Toward Shared Goals: Building Multi-Sectoral Coordination for Nutrition in Uganda and Nepal

This brief is part a series of "interim" technical briefs, culminating in a final two-year study report in 2016. In this technical brief, we review some of the global guidance countries can refer to for building sustainable, predictable funding mechanisms for nutrition and share some of what we have found thus far on current capacities and systems strengthening efforts for nutrition financing in the two case study countries.

This brief is part of the Pathways to Better Nutrition (PBN) case study series.

Background

"No single organization, no single government can act alone to achieve the goal of ending hunger and global malnutrition. Working together, we have the ability to establish powerful partnerships that change the global landscape, from one of hunger to one of hope, country-by-country, community-by-community, family-by-family and child-by-child; until no one goes hungry." – Ertharin Cousin, World Food Programme Executive Director and Scaling Up Nutrition (SUN) Lead Group (SUN 2014)

Coordination of nutrition planning, funding and implementation across sectors, stakeholders, and government levels is critical to the scaling up of nutrition programs and impacts. In identifying a multi-sectoral approach as a key principle for improving nutrition outcomes, the SUN Movement has been pivotal in advocating for the importance of multi-sectoral coordination (Alderman et al. 2013). However, multi-sectoral coordination for nutrition is also very challenging as it involves multiple sectors and partners that have different approaches, visions, and understandings of the problem (Garrett, Bassett, and Levinson 2011). It is difficult to influence and sustain nutrition-based mandates across line ministries whose performances are evaluated on non-nutrition oriented activities (Levinson, Balarajan, and Marini 2013).

Uganda and Nepal are both global success stories in developing political commitment for nutrition. As SUN countries, both countries have created multi-sectoral plans to carry out this commitment, and have mobilized support for effective joint action at scale. Both countries have also developed multi-sectoral coordination mechanisms to manage stakeholders and have worked to overcome the challenges that this entails. Over the course of two years, the Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project analyzed stakeholder perspectives in these two countries, and identified recommendations for improving the coordination mechanisms in the next phases of the Nepal Multi-sector Nutrition Plan (MSNP) and the Uganda Nutrition Action Plan (UNAP). The recommendations shared in this brief can also be helpful to other countries planning and implementing their own national nutrition action plans (NNAPs).

The PBN Case Studies

Between 2013 and 2016, SPRING collected data prospectively in two countries—Uganda and Nepal—to document the decision-making process for prioritizing and funding nutrition-relevant activities within the context of their NNAPs. The goal of the "Pathways to Better Nutrition" case studies was to provide insight into how NNAP activities are prioritized across sectors, and how that prioritization affects funds committed. In addition, the case studies have explored the drivers of change in prioritization and funding. Coordination is a key driver of change.

Methods Summary

These case studies took a mixed method, prospective, multi-level approach to document the process of NNAP rollout at the national level and in a few selected districts in two countries:

• Nepal PBN Study: 2014 – 2016
• Uganda PBN Study: 2013 – 2015

These countries were selected through a rigorous "most different" case selection methodology (Seawright and Gerring 2008) to represent countries of different contexts that have similar nutrition goals. Uganda and Nepal represent countries actively rolling out multi-sectoral NNAPs and which have shown above average performance both on the WHO nutrition governance indicators and on reduction of stunting in the last 10 years.

The qualitative data presented in this report were collected over the course of two years through

• rolling key informant interviews (KIIs) across six stakeholder groups
• news content from major news outlets in each country
• notes from NNAP-related meetings among different stakeholder groups.

These data provided insights into key events, successes, and barriers related to the coordination of planned activities. Further information on the PBN study methodology and final reports from both case studies can be found at: www.spring-nutrition.org/pbn. This particular brief also draws from the global literature on multi-sectoral coordination for nutrition.

Global Understanding of Multi-Sectoral Coordination for Nutrition

A multi-sectoral approach to nutrition – one that systematically and comprehensively engages multiple ministries, departments, and agencies in addition to other stakeholders (e.g., donors, civil society organizations (CSOs), nongovernmental organizations (NGOs), academia, development partners and the private sector) – is often seen as best practice. A number of international agencies have initiated global efforts to implement and scale up multi-sectoral programs and policies, including the United States Agency for International Development (USAID) Feed the Future Initiative, the World Bank Secure Nutrition platform, the United Nations-REACH partnership, and the SUN Movement. The SUN Movement, which has been endorsed by 57 countries and a range of key stakeholders, asks countries to commit to multi-stakeholder partnerships, and encourages and supports countries in the development of NNAPs and policies (SUN 2015). There is no prescribed approach to bring people together in multi-stakeholder partnerships (SUN 2014) and evidence of the effectiveness of such partnerships is currently limited.

