Exploring multi-sector programming at district level in Senegal, Nepal and Kenya

ENN has published a series of case studies on multi-sector nutrition programming at the sub-national level as part of its Knowledge Management (KM) work under the UK Department of International Development (DFID)-funded TAN programme (supporting learning within the Scaling Up Nutrition (SUN) Movement). ENN’s objective was to construct detailed descriptions from sub-national and implementation levels of how sectors are working together to implement programmes and how new programme approaches fit within existing institutional architecture. For practitioners and policymakers working in nutrition, limited evidence and documentation is available on how nutrition-sensitive (see Box 1) and multi-sector programmes are being operationalised and how these interact with existing institutional architecture and structures at the sub-national level. Documentation has often centred around national policies, strategies and frameworks and guidance available is still fairly generic and ‘top down’. This series of case studies aims to help fill this gap by providing important lessons learned to help shape future approaches and practice.

This work comprises three country case studies from selected ‘high achieving’ SUN countries with a strong track record in championing and improving undernutrition: Kenya, Nepal and Senegal. The case studies are based on fieldwork and interviews conducted by ENN’s Regional KM specialist team in late 2017. In each country, two districts (or counties) were selected to explore in detail how institutional change and commitments at the national level have translated into new types of programmatic approaches at the implementation level, as well as how concepts of multi-sectorality and nutrition sensitivity are being understood and operationalised. Within each focus district a specific multi-sector programme was examined. In Kenya, focus districts were Homa Bay and Makueni (with some field work also in Busia); the focus programme was the United States Agency for International Development (USAID)-funded agri-nutrition programme Accelerated Value Chain Development (AVCD). In Nepal, the district of Jumla was selected from the western mountains region and Kapilavastu from the Terai, with a focus on the government-led Multi Sectoral Nutrition Plan (MSNP) phase 1. In Senegal, focus districts were Matam in the north east, bordering the Sahara desert, and Kédougou in the south east, with a main focus on the multi-sector PINKK project in Kédougou and the (now complete) Yaajeende project in Matam. The range of focus districts reflects the significant diversity that exists within these countries in terms of patterns of malnutrition, socioeconomic status of the population and ecological zones. This provided insights into how national infrastructure, plans and approaches are adapted to different regions.

A synthesis document shares key findings and observations on the realities of multi-sector programming based on the three case studies. Emerging changes to practice are discussed, as are challenges and opportunities that sub-national-level stakeholders are experiencing. Key findings from the synthesis are summarised below.

 Box 1: Making programmes nutrition-sensitive 

The case studies and synthesis identify five types of programme or adaptations that can render an intervention increasingly sensitive to nutrition:

• Multiple sectors converge on nutritionally vulnerable households or demographic groups to offer programmes services; e.g. targeting of services to first 1,000 days households.
• Multiple sectors converge at the level of village or commune believed to be vulnerable to undernutrition; e.g. agriculture and health workers use the same list of target beneficiaries to deliver complementary agriculture and nutrition inputs within the same village commune.
• Nutrition messaging is incorporated into the work and activities of other sectors; e.g. education curricula changes to include nutrition components, nutrition behaviour-change communication (BCC) within a social protection programme.
• Nutrition-sensitive sectors change or add inputs into programmes; e.g. replacing poultry with milk-producing animals, introducing seeds for fortified crops, changes in hardware.

Nutrition-specific platforms utilised to introduce nutrition-sensitive messaging from other sectors; e.g. food and personal hygiene, need for dietary diversity, etc.

High-level commitments around stunting and wasting reduction, along with other improvements in nutrition, must take account of districts’ or counties’ plans, capacities and resources. The shift towards devolved governance in many countries means that careful analysis is necessary to understand how this may positively or negatively impact the drive towards multi-sector nutrition programming. Little or no work has been conducted on the impact of devolution on multi-sector nutrition programming to date.

The case study countries are at differing stages of decentralisation or devolution, but in all three the trend is towards the decentralisation of power, with budgeting, coordination and implementation increasingly being decided sub-nationally. This is changing the nutrition landscape and has implications for the design of future national programmes, policies and funding arrangements.

Although understanding of the impact of devolution on multi-sector nutrition programming in the three case study countries was largely impressionistic, a few issues are noteworthy. In Kenya, there was a strong sense that devolution has facilitated multi-sector engagement at sub-national level as there is less bureaucracy. In Nepal, the impression was that decentralisation will create new opportunities, but also significant challenges, especially with respect to resourcing and capacity. There is also a frustration that, while data produced through monitoring of national nutrition efforts at the sub-national level is being collected centrally, there is scarcely any feedback from national level. In Senegal, there was a strong sense that national-level nutrition policies and frameworks need to be regionalised and more embedded in sector policies to allow more context-appropriate interventions.

Devolution impacts programme implementation capacity, flexibility of programming and the underpinning institutional architecture. Through devolution, sector or ministerial heads at the national level have less control over expenditure, what is prioritised and how sectors work together on the ground in nutrition. Adaptation is needed to ensure that guidance and support can still be provided to the districts in the form of policy guidance, capacity building and aligning actions around national goals and targets. This is an important area for future documentation and enquiry.

Coordination between sectors is critical to enable multi-sector action. However, available guidance on how to coordinate multi-sector programming is mainly generic and ‘high level’, outlining the need for a set of enabling factors; e.g. a Common Results Framework attached to a national plan, a ‘multi-sector platform’, and a high-level representative of government office convening on nutrition. This form of guidance is mainly geared towards the national level and is not easily transferable to sub-national institutional and administrative arrangements. Furthermore, institutional architecture and coordination processes, especially at sub-national level, are highly context-specific and, in many countries, evolving towards devolution. As a result, it is difficult and may be unwise to generalise about the optimal processes for enhanced sub-national, multi-sector coordination.

