uganda Nutrition Action Plan (UNAP) 2011 to 2016 was borne out of the 2010 United Nations General Assembly, where the Government of Uganda (GoU) committed to tackling high rates of malnutrition through a multi-sector approach. The UNAP suggests a set of nutrition activities across five major objective areas, six sector ministries and various non-government stakeholder groups (external development partners (EDPs)). The UNAP coordination secretariat was sited in the Office of the Prime Minister (OPM) to signal high-level commitment to nutrition. The OPM is responsible for coordination of all UNAP activities but does not implement nutrition activities directly. The 2011 UNAP gap analysis identified several remaining barriers to addressing malnutrition effectively in Uganda. These included: weak advocacy at all levels; weak infrastructure, coordination and information management systems; limited involvement of communities in nutrition work; and low coverage of nutrition services at all levels. The UNAP objectives were designed to address these barriers.

The objective of the Uganda Pathways to Better Nutrition (PBN) study, designed by the SPRING project in collaboration with the OPM, is to document if and how the UNAP influenced the enabling environment for nutrition action (including enabling factors, prioritisation and funding) over two years (2013-2015). This focus was for several reasons; even well executed policies and plans cannot immediately impact nutritional status and must be operationalised, which takes time, especially when many sectors are involved. The observation period of two years meant focusing on areas where change was expected in this timeframe. The study was timed to capture a significant portion of the UNAP (2011-2016) but was not designed to measure the impact of the plan.

The study followed four key study questions and, to the authors’ knowledge, is the first prospective study on multi-sector nutrition policy processes in Africa. The study used a longitudinal, mixed-method design whereby both the qualitative and budget components ran over the same two-year period but used a different timescale.

Stakeholder groups

At the national level, the study followed six distinct stakeholder groups: government, donors, United Nations (UN) groups, civil society organisations (CSOs), academia and the private sector. Within government, representation was sought from each nutrition-related ministry and from policy and oversight bodies related to the UNAP (OPM, National Planning Authority (NPA), Ministry of Finance, Planning and Economic Development (MoFPED), and any related parliamentarians). The UNAP-related ministries included Ministry of Agriculture, Animal Industry, and Fisheries (MAAIF); Ministry of Education, Science, Technology and Sports (MoESTS); Ministry of Gender, Labour and Social Development (MoGLSD); Ministry of Health (MoH); Ministry of Local Government (MoLG); and Ministry of Trade, Industry, and Cooperatives (MTIC). The Ministry of Water and Environment (MWE), while not an official UNAP signatory, has become involved in the implementation of UNAP activities, thus OPM requested its inclusion in this analysis.

Two case-study districts that have already begun the UNAP rollout process, Kisoro and Lira, were selected to provide a sub-national perspective. The same stakeholder groups were followed in the districts, with some modifications. First, all members of the District Nutrition Coordination Committee (DNCC) were included. Second, few donor and UN agencies had district-level representation; instead representatives of key projects funded by these agencies were selected. Third, community-level opinion leaders and community-based organisations were also included.

Process

Two rounds of structured, key informant interviews (KIIs) were conducted with 26 national-level stakeholders and 47 district-level stakeholders. Nationally, semi-structured follow-up interviews were also conducted quarterly in the intervening period, depending on the news and events. In the districts, some focus group discussions were used when individual interviews could not be arranged. Finally, observation of turnover in position holders was also recorded.

Weekly news searches were conducted for six news outlets using a set of search terms to identify activities, events and actions related to individual and institutional nutrition stakeholders in all six groups, nationally and in both districts. In total, 262 articles were included across the study timeframe. Study team members tracked official UNAP stakeholder meetings and notes from other nutrition-related meetings, trainings and workshops. Any new or changed activities listed in these documents was noted.

Findings

Enabling factors and prioritisation

In general, there was good existing understanding of the UNAP at the start of the study and positive changes over the course of the study in understanding the concept of multi-sector nutrition efforts, but persistent confusion about specific roles stakeholders could play to support the policy.

There was significant improvement in multi-sector coordination of nutrition and UNAP activities in the latter half of the study. Some of the most meaningful examples included increased participation in the national multi-sector coordination structure (meetings, trainings, etc) by the donor and UN groups. Inter-sector coordination across units and departments also increased within almost all ministries and district-level coordination structures were established in Kisoro and Lira.