Poor coordination and collaboration¹ across sectors has been cited as one of several reasons why multi-sectoral nutrition efforts have failed to gain momentum in the past (Levinson, Balarajan, and Marini 2013). Garrett and Natalicchio (2011) define multi-sectoral coordination as a process in which organizations exchange information and alter activities for mutual benefit and to achieve a common purpose. In their book on working multi-sectorally for nutrition, Garrett, Bassett, and Levinson (2011) identified a number of factors that affect coordination, including the internal context, external context, the larger environment, as well as institutional links (see Box 1). Related to the internal context is commitment, which is defined as "the will to act and to keep on acting until the job is done" (Heaver 2005). Heaver explains that commitment requires a better understanding of the causes of malnutrition, the seriousness of the problem, and the role of actors from all sectors in addressing those problems (Heaver 2002).

Coordinating nutrition planning and implementation across sectors and levels – from the community to the national level – is no small task. Each stakeholder group will likely seek to preserve its own autonomy and independence; they may have different visions, goals, routines, procedures, and constituencies; and they may hold uneven organizational capacities and power (Garrett, Bassett, and Levinson 2011). Other challenges to multi-sectoral coordination include a lack of knowledge about the multi-sectoral causes of nutrition, limited staff time, inadequate funding and budgeting structures that dis-incentivize investment in nutrition by multiple sectors (Alderman et al. 2013).

This new wave of NNAPs includes plans and policies in many forms, but they are unified by their commitment to nutrition, the inclusion of two or more sectors, and a coordinating structure or mechanism. Coordinating agencies are meant to serve multiple functions, including coordination of planning and implementation, advocacy, and resource mobilization. However, an evaluation of cross-sectoral national nutrition coordination agencies in Mozambique, Nigeria, and Uganda concluded that these agencies have "proven [to be] of limited value to the malnourished in these countries" primarily because of their "inability to maintain continued political commitment" (Benson 2007). They also may lack sufficient authority over individual government sectors and/or fail to provide incentives to these sectors to carry out nutrition-related activities (Heaver 2002). As Garrett and Natalicchio explain, "An effective coordinating agency cannot merely tell other agencies what to do. Influence over alignment and integration has to come from understanding the perspectives and concerns of the partners and devising incentives for them to cooperate" (2011 p.151).

Coordination of multi-sectoral NNAPs also requires coordinating horizontally among government agencies from different sectors at more or less the same government level, coordinating vertically within government agencies at different levels of administration, as well as coordinating between the public and private sectors. Our findings from Nepal and Uganda are organized in this way.

Multi-Sectoral Coordination of Nutrition Activities in Nepal and Uganda

While the challenges of coordinating are numerous, the data we collected in Nepal and Uganda provide evidence of improvements in coordination structures, factors affecting coordination, and in the coordination of planning and implementation for nutrition. Both the challenges faced and progress made in coordination of nutrition activities are presented below.

 Multi-sectoral is always good to think about but is always challenging to make it happen.
– National government stakeholder, Nepal

Coordinating agencies

The National Nutrition and Food Security Secretariat (NNFSS) of Nepal, within the National Planning Commission (NPC), and the UNAP Secretariat in Uganda, within the Office of the Prime Minister (OPM), serve as central mechanisms for multi-sectoral coordination. They are responsible for supporting both vertical and horizontal coordination of multiple stakeholders to advance nutrition and food security with enhanced linkages to national and local processes.

In both countries, the nutrition secretariat has played a crucial role in facilitating multi-sectoral coordination for the respective NNAPs. Stakeholders reported that coordination at the central level improved during the study period, and many attributed this improvement to the NNAP structures – particularly the placement of the respective secretariats in the NPC in Nepal and the OPM in Uganda, and their efforts to create active coordination platforms across a wide range of stakeholders. It was also noted that, over the course of the study, working groups or technical committees became more active with regular coordination meetings and greater participation of different sectors during meetings. Moreover, there has been greater acceptance of the nutrition secretariats – the NPC in Nepal and OPM in Uganda – as coordinating bodies.

