A qualitative study of Suaahara II influence on nutrition governance in Nepal.

Maternal and child undernutrition remain major public health problems in Nepal. Suaahara is a USAID-funded multi-sectoral nutrition programme aiming to strengthen local nutrition governance to reduce maternal and child undernutrition, among other objectives. The purpose of this study is to present findings from a recent qualitative evaluation of Suaahara II's influence on the decentralised implementation of Nepal's Multi-sectoral Nutrition Plan (MSNP) and identifying gaps and areas for improvement at the federal, provincial, and local levels to strengthen nutrition governance. This study employed multiple qualitative methods, engaging over 100 multi-sectoral nutrition stakeholders across three levels of government and eight districts. Thematic qualitative analysis was employed to identify emergent and salient themes, which were triangulated with other secondary data sources. Suaahara II had a positive influence on strengthening horizontal coordination for implementing the MSNP and effectively leveraged existing networks to strengthen implementation of nutrition-focused activities at the municipal level. Although there was an observable increased demand for nutrition budgets attributable to Suaahara II activities, sufficient allocation and utilisation, particularly in non-health sectors, did not meet these levels. Nepal's shift to federalism hindered vertical coordination of MSNP implementation. Some formal coordination mechanisms were strengthened, but variation in their effectiveness to strengthen horizontal and vertical coordination to implement MSNP activities continues. Finally, limited government ownership over nutrition activities and facilitating multi-sector coordination to implement the MSNP threatened sustainability of Suaahara II's outcomes on nutrition governance. Future programmes should continue to build on the progress made under Suaahara II, and specifically aim to address challenges in vertical coordination to strengthen nutrition governance in Nepal.

Understanding differential reductions in undernutrition among districts in Rwanda through the perspectives of mid-level and community actors on policy commitment and policy coherence.

Understanding the drivers of improvements in child undernutrition at only the national level can mask subnational differences. This paper aimed to understand the contributions of factors in the enabling environment to observed differences in stunting reduction between districts in Rwanda. In 2017, we conducted 58 semi-structured interviews with mid-level actors (n = 38) and frontline workers (n = 20) implementing Rwanda's multi-sectoral nutrition policy in five districts in which stunting decreased (reduced districts) and five where it increased or stagnated (non-reduced districts) based on Rwanda's 2010 and 2014/15 Demographic and Health Surveys. Mid-level actors are government officials and service providers at the subnational level who represent the frontline of government policy. Interviews focused on political commitment to and policy coherence in nutrition, and contributors to nutrition changes. Responses were coded to capture themes on the changes and challenges of these topics and compared between reduced and non-reduced districts. Descriptive statistics described district characteristics. Political commitment to nutrition was high in both reduced and non-reduced districts. Respondents from reduced districts were more likely to define commitment to nutrition as an optimal implementation of policy, whereas those from non-reduced districts focused more on financial commitment. Regarding coherence, respondents from reduced compared to non-reduced districts were more likely to report the optimal implementation of multi-sectoral nutrition planning meetings, using data to assess plans and progress in nutrition outcomes and integration of nutrition into the agriculture sector. In contrast, respondents from non-reduced districts more often reported challenges in their relationships with national-level stakeholders and nutrition and/or monitoring and evaluation capacities. Enhancing the integration of nutrition in different sectors and improving mid-level actors' capacity to plan and advocate for nutrition programming may contribute to reductions in stunting.

Utilising emerging perspectives at the global and regional level to frame multisectoral nutrition governance landscape in Kenya.