Advocacy for nutrition also appeared to increase over the course of the study period and building up to the launch of the National Development Plan II (NDP II) in mid-2015. Advocacy efforts organised by OPM, NPA and CSOs pushed nutrition to a higher priority level in the NDP II than in the previous NDP. At the district level, staff within the health sector were found to have advocated for the inclusion of nutrition in the next round of district development plans. Many stakeholders suggested that advocacy is most needed within the MoFPED to lobby for funding.

The study found moderate improvements (relative to other factors) in adaptation of the UNAP to local needs. The most notable change in this area was the development and launch of the National Nutrition Planning Guidelines for Uganda, released near the end of 2015, which offers a more practical understanding of what the UNAP means for planning and implementation by government stakeholders. The OPM (with the support of EDPs) also developed and launched a series of UNAP trainings in over half of all districts to orient DNCCs about the nutrition planning process. The DNCCs were, in turn, working to engage sub-county nutrition coordination committees (SNCCs) and parishes in their planning processes by the second round of district data collection, to take into account the needs of the community. However, DNCCs in both case-study districts mentioned that even when they were aware of local needs, they were not necessarily able to address them since the conditionality of national-level grants did not provide flexibility to develop and implement targeted programmes. The functionality of DNCCs and SNCCs across the country also varied, depending on the EDP support.

There was a persistent call for greater human resources for nutrition throughout the study period, for both planning and implementation. Concerns focused on availability, capacity and excessive turnover of existing staff. While some small positive changes were noted with regard to structures over the study period, most represented nascent movement rather than fully fledged change in sustainable structures. Remaining barriers included insufficient financial buy-in by the GoU, a lack of specific funding for nutrition or the UNAP, particularly at the district level, and an unapproved monitoring and evaluation (M&E) framework that lacked ministry implementation guidance.

While several non-traditional nutrition sectors did not identify nutrition as their priority at the beginning, responses from KIIs conducted towards the end of the study indicate improvements in prioritisation for four of the seven ministries. Three ministries (MAAIF, MoH and MTIC) took multiple steps in 2015 to get inter-ministry agreement to include nutrition as a named priority in their development strategy and investment plans, which is understood as the primary sector document used for priority-setting each fiscal year. In addition, by the end of the study, the MoLG treated nutrition as a formal, crosscutting issue in its planning process and also launched the sub-national, nutrition-planning guidelines. Changes were also seen within MoGLSD that culminated in the ministry successfully lobbying parliament for a new activity to support children; the majority of this activity will focus on feeding programmes. All of these changes evolved over the course of the study and stakeholders most often cited the positive changes previously mentioned in inter-ministry coordination, increased advocacy and improved planning structures as enablers of these changes.

Less obvious changes were observed in the prioritisation of nutrition among donors, UN groups and private-sector stakeholders. At the end of the study, they still said they primarily followed internal planning and policy documents for national and strategic funding decisions. Some donor and UN groups indicated that their intention was to use the UNAP to update internal strategies, but given the five-year life of many of these policies, this had not yet happened. Most EDPs did note that their activities were funded and planned in cooperation with the GoU, so national priorities were always considered. However, only one donor listed the UNAP in the top tier of national plans consulted when planning nutrition activities. Other factors mentioned as barriers to further EDP prioritisation were lack of M&E feedback structures for nutrition programming and high turnover of EDP staff in positions that could advocate for nutrition during work plan development.

Little evidence was found of implementation of new nutrition projects explicitly developed to support UNAP activities or existing projects that have increased alignment with the UNAP. While a handful of new nutrition activities were implemented during the study time period, implementation was usually the result of existing EDP priorities, non-UNAP government plans or priorities, or non-UNAP-related assistance requests by districts. In the two study districts, there was a modest increase in nutrition activities between the first and second rounds of interviews, but only the UNAP trainings were explicitly conducted in support of the plan. With little evidence of new or expanded nutrition activities, this limits how much change can be expected to be seen in financing for nutrition.

Financing

The study found that funding allocations did not increase over the two years of data included in the study. Differences were observed by funding mechanisms (on and off budget) and sources (GoU and EDP) and UNAP objective area. In addition, there was some volatility in expenditure rates across all categories of nutrition funding. Funding for nutrition exists across multiple funding mechanisms and sources, but on-budget levels remain stagnant.

Combined nutrition allocations in 2014 to 2015 totalled 472 billion UGX (US$179 million; 2014-2015 exchange rates). It appears there was a large decrease in nutrition allocations from year to year, driven primarily by decreasing off-budget funds. Examining this funding mechanism, it seems likely that off-budget allocations for 2014 to 2015 were underestimated, as they were projections and thus did not include any projects planned since the last published document from 2013. From qualitative data, there was no mention of major funding cuts to existing off-budget nutrition projects. Focusing on the more accurate on-budget allocations for assessing change over time, a moderate decrease is found of approximately 8% between the two years, after adjusting for inflation.