Despite all the improvements, high-level meetings on nutrition, which were initially organized regularly in both countries, became less and less frequent towards the end of the study and stakeholders felt that the nutrition secretariats had not been fully successful in bringing all stakeholders together for NNAP implementation.

 Coordination at the higher level is challenging; high-level nutrition and food security steering committee only meets once or twice or year.
– National academician, Nepal

 There is not a person at the top [within the Office of the Prime Minister] asking for reporting on meeting UNAP objectives/indicators and we want this information to come back to us.
– National government stakeholder, Uganda

Coordination between different sectors and stakeholder groups

Coordination across different sectors (intersectoral), across departments within the same sector (intrasectoral), and between stakeholders groups, presumably at the same level (e.g., national-level stakeholders) is often referred to as horizontal coordination. It involves engagement from high-level officials from all sectors, as well as from parliamentarians and other high-level government officials, so that they recognize their role in improving the nutritional status of women and children in their country through policy change, systems strengthening, and coordination. Stakeholders in both countries deemed horizontal coordination—between departments and ministries—at the national level as one of the greatest challenges. Nonetheless, during our final round of interviews we found that stakeholders from both countries reported improvement in this type of coordination; increased understanding of multi-sectoral approaches to nutrition and the importance of such an approach to combating malnutrition; increased understanding of the purpose and content of their NNAP; and increased understanding of each sector's roles and responsibilities for supporting the NNAP.

In mid-2014, many stakeholders in Nepal indicated that they were used to working in isolation and that, particularly for external development partners (EDPs) and newer government stakeholders, coordination for MSNP was not enough to bring busy people together. In particular, stakeholders highlighted coordination between departments (within the same sector) and inter-ministry coordination as most challenging. Key informants thought that the reduction in high-level meetings on nutrition had a negative influence on coordination, but the majority of those interviewed thought that coordination for MSNP and nutrition had improved. Examples of improvement in coordination during the course of the study including the following:

• By the end of data collection, representatives from the government, donor agencies, and CSOs said that they were working in a coordinated way, especially when finalizing manuals and guidelines related to MSNP. Key informants from the Ministry of Health (MoH) and the Ministry of Agriculture and Development (MoAD) attributed this to the MSNP.
• Government and donor stakeholder groups felt that coordination at the national level had improved over the course of the study, and many attributed this to the MSNP structures, particularly the placement of the NNFSS within the NPC and NNFSS's efforts to create active coordination platforms or working groups across a wide range of stakeholders.
• During the study period, three MSNP working groups for nutrition advocacy and communication, capacity development, and monitoring and evaluation became more active with regular meetings and follow-up activities.

 Those who didn't know about nutrition are now aware of the importance of nutrition. There is awareness among multi-sectoral partners of nutrition.
– National government stakeholder, Nepal

In Uganda, even in the early days of our study, the majority of respondents (with the exception of a few private-sector stakeholders and ministry staff newly appointed at the time of the interview) agreed about the importance of nutrition and understood the objective(s) within the UNAP that they could help address. By the end of the study, this had increased to nearly every stakeholder in every group. Stakeholders interviewed at the end of the study period indicated that there was greater coordination between Ministry of Health (MoH) and Ministry of Agriculture and Animal Industry and Fisheries (MAAIF) because of the UNAP Secretariat. Some of those who said they had a positive change in perception of nutrition within their own sector specifically credited the UNAP for this change. As for the concept of multi-sectoral nutrition, many stakeholders in various ministries (as well as some EDPs) appeared skeptical or confused about how multi-sectoral nutrition would work at the beginning of the study, but by the endline, the majority of sectors spoke more positively of the concept and how they were contributing. Specific examples from key informant interviews and news article analysis of improved coordination during the course of the study include the following:

• By the end of our study, UNAP working groups were more active with regular coordination meetings and there was greater participation of different sectors during the meetings.
• The OPM organized a National Partnership Forum in December 2014, which, while not specific to nutrition, supported alignment of donor and government priorities.