OBJECTIVE: Multisectoral nutrition governance (MNG) is a vital enabling determinant of improved nutrition outcomes. Despite this, it remains to be a complex phenomenon that lacks adequate understanding, especially in developing countries like Kenya. This narrative review aims to discuss the evolution of MNG, the current state of MNG, barriers and challenges, and based on these identify entry points for improvement within the complex governance structure in Kenya. DESIGN: The Peer Review of Electronic Search Strategies (PRESS) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to ensure rigorous and transparent identification of literature and interpretation. SETTING: Kenya and developing countries with similar contexts. PARTICIPANTS: The review included forty-five documents (peer-reviewed articles and grey literature) that reported on MNG in developing countries. RESULTS: We acknowledge that MNG is a complex and evolving determinant of better nutrition outcomes. The paper highlights challenges Kenya and other developing countries face such as inadequate leadership, inadequate coordination, insufficient capacity, inadequate monitoring and evaluation systems, and limited financial resources, among others. For Kenya in particular, there is inadequate understanding of what MNG is and how it can be effectively operationalised and tracked. CONCLUSIONS: To enhance understanding of MNG in Kenya, a country-specific assessment of MNG processes and impact outcomes using standard tools and defined metrics is vital. Such assessment will generate evidence of progress, successes, and challenges that will compel the government and stakeholders to invest more in multisectoral nutrition approaches to achieve its nutrition goals.

Nutrition in Nepal: Three decades of commitment to children and women.

South Asia has made significant progress in reducing child undernutrition. The prevalence of stunting declined by one third between 2000 and 2019; as a result, in 2019, there were 34 million fewer stunted children than in 2000, indicating that progress for child nutrition is possible and is happening at scale. However, no country in South Asia is on track for all nutrition targets of Sustainable Development Goal 2, and the region has the highest prevalence of stunting (33.2%) and wasting (14.8%) in the world. Nepal, the best performing country in the region, narrowly missed the Millennium Development Goal (MDG) target to half the prevalence of child underweight between 1990 and 2015 and achieved the fastest recorded reduction in stunting prevalence in the world between 2001 and 2011. In 2019, UNICEF Nepal completed a series of papers to examine Nepal's progress on maternal and child nutrition during the MDG era. The series explores the trends, distribution and disparities in stunting, micronutrient deficiencies and feeding practices in children under 5 years and anaemia in adolescents and women. Besides, it reviews national micronutrient programmes (vitamin A supplementation, iron and folic acid supplementation and universal salt iodization) and Nepal's first Multi-Sector Nutrition Plan, to illuminate the success factors and enduring challenges in the policy and programme landscape for nutrition. This overview paper summarizes the evidence from these analyses and examines the implications for the direction of future advocacy, policy and programme actions to improve maternal and child nutrition in Nepal and other similar contexts.

Measuring Governance: Developing a Novel Metric for Assessing Whether Policy Environments are Conducive for the Development and Implementation of Nutrition Interventions in Nepal.

BACKGROUND: The Nutrition Governance Index (NGI) defines a first standardized approach to quantifying the 'quality of governance' in relation to national plans of action to accelerate improvements in nutrition. It was created in response to growing demand for evidence-based measures that reveal opportunities and challenges as nutrition-related policies on paper are translated into outcomes on the ground. Numerous past efforts to measure 'governance,' most notably World Health Organization's (WHO's) NGI and the separate Hunger and Nutrition Commitment Index (HANCI), both of which lack granularity below the national level and each of which fails to capture pinch points related to necessary cross-sectoral actions. This paper addresses such caveats by introducing an innovative metric to assess self-reported practices of, and perceptions held by, administration officials tasked with implementing government policy at the sub-national level. The paper discusses the development of this metric, its methodology, and explores its application in the context of Nepal. METHODS: Conducted as part of a nationally representative longitudinal survey across 21 of Nepal's 75 districts, the substudy??? on which this paper is based used data from 520 government and non-government officials at different geographic and administrative tiers of authority. Using robust statistical techniques, structured questionnaire data were condensed into a score using a scale from 0 to 100. RESULTS: Six domains were identified through the analysis: Understanding Nutrition and related responsibilities; Collaboration; Financial Resources; Nutrition Leadership, Capacity, and Support. About half of all health sector representatives achieved a high score (>3 on 5-point scale) compared to representatives in other sectors of government activity (such as agriculture or education) (χ2=12.99, P<.003). The health sector also showed the most improvement in mean NGI score over a two-year follow-up period. CONCLUSION: This paper shows that self-reported perceptions and behaviors of those responsible for policy implementation can be usefully quantified. The NGI can be used to assess countries' readiness for the application of nutrition policies.