The case studies clearly show coordination to be a key challenge in the implementation of multi-sector programmes across multiple levels. Some challenges observed include limited incentives to coordinate with other sectors at the sub-national level, limited financial resources to effect district-level coordination, and the existence of multiple parallel coordination meetings for nutrition and related sectors. New multi-sector approaches to nutrition have been introduced at the programmatic level, requiring input from multiple sectors, but the structures and institutions in place have not yet evolved to enable this.

As a result of these challenges a type of coordination has evolved in all three countries at sub-national, operational level variously described as "loose", "unstructured" and "opportunistic".

In Nepal, part way through the implementation of the first phase of the national MSNP, a Technical Support Unit (TSU) was introduced in each programme district to better coordinate the seven implementing ministries. To date, the TSUs have been a ‘game changer’ in the way the MSNP works, facilitating routine meetings between the sectors and carrying out other crucial tasks that previously had no ‘institutional home’, such as creating activity plans, tracking progress against set targets and sending quarterly reports and monitoring data to central level. A non-governmental organisation (NGO), HERD, seconded staff to each TSU. In the Kenya case study, the important role of development partners in helping to coordinate sector activities was also highlighted.

A primary consideration in the case studies was the extent to which programmes have enabled more comprehensive sector support for household members and what lessons there are for future programming design and scale-up. It is commonly understood that households who receive a comprehensive package of services that simultaneously address the underlying causes of malnutrition have better outcomes, but what this looks like ‘on the ground’ is still not well documented. None of the case study programmes collected robust data on the proportion of households in the intervention area in receipt of multi-sector/multiple interventions. This information is critical for convergence and targeting of multi-sector programming and therefore needs further attention and enquiry. Smaller-scale programmes seem to be able to deliver a ‘complete package’ to target households, but the extent to which this sometimes resource-intensive approach can be implemented by government and at scale is another issue requiring attention.

None of the case study country programmes collected data on the (additional) cost of implementing multi-sector nutrition sector programming. This is complex, requiring precise definition or categorisation of what activities or processes are, or contribute to, nutrition-sensitive, multi-sector programming; e.g. substituting milking animals for poultry, adding nutrition messaging to a sector intervention and targeting particular households. Without this information, it is difficult to assess the cost-effectiveness of multi-sector nutrition programming; or indeed, what funds need to be made available by government and development partners to enable programming. In Nepal, there were reports from both MSNP study regions that money made available for sectors was not adequate to implement real change to programming and MSNP-specific funding was dwarfed by the larger sector-specific spend. At best, the small sums of money made available by government simply reminded sectors to consider the nutrition sensitivity of their work.

The programmes studied have not yet developed robust monitoring systems able to demonstrate the nutrition impact of multi-sector interventions, although in the case of Nepal, evaluation of MSNP I identified this as a substantial gap and plans have been made to monitor impact on nutrition and other outcomes in the next phase. In Senegal, the programme in Matam (Yaajeende) conducted baseline, mid-term and end-term evaluations, which included nutrition impact assessments. (So far these have demonstrated only limited impact on nutrition indicators).  

Given the nature of the changes brought about by multi-sector programming (mainly changes in targeting or convergence, BCC and project inputs), there is a pressing need and substantial opportunity to demonstrate effectiveness and impact of the interventions.

Three key points are made based on the findings from the case studies. Firstly, effecting and enabling multi-sector programming is considerably more difficult than has perhaps been realised. Effort and changes required to enable multi-sector programming must therefore be matched by proven benefit (on nutrition), making M&E a critical area for focus in future programmes. Secondly, the type of changes to programming that can occur in a multi-sector approach (with the exception of targeting and convergence) have not yet been proven to impact nutrition. For example, the evidence base for nutrition-sensitive agriculture and water, sanitation and hygiene (WASH) is not strong and the evidence around BCC is also inconclusive. Thirdly, there are hitherto unique opportunities for measuring impact of a multi-sector approach, given the momentum for it in many countries, yet these opportunities are not currently being capitalised upon. The gradual rollout of the programmes in Kenya and Nepal offers the perfect opportunity to conduct research with control or comparison groups.

It was clear from interviews conducted that there are diverse understandings of what ‘nutrition sensitivity’ means among the many stakeholders consulted. In some cases, stakeholders saw their work or the work of their sector as ‘already sensitive to nutrition’, i.e. contributing to food production, and did not necessarily understand the need to tailor or adapt programmes or change the way in which they are measured. This suggests that, while many stakeholders appeared to understand the need for a multi-sector approach to tackle undernutrition, fewer understood nutrition-sensitivity or the impact pathways that lead to undernutrition. The multi-sector approach was articulated by some stakeholders as simply requiring that every sector ‘does its bit’ for nutrition, largely through business-as-usual, rather than tailoring or adapting approaches or the way that programmes are measured.

This series is the first in what ENN hopes will be several rounds of this kind of documentation carried out under this project. By focusing on documentation at the sub-national level, it is hoped that a richer understanding of multi-sector practice and programming will emerge to inform and improve future practice, programme design and implementation. 

For more information, contact Tui Swinnen.

All three case studies and the synthesis report are available for download online at: www.ennonline.net/ourwork/knowledgemanagement/sunkm