Drivers of change in nutrition in Senegal

Drivers of change in nutrition in Senegal:

the critical role of political institutions

Halie Kampman, Amanda Zongrone, Rahul Rawat, and Elodie BecqueyInternational Food Policy Research Institute (IFPRI)

October 23, 2016

MethodsDecomposition Analysis; Policy Reviews; Stakeholder Interviews

POLICIES

• Letter of Nutrition Policy (2001) / National Nutrition Policy (2015)

•National Plan for Local Development (2006)

• Strategic Document for the Reduction of Poverty II (2006-2010)

•National Policy for Integrated Early Childhood Development (2007)

•National Plan for Child Survival (2007-2015)

•National Health Development Plan (2009-2018)

•National Agricultural Investment Program (2011-2015)

• The National Strategy for Economic Development (2013-2017)

• Plan for an Emergent Senegal (2014-2035)

• Policy Document of Health/Nutrition/Environment in the Education System (2015)

STAKEHOLDER INTERVIEWS

National Stakeholder Interviews with 4 different sectors (Government, CSOs, UN, Academia)

• Ministry of Education

• Ministry of Health

• Ministry of Agriculture

• Ministry of Women, Family and Childhood: National Agency for Early Childhood

• National Program of Local Development

• Ministry of Finance: Planning

Community Interviews (FLWs, mothers)

Analysis (3C Framework) COMMITMENT COHERENCE COMMUNITY

1. How has understanding about the nature of nutrition issues changed?

2. What have been the major changes in the political context around nutrition?

3. Across sectors what kinds of changes can we see in policies related to nutrition?

1. How is institutional coherence established, and how has it changed?

2. What changes can we see regarding horizontal coherence (between and across sectors)?

3. What changes can we see regarding vertical coherence (from policy to community level implementation)?

1. What changes can we see in nutrition service delivery at the community level?

2. What are the changes regarding human resources, and how do these changes affect service delivery?

3. What motivates FLWs, and how have changes in these motivating factors affected service delivery?

4. How do FLWs contribute to changes in knowledge and awareness of nutrition, and how does this affect service delivery?

RESULTS: Decomposition Analysis• Change in stunting

prevalence from 33% (1993) to 19% (2014)

• The model explains approximately half of the actual change in HAZs observed over this period.

• Among the sources of predicted change, wealth accumulation is the dominant factor, followed by healthcare and parental education.

Mother's education (6%) Husband's education (1%)

Asset index (24%)

4 or more antenatal visits

(8%)

Born in a medical facility (6%)Birth interval (2%)

Unexplained (53%)

Data source: DHS data 1993-2014

RESULTS: Commitment

• End of the PNC (1994-2001); recognizing that nutrition needs “a home”

• Creation of the CLM in 2001 housed in the PMO

• Moving from PNC to the PRN (2002-2016)

Political Context

• Nutrition Policy

• Letter of Nutrition Policy (2001-2014) to the National Nutrition Development Policy (2015-2025)

• Increased presence of nutrition in policy documents (Health, Education, and Agriculture)

Policy Changes

RESULTS: Coherence

• Stakeholders from multiple sectors agreed that the CLM introduces a platform for institutional coordination at a new level: one which is about relationship building

Institutional

• Increased awareness across the sectors for the need for horizontal coordination

• CLM focal points from each sector

Horizontal

(between sectors)

• Increased engagement and flow of information between policymakers and technical agencies, and communities

Vertical

(policy to community)

RESULTS: Community, FLW perceptionsHuman resources: The PRN has substantially increased the network of

volunteer health and development agents (relays) at the community level through its broad network of implementers

Motivation: Many relays are strongly motivated by their ability to play a new role as community health agents. Financial considerations are the biggest hurdle to FLW motivation and is cited cited as the biggest risk regarding long term sustainability.

Knowledge and awareness: Increased community awareness of nutrition services and knowledge were attributed to the PRN

CHALLENGES1. Fragility of leadership and sustaining nutrition champions

2. CLM’s authority to enforce coordination

3. Multi-sectoral coordination• Budget line items for nutrition• Lack of clear nutrition objectives• Lack of specificity around indicators and measurement.

4. PRN sustainability at community level through dependency on a broad network of community implementers.

5. Lack of costing to scale up nutrition specific interventions

KEY MESSAGES

Government ownership of nutrition is evident, with strong political commitment

This commitment has translated into inclusion of nutrition in policies across several sectors

The CLM plays a critical role as the anchor for nutrition and facilitator pf community reach for nutrition through the PRN—there are sustainability questions at community level

To realize further impact, Senegal needs to cost out the scale up of nutrition specific interventions

1

2

3

4

ConclusionCommitment

Understanding: Stakeholders feel that there is more awareness about the way that nutrition touches upon multiple sectors. However, nutrition remains “homeless” and difficult to take ownership of.