Star Trek Offers Insights That Illuminate Actor Engagement in Global Nutrition Governance Comment on "Towards Preventing and Managing Conflict of Interest in Nutrition Policy? An Analysis of Submissions to a Consultation on a Draft WHO Tool".

This commentary describes insights from Star Trek's fictional television series to understand how state and non-state actors address conflicts of interest (COIs) through global nutrition governance. I examine the findings of Ralston and colleagues for 44 state and non-state actors who responded to the World Health Organization's (WHO's) consultation for a COI risk-assessment tool, developed for member states to engage effectively with non-state actors to address malnutrition in all forms. Star Trek reveals that actor engagement is inevitable in a shared universe. The Prime Directive is a non-interference principle reflecting a moral commitment to reduce harm, respect autonomy and protect rights. Engagement principles are relevant to all actors who influence nutrition policies and programs, and must be held accountable when their actions undermine healthy and sustainable food systems. Certain actors use COI to justify non-engagement with commercial actors yet competing interests, biases, corruption and regulatory capture are distinct challenges to manage. Finally, Star Trek's characters serve as allegories to understand actors' motives and actions to promote healthy and sustainable food systems. Unlike non-state actors, states are legally required to achieve their commitments and targets in the United Nations' (UN) Decade of Action on Nutrition (2016-2025) and Sustainable Development Goals (SDGs) 2030 Agenda.

Effective nutrition governance is correlated with better nutrition outcomes in Nepal.

BACKGROUND: The public health burden of undernutrition remains heavy and widespread, especially in low-income countries like Nepal. While predictors of undernutrition are well documented, few studies have examined the effects of political will and quality of policy or program implementation on child growth. METHODS: Data were collected from two nationwide studies in Nepal to determine the relationship between a metric of nutrition 'governance' (the Nutrition Governance Index), derived from interviews with 520 government and non-government officials responsible for policy implementation and anthropometry measured for 6815 children in 5556 households. We employed Generalized Estimating Equation (GEE) and multilevel regression models. RESULTS: A higher NGI (more effective nutrition governance) is positively associated with height-for-age as well as weight-for-height in children over 2 years of age compared to younger children (HAZ; ß = 0.02, p < 0.004, WHZ; ß = 0.01, p < 0.37). Results from the hierarchical model show that a one-point increase in the NGI is significantly associated with a 12% increase in HAZ and a 4% increase in WHZ in older children (> 24 months old). Mothers' education, child's age, BMI and no fever in the past 30 days were also protective of stunting and wasting. Seven percent and 17% of the overall variance in HAZ and WHZ, respectively, are accounted for by variations across the 21 district locations in which sampled households were located. Mean HAZ differs considerably across districts (intercept = 0.116, p < 0.001). CONCLUSIONS: These results highlight the importance of effective management of policy-based programming and resource use to bring about nutrition gains on the ground. The NGI explained a non-negligible amount of variation in HAZ and WHZ, which underscores the fundamental role that good governance plays in promoting child nutrition and growth, and the value of seeking to measure it to assist governments in moving policies from paper to practice.

UN Food System Summit Fails to Address Real Healthy and Sustainable Diets Challenges.

Evidence of the impacts of corporate food systems on people's health raised concerns about the multiple outcomes of malnutrition and climate change, including commodities production and high consumption of ultra-processed food products. The COVID-19 pandemic overwhelms this scenario, highlighting the urgency for improvements in governance spaces and regulatory measures that can tackle the advance of large corporations, which act exclusively based on their private interests.

What Is the Role of Civil Society in Multisectoral Nutrition Governance Systems? A Multicountry Review.