Breaking figures down by funding source, GoU funds made up one quarter of all nutrition allocations in 2013 to 2014, and just over one third in 2014 to 2015. This represents roughly 1% of the total GoU budget for 2014 to 2015. Nutrition funding from EDPs, which comprised the majority of total nutrition-related allocations in these two years, was primarily provided off-budget (96%) in 2014 to 2015. Regarding spending, no public records were found of expenditures for on-budget central transfers or off-budget allocations. Expenditure data are available for on-budget national ministry allocations; just over half (55%) of those nutrition-related allocations were spent in 2014 to 2015. This is a decrease in spending from the previous year. Spending rates decreased for both GoU nutrition-related funding (from 69%-52%) and on-budget EDP funding (from 152%-83%).

When compared to the costs projected for the UNAP, MAAIF and MoESTS contributions matched their expected share of support for UNAP activities, while MoH and MoGLSD contributed less than expected and MoLG and MTIC contributed more than expected. In terms of relative financial contributions in the last year of analysis, MoLG had the highest total allocations for nutrition, with or without central transfers included. The MoLG nutrition activities primarily related to strengthening local service delivery and development. The MAAIF provided the second-largest sector contribution, but also saw the largest decrease in nutrition-related allocation between 2013 to 2014 and 2014 to 2015 (nearly 50%). The MTIC provided the third-highest allocation for nutrition. Although the MoH contributions were not as high as that of these three ministries, the MoH provided the only nutrition-specific allocations within the government.

Central transfers to the districts were by far the largest contributor to total, national on-budget allocations but presented a methodological challenge. In the detailed analysis of allocations in Kisoro and Lira, it was verified that significant portions of total district nutrition-related allocations came from central transfers for the study years. However, it was not possible to validate these transfers nationally for all 112 districts. For off-budget allocations, health-related EDP projects contributed the most nutrition funding by far in both years, with 26% of that total going to nutrition-specific activities. For 2014 to 2015, the health projects represented nearly two thirds of the total, off-budget, nutrition-related allocations. Expenditures by sector showed no particular patterns and there was volatility by sector and year. On-budget spending among EDPs was heavily influenced by a large overspend of one health programme, although overspending of EDP allocations appeared to be an issue for MWE as well.

Two primary factors appear to be causing the gap in spending across sectors for on-budget funds:

Delayed release of funds: Prior to 2015, tax proposals and allocations were debated well into the start of the fiscal year, delaying the release of funds. Also, because Uganda utilises a cash budget based on tax revenue projections, there is some volatility in the actual funding releases, which destabilises the budget process.

Procurement delays: The bidding process for commodities, capital investments, building projects and engineering works was cited as a major delay and a hindrance to the sector’s ability to “absorb” new funds. Bureaucracy was cited as a primary culprit for these delays.

Allocations appear more than sufficient to cover projected costs; they were almost 10 times the projected yearly cost for 2014 to 2015. However, allocations do not always align with the relative priority given to each objective in the costing exercise. On comparing allocations to costs by UNAP objective area, there is some mismatch in relative proportions. This could signal some inefficiency in the allocation of nutrition funds. Objective 2, related to dietary diversity and food security, was allocated nearly triple the percentage projected in the costed plan. Conversely, for objective 4, related to systems strengthening, allocations were a much smaller proportion of the amount included in the costed plan. Objective 5, related to creating nutrition awareness, received no allocations at all, despite an estimated cost of nearly 2 billion UGX (US$760 000).

Conclusions

The study results suggest the UNAP has played a role in improving the enabling environment for nutrition via its influence on three key factors: multi-sector coordination, advocacy and adaptation of the plan to local needs. Slow progress in the remaining three factors (unified identity for nutrition, human resources and sustainable structures) could explain why these improvements did not translate to any major increases in new UNAP-related activities within the study period. Further improvements in off-budget financing data are also needed to accurately track the majority of nutrition-related resources. The UNAP is the first major multi-sector nutrition plan the GoU has implemented. The improvements identified by this study do not indicate that scaling up of nutrition interventions has occurred, but they do indicate that a stronger foundation has been laid for scale-up in the future. Other SPRING work on scaling up NNAPs found that it may be unrealistic to see major increases in the implementation of nutrition activities within just five years precisely because of the need to strengthen the underlying enabling environment.