What Drives Nutrition Policy Reform in Africa?

Findings of a Three-Country Case Study Comparison

Malawi, South Africa, and Zambia

Sheryl Hendriks

Slow Progress but Way Off Targetfor Some Micronutrients

• Iodine fortification: Same solution but different timing and impact

• Addressing Vitamin A deficiencies: Different vehicles and differing outcomes

• Iron: What is the sticking point?

• Multi-mixes in fortification: Complex decisions

Nutrition Re-emerges on Policy Agendas

(1) A relevant problem in all 3 countries, but real action after 1990

(2) International focusing events played a major role in initiating change with supporting evidence, ready solutions, targets, and binding agreements focusing on rights

(3) Supported by powerful advocates and coalitions– both international and local

Consideration of Design Modalities

(4) International best practice informed and shaped policies but not always interpreted in the same way

(5) A few incidences of ideas, ideologies, and beliefs

(6) Cost-benefit was a deciding factor in choice of fortification vehicle, but not a major constraint.

• Costs shifted to private sector

• Coverage is more important with supplementation programmes

Transforming Proposals into Adopted Policies

(7) Powerful opponents - especially from private companies and millers

(8) Implementing veto players played a role in fortification programmes –presidents, private sector, and health professionals

(9) Propitious timing played a role in South Africa as well as with regular UN reporting cycles on children’s rights

Ensuring Implementation on the Ground

(10) Budgets typically came from donors initially and support continues in various ways but fortification costs transferred to the private sector

(11) Institutional capacity is a major constraint for supplementation rolled out through health systems; private-sector fortification compliance; and coverage

(12) Implementation veto players are essential due to high levels of coordination among multiple stakeholders

(13) The commitment of policy champions is not strong in this phase

Evaluating, Reconsidering, and Reforming

(14) Constantly changing information and beliefs trigger the need for review and revision of policies

(15) Changing material conditions do not really affect private-sector fortification programmes, but are a problem with supplementation

(16) Institutional shifts seldom influence micronutrient policies

Conclusions and Recommendations

• Except for iodine, suboptimal progress in addressing micronutrient deficiencies.

• The Kaleidoscope Model was useful in identifying the drivers of and constraints on change in micronutrient policies in the developing world.

• Common drivers included– the global knowledge base;

– call for action and international targets;

– national leadership; and

– the champions and support of the development partners.

• Differences were seen in – the level of engagement with various stakeholders;

– design and funding considerations;

– the institutional and regulatory infrastructure; and

– long-term investment in sustainable solutions.

We wish to acknowledge the co-authors of the six initial

field studies:

Suresh Babu, Nicolette Hall, Jody Harris, Nicole Mason, Elizabeth

Mkandawire, David Mather, Stephen Morgan, Flora Nankhuni, David

Ndyetabula, Dorothy Nthani, Nic JJ Olivier, Nico JJ Olivier, Phillip

Randall and Hettie C Schönfeldt.

For More Information, Please Visit

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