BACKGROUND: Solutions to create enabling nutrition environments must come from within communities and involve multiple sectors. As vital actors in community mobilization, rights-based advocacy, and accountable public institutions, civil society organizations (CSOs) can help ensure nutrition programs and policies represent and reach all community members to achieve impact. OBJECTIVES: To review attributes of civic engagement in multisectoral nutrition governance systems and to provide recommendations to increase CSO participation. METHODS: We reviewed 7 national case studies of Civil Society Networks involved with the Scaling Up Nutrition movement and characterized 6 functional attributes of CSOs in multisectoral nutrition governance: identify needs of all community members, mobilize and build civic capacity, advocate for political commitments, inform program design and evaluation, ensure accountability mechanisms in public institutions, and report challenges and successes using broad media campaigns. RESULTS: All studies described government agencies involved with multisectoral nutrition governance systems, at national and subnational levels; however, there was limited evidence of subnational platforms for CSO engagement. Although countries increased investments in public institutions for nutrition, it was unclear whether nutrition service quality improved and none reported corresponding investments in civil society. CONCLUSION: Our characterization identifies strategies to engage CSOs in multisectoral nutrition governance at multiple ecological levels. We hope future adaptation and application of this characterization will increase community ownership and diverse representation in nutrition governance systems. Both of these are key to enabling national and international entities to address malnutrition's underlying determinants in ways that align with local contexts, values, and systems change processes.

Boundary-spanning actors in complex adaptive governance systems: The case of multisectoral nutrition.

A growing literature highlights complexity of policy implementation and governance in global health and argues that the processes and outcomes of policies could be improved by explicitly taking this complexity into account. Yet there is a paucity of studies exploring how this can be achieved in everyday practice. This study documents the strategies, tactics, and challenges of boundary-spanning actors working in 4 Sub-Saharan Africa countries who supported the implementation of multisectoral nutrition as part of the African Nutrition Security Partnership in Burkina Faso, Mali, Ethiopia, and Uganda. Three action researchers were posted to these countries during the final 2 years of the project to help the government and its partners implement multisectoral nutrition and document the lessons. Prospective data were collected through participant observation, end-line semistructured interviews, and document analysis. All 4 countries made significant progress despite a wide range of challenges at the individual, organizational, and system levels. The boundary-spanning actors and their collaborators deployed a wide range of strategies but faced significant challenges in playing these unconventional roles. The study concludes that, under the right conditions, intentional boundary spanning can be a feasible and acceptable practice within a multisectoral, complex adaptive system in low- and middle-income countries.

The political process in global health and nutrition governance: the G8's 2010 Muskoka Initiative on Maternal, Child, and Newborn Health.

Why do informal, plurilateral summit institutions such as the Group of Eight (G8) major market democracies succeed in advancing costly public health priorities such as maternal, newborn, and child health (MNCH), even when the formal, multilateral United Nations (UN) system fails to meet such goals, when G8 governments afflicted by recession, deficit, and debt seek to cut expenditures, and when the private sector is largely uninvolved, despite the growing popularity of public-private partnerships to meet global health and related nutrition, food, and agriculture needs? Guided by the concert-equality model of G8 governance, this case study of the G8's 2010 Muskoka Initiative on MNCH traces the process through which that initiative was planned within Canada, internationally prepared through negotiations with Canada's G8 partners, produced at Muskoka by the leaders in June, multiplied in its results by the UN summit in September, and reinforced by the new accountability mechanism put in place. It finds that the Muskoka summit succeeded in mobilizing major money and momentum for MNCH. This was due to the initiative and influence of children-focused nongovernmental organizations (NGOs), working with committed individuals and agencies within the host Canadian government, as well as supportive public opinion and the help of those in the UN responsible for realizing its Millennium Development Goals. Also relevant were the democratic like-mindedness of G8 leaders and their African partners, the deference of G8 members to the host's priority, and the need of the G8 to demonstrate its relevance through a division of labor between it and the new Group of Twenty summit. This study shows that G8 summits can succeed in advancing key global health issues without a global shock on the same subject to galvanize agreement and action. It suggests that, when committed, focused NGOs and government officials will lead and the private sector will follow, but that there will be a lag in the implementation needed to obtain the intended results. The need to improve the accompanying accountability mechanisms to improve implementation, thus, remains.