As you may have seen, ENN recently launched its latest issue of Field Exchange Issue 65. As one of the sub-editors, I have enjoyed the privilege of editing some of the articles, a number of which have explored the topic of multi-sector nutrition programming. These articles have provided a lot of ‘food for thought’, particularly in relation to how these projects take time and that change often occurs in a broader and often more complex environment which makes programming for nutrition improvement more challenging.

One field article authored by Welthungerhilfe explored the ‘SMART nutrition village model’ implemented in India and Bangladesh. This model uses village institutions as a platform to support communities to plan and implement multi-sector nutrition activities. Interventions include linking agriculture and natural management toward nutrition security, implementing sustainable, integrated farming systems, promoting nutrition gardens, conducting nutrition-sensitive micro planning, rolling out nutrition behaviour change campaigns and strengthening village institutions for improved nutrition actions. Results highlighted that in Bangladesh the levels of child wasting in Nutrition Smart Villages were reduced during the 24-month project period, particularly severe wasting which reduced to zero. However, the number of cases in India did not improve and in fact rose slightly. Perhaps one thing to explore within these findings is the secular trends seen in the non-intervention study villages, particularly in India- that is to say, those changes (either positive or negative) that were taking place naturally that could have influenced the comparisons being made (as outlined below).  

Another field article from Nepal reflects on the multi-sector approach being used by the Suaahara II programme to reduce undernutrition in 42 of Nepal’s 77 districts. WASH actions were integrated across Suaahara II districts to develop a conducive environment for improved WASH through the coordination and capacity building of local government stakeholders, better demand and awareness creation for both improved WASH facilities and behaviours among households, and engagement with private sector actors to strengthen WASH supply chains. Interventions were divided into so-called ‘WASH intensive wards’ and ‘WASH non-intensive wards’. Monitoring data highlighted the successful uptake of some promoted WASH behaviours in both non-intensive and intensive areas, with a greater change over time observed in intensive areas. However,  at the time of publication, data was not yet available to show the impact of Suaahara II interventions on WASH outcomes or to link WASH interventions with health and nutrition outcomes.

A mid-term evaluation is also included in this edition of Field Exchange which explores the results of the UNICEF-supported Swabhimaan initiative in India.  Swabhimaan is a five-year initiative (2016-2021) integrated within the Government of India’s flagship poverty alleviation programme, Deendayal Antyodaya Yojana-National Rural Livelihoods Mission (DAY-NRLM), across three states in India. The programme aims to mobilise women via village-level women’s collectives, which develop and implement integrated nutrition microplans and strengthen local government services, in order to improve the nutrition outcomes of women and adolescent girls. The mid-term results revealed progress in implementation with 336 village-level microplans developed and 77,000 females screened, with 15,122 of these women identified as being at nutritional risk and subsequently referred for nutrition, agriculture and social protection support. Midline results indicated a reduction in thinness in adolescent girls and mothers with children under two years of age, and an increase in the average mid-upper arm circumference of pregnant women.

These three examples of multi-sector programming demonstrate some positive directions but haven’t as yet been able to evidence impact. This highlights the complexity of undernutrition and reminds me of some of the key learning we identified, when ENN conducted eight case studies on multi-sector nutrition programmes, within our knowledge management work for the Scaling Up Nutrition Movement. Some reflections I had when reading these recent articles include:

• Multi-sector nutrition programmes take time and showing impact is challenging. To me, a stand out feature of multi-sector programmes is the amount of time they take to initially set up, given the complexities of working across multiple sectors and the fact that communicating the importance of nutrition related messages across sectors is complex- many sectors are already stretched and communicating the need to take a nutrition lens to their programmes can at times be challenging. Furthermore, seeing results takes time. Impact cannot be achieved in a matter of 12 or even 24 months and we should be patient in ensuring sufficient time to see the benefits of multi-sector nutrition programming. Furthermore, impact on nutrition is not achieved in isolation, it is subject to broader social and economic changes.
• Multi-sector nutrition programmes require government leadership and ownership, leaving them subject to systemic challenges. Learnings from the ‘Nutrition Smart Village’ approach highlighted the limitations of local government institutions as a major impediment to sustainable change, in particular the lack of staff at grassroots level. The authors noted that strengthening local institutions and financially supporting volunteers were found to be a suitable stopgap in this context. In order for multi-sector nutrition programmes to be successful and sustainable, governments need to lead and direct programming and local institutions need to be provided with sufficient resources in order to do so.
• Multi-sector nutrition programmes require contextualisation. As you can see from these three examples there is great diversity in what is classified as a multi-sector nutrition intervention. What makes up a package of interventions should be tailored to the context and the causal factors driving nutrition in that context. Localised, tailored solutions are required in order to depict the true nutrition impact and there is no ‘one size fits all’ solution.
• Linked to contextualisation, because there are so many factors influencing nutrition, multisectoral programmes need to consider secular trends when exploring interventions- that is to say, what is happening outside of the intervention itself or more specifically ‘what is happening in the control arm?’ We need to understand what is determining any shifts (either positive or negative) in nutrition status, in areas where interventions aren’t in place and what might explain these changes over time.
• Collecting data on secular trends is a first important step in this regard. The second, ensuring that studies are sufficiently powered to detect a difference over and above such trends. Subsequently, there are opportunities for future programmes to build upon the successes seen within these secular trends.  
• Changing behaviour is complex and nutrition education doesn’t equate to behaviour change. In fact, increasing knowledge is only the second out of five steps in successful behaviour change, as per the designing for behaviour change approach. Both the example from Nepal and the SMART village approach highlighted that increased knowledge can only translate into new behaviours in the context of an enabling environment. More focus is needed on understanding the enabling environment for behaviour change and how to tailor information accordingly.
• Multi-sector nutrition programming is not a magic bullet. It won’t result in rapidly decreasing stunting and wasting prevalence rates. However, with sustained, long-term, flexible investment from donors, it will result in a broad range of improvements in nutrition and serve as a critical mechanism for preventing malnutrition.

I hope these three articles provide some nuggets of thought and inspiration for you and your contexts. And if you have any articles to share on multi-sector nutrition programming, please do get in touch so we can highlight them in Field Exchange and continue this conversation!