Political context: The founding of the CLM allowed for a new platform for commitment, and the change from the PNC to PRN invited new multi-sectoral engagement. This multi-sectoral team can be difficult to responsible-ize, and is dependent on the maintenance of a certain level of leadership and trust

Policies: We see renewed engagement of health, education, sectors, and to some extent agriculture. However, across the board there are often a lack of indicators and budget for nutrition, and often a conflict of interest with other priorities.

ConclusionCoherence

Institutional coherence: strengthened through the CLM, which brings coordination to a new level building collaborative relationships between actors. CLM does not have the authority to enforce cooperation: the future of this institutional coherence rests to a certain extent upon the willingness of actors.

Horizontal coherence: has the potential to become stronger, as the different sectors are aware of the need. However many sectors are held back because a lack of internal initiative, connected to the absence of a real nutrition budget.

Vertical coherence: increased flow of information both “up” and “down” between experts/policy makers actors and the community. However, many local governments still don’t have a clear vision of the problematic of nutrition, and some claim there is a disconnect between experts and the communities they serve.

CommitmentChanges in political context

CHANGES

•The end of the PNC, and the recognition that nutrition needs “a home”

•Creation of the CLM in 2001 housed in the prime ministers office: high level of political priority, new opportunity for the nutrition community to grow

•Moving from PNC (1995-2001) to PRN (2002-2016) opened a window for a change in both leadership and policy• PRN had a “home” within an institution, the CLM (unlike

PNC)

• The PRN anchored the community approach

• Coordinating body, platform, team of leaders with a common vision, multi-sectoral team

CHALLENGES

•Some stakeholders felt there was an initial fragility of new structure and and dependency on the right mix of leadership and trust

•Multi sectoral team can be difficult to responsible-ize

“Change is about people. It’s about men, and not men as a gender but change is about how we relate to each other…If there is not that trust then change cannot happen. What happened to nutrition here, has been big changes, so what you can be sure of is that there has been trust at lots of different levels ” (Respondent from an IO)

Data source: national stakeholder interviews

CommitmentPolicy changes

CHANGES

•Nutrition Policy• Letter of Nutrition Policy to the National Nutrition Policy

• A greater emphasis on multi-sectoral collaboration

• A participatory process

•Increased presence of nutrition in policy documents (Health, Education, and Agriculture)

• Increased mention of nutrition

• Involvement of CLM

CHALLENGES

•Lack of standardized indicators

•Lack of specified budget for nutrition

•Competing priorities

Data source: national stakeholder interviews, policy review

RESULTS: Coherence

• Stakeholders from multiple sectors agreed that the CLM introduces a platform for institutional coordination at a new level: one which is about relationship building

Institutional


• CLM focal points from each sector

Horizontal

(between sectors)

• increased engagement and flow of information between policymakers and experts, and communities

Vertical

(policy to community)

CoherenceInstitutional

CHANGE

•Stakeholders from multiple sectors agreed that the CLM introduces a platform for institutional coordination at a new level: one which is about relationship building

“It’s the conductor of the orchestra who we need to identify, give him appropriate ‘arms’, instruments, so that he can organize this whole symphony in a manner that there is not any dissonance .” (Respondent from an IO, speaking about the CLM)

“...there can be links, but really we are not working on the links. Its the glue, the cement, that we need to put between the bricks. It’s that we are looking for at the CLM .” (Respondent from the government)

CHALLENGES

•The CLM as a coordinating body does not have the authority to enforce coordination


CoherenceHorizontal (between sectors)

CHANGE


•CLM focal points from each sector

•“I think that sectors are more aware of the fact that there are transformations happening…two years ago I sat with a multi-sectoral group and I said to agriculture, you must include nutrition indicators. They said no that’s not our affair. But now when you talk to agriculture, they say, can you help us to integrate nutrition in our affairs.”

(Respondent from the government, agriculture sector)

CHALLENGES

•Some sectors show lack of initiative, often based on the lack of budget to integrate nutrition

“We cannot impose plans of action without the financial means to follow...People tell us we need a plan of action… unfortunately there are no means ”

(Respondent from government, agriculture sector)


CoherenceVertical (policy to community implementation)

CHANGE

•There is increased engagement and flow of information between policymakers and experts, and communities• Bottom up: Since 1994 decentralization,

increased power in hands of community defining their own needs, increased influence from bottom up

• Top down: Growth of nutrition community, and highly specialized nutritionists

CHALLENGES

•Despite flows of information, actors felt that many local governments don’t have a clear vision nutrition, so they don’t take ownership

•Some actors feel there can be a disconnect between “esoteric” experts and policy makers and communities they serve

“...local governments...they don’t have a clear vision of the problematic of nutrition, they don’t have just one priority.” (Respondent from an NGO, representing civil society)

“...from my point of view, nutritionists, not to throw a stone, they consider nutrition as an esoteric science.”(Respondent from the government, agriculture sector)
