Zambia’s First 1,000 Most Critical Days Programme: a case study

It is more than ten years since Zambia joined the Scaling Up Nutrition (SUN) Movement. The country is now in the second phase of its flagship stunting reduction programme - the First 1000 Most Critical Days Programme (MCDP) - building on lessons learnt during Phase 1. Zambia has achieved a progressive decline in the stunting rates of children under five years over the last two decades, reducing by a third from a peak of 53% in 2001 to 35% in 2018. However, stunting rates still remain high, despite Zambia moving into lower middle-income status and the country remains off track for meeting World Health Assembly Targets by 2025.

While stunting rates do remain high, Zambia has provided many positive examples of the key ingredients for successful multi-sector programming. Through a visit to the country in early 2020 and a series of key informant interviews, a case study has been developed to document and share Zambia’s valuable experience, achievements and lessons learnt in establishing and implementing multi-sector programming for stunting reduction.

The National Food and Nutrition Commission is the government statutory body charged with coordinating actions for nutrition and has led the development and implementation of MCDP. Based on global evidence and programming experience in Zambia, the first phase (MCDP I) aimed to scale up 14 priority nutrition-specific and nutrition-sensitive interventions in 14 districts of seven provinces, coordinated across six line ministries. MCDP I was originally planned to run from 2013 to 2016 but, with set-up delays during the first year, it was extended to December 2017.

Unique among the SUN Movement member countries, the donor community in Zambia established an innovative pooled fund mechanism. The success of this funding mechanism has shown that the pooling of funding and resources for nutrition is possible and can work with sufficient commitment, collaboration and support among partners. Critical to the success of this model is having an existing national structure that is mandated to convene across sectors. The right combination of cooperation, commitment and ambition paved the way for other donors to see its value, come on board and unify efforts in support of one overarching government programme. The existing strong working relationship between the government and cooperating partners was also noted to be a key enabling factor.

Phase 1 of the programme was not without its challenges: there were heavy demands on fund management and the technical assistance role did not therefore receive the required attention as both aspects were managed by one organisation. The slow disbursement of funds through multiple district line ministries also hampered delivery. Whilst funding through government systems undoubtedly increases ownership and strengthens capacity, the delays in fund disbursement in Phase 1 diminished programme impact. Technical, financial and administrative capacity constraints at all levels hindered implementation, alongside gaps in vertical and horizontal communication and coordination. The full package of 14 priority interventions proved challenging to implement in the Zambia context as demonstrated by the variable coverage across districts and low convergence achieved at the household level. Weaknesses in routine monitoring and evaluation (M&E) limited the ability of the programme to generate evidence and demonstrate effectiveness.

Following an interim phase, the follow on five-year stunting reduction programme, MCDP II, was launched by the government in 2018 and plans to run until 2023. It has been based on lessons learnt from MCDP I and updated with national and global evidence. Key features of MCDP II that incorporated lessons learnt from the first phase include a simplified package of high impact, multi-sector interventions converging at household level, greater investment in a robust M&E component, greater concentration of effort at district level including increased capacity building, financial and technical support and increased engagement at community level. Furthermore, sustained advocacy at national level attracted additional donors and the second phase is now the largest multi-sector and multi-donor funded programme in Zambia. A key success of MCDP II was the alignment of all partners behind a common set of agreed core elements and principles of cooperation and collaboration. This was, and continues to be, a major achievement considering the number of partners involved, each with their own domestic priorities and policies to fulfill.

Zambia’s experience highlights how multi-sector programming is challenging, complex and takes time to implement and effect change. Investment at the lowest level of decentralisation is critical. Strong district level nutrition coordination mechanisms were key to the success of the programme, in particular the key role of district nutrition coordinators. As well as being based on global evidence, the intervention package needs to be both tailored and context specific to avoid being overambitious. A greater focus on nutrition-sensitive approaches and achieving good coverage and convergence of interventions at household level may increase impact. A robust community-level approach is required for effective sensitisation and behaviour change communication.

In terms of capacity, nationally resourced degree courses are beginning to address the gap in local nutrition expertise. Further investment is needed to address the considerable remaining capacity constraints in technical, coordination and financial management aspects, particularly at district level. Furthermore, demonstrating evidence of what works is critical. A comprehensive and robust M&E framework is essential to routinely measure impact, coverage and convergence of multi-sector actions at household level and to generate ongoing evidence that can be translated into action. Robust evidence supported by sustained and consistent advocacy during MCDP I and widespread increased awareness of the importance of nutrition was achieved. However, despite strong advocacy efforts from both cooperating partners and civil society, domestic allocations for nutrition remain limited in the difficult fiscal space that Zambia is currently experiencing. The challenge remains to match technical commitment from the government with stronger political and financial commitments to ensure the sustainability of the programme and its achievements to date.

The important role of civil society needs greater recognition. The Civil Society Scaling up Nutrition Alliance in Zambia considerably strengthened the awareness of stunting and support for SUN efforts across political, policy and public realms. It achieved this through engaging with government officials, parliamentarians, policy makers and the media. Adequate funding of civil society and structures that support the coordination and mobilisation of civil society actors is needed to build capacity at grassroots level and to ensure accountability systems are in place.

Finally, people and personalities matter. The programme hinged around the vision of a few key individuals who understood the potential and were able to not only be innovative but to translate their vision into programme conception. For multi-sector programming, these qualities are critically important and need to be matched with strong convenors and willingness from governments to drive forwards and effect change.