 Now everybody seems to appreciate that nutrition is multi-sectoral problem, it requires calling for the different actors and from what I have seen so far every sector is playing its own role.
– National government stakeholder, Uganda

Coordination within agencies, between the national and district levels and below

Vertical coordination is equally important as horizontal coordination. Vertical coordination refers to coordination between the national, district, and community levels, which all play important but distinct roles in scaling up nutrition programming. However, this can be one of the biggest operational challenges to working multi-sectorally. Ineffective vertical coordination was identified as a key barrier to implementation of nutrition activities proposed in NNAPs. In both Nepal and Uganda, structures had been established for coordination at the district level and below, but many stakeholders felt that these structures remained detached from the national level, particularly within Nepal at the level of the Village Development Committee (VDC).

In Uganda, with no system for monitoring the UNAP in place, no nutrition surveillance, and limited inclusion of nutrition indicators in health management information systems, lower-level data were not reaching the national level to facilitate the provision of feedback on, or support to, implementation of NNAP activities. Stakeholders also voiced concern that district- and state-level coordination committees were weak and highly dependent on the buy-in and leadership of nutrition partners.

 The district level coordinating structures have remained detached from the national level.
– National government stakeholder, Uganda

In Nepal, while district stakeholders generally had a positive view of the District Nutrition Food Security Steering Committee, the VDC Nutrition Food Security Steering Committees were not functioning. This was attributed to human resource issues (too few people who can sit on committees as well as too many committees). Concerns about VDC coordination was echoed by central level stakeholders who also noted that such efforts depend on the commitment and motivation of the VDC secretary. The district and VDC stakeholders also acknowledged that the VDC secretary was overburdened with too many responsibilities for too many programs.

 ...we haven't been able to call the meeting after forming the committee. There is a problem giving time for this. There are no elected representatives so there are a lot of daily tasks that fall on me...
– VDC government stakeholder, Nepal

Coordination between the public and private, nongovernmental sectors

The private sector, nongovernmental sector, and academia also play an important role in improving nutrition. The SUN movement includes the private sector as a key actor and also heavily emphasizes private sector engagement to improve nutrition at scale. Indeed, both the UNAP and MSNP indicate an intention to engage the private sector for nutrition work. At the start of the study period, private sector organizations were not aware of coordination activities and did not understand their specific roles with respect to the NNAPs. While we did see an increase in private sector organizations' interest in nutrition and the NNAPs in both countries, this had not yet translated into increased engagement.

In Nepal, the NNFSS supports the NPC, and has helped develop platforms for convening representatives from government, donor agencies, and CSOs; it also plans to include academia and the private sector in the future. However, key informants from private sector organizations in Nepal felt that they needed to have a nutrition focal person dedicated to coordinating private sector actions and meetings with private sector representatives. During the course of the study, NNFSS helped develop terms of reference for each stakeholder group and, by the end of our study, several groups specifically credited the NNFSS with improving their understanding of the MSNP and their roles. However, key informants remained concerned with the lack of engagement of academia and the private sector, which they felt had remained relatively unchanged over the course of the study.

 Government has not been able to engage private sector for MSNP.
– National private sector stakeholder, Nepal

In Uganda, key informants rarely mentioned the influence of academia in relation to their coordination activities. While the few who spoke about academia acknowledged that they were well positioned to provide research and an evaluation of UNAP activities—as well as technical advice to OPM—we found no active nutrition projects or activities directly linked to UNAP in which academia was engaged. Partnerships between the public and private sectors do exist, but operate outside the UNAP system. With regard to CSO engagement in the UNAP, by the end of the study period, external partners were in discussions with the Uganda Civil Society Coalition to plan for the next three years.

Recommendations

We elicited the following recommendations from our key informants, who came from a wide range of stakeholder groups:

1. Revitalize the high-level nutrition and food security committees to help advocate for, and give ownership to, NNAP efforts. High-level coordination is critical to the scaling up of nutrition activities – educating parliamentarians, lawmakers, and other high-level leaders about the importance of nutrition, engaging them, and creating momentum for nutrition work among officials from every sector. Regular coordination meetings should be one of the prime agenda items for NNAPs.

 Coordination will be easy if joint secretaries of all ministries are assigned for coordination – everyone will listen to what the concerned ministry's joint secretary is saying and there will be chain effect till the lower level.
– National government stakeholder, Nepal

 There is a need for a high-level champion for nutrition in Parliament or at the cabinet level.
– National government stakeholder, Uganda

2. Facilitate horizontal coordination through strategic collaboration with sectors at the time of planning. There have been a lot of improvements in horizontal coordination between multiple sectors for NNAPs and nutrition; however, coordination will not be effective unless multiple sectors plan together or are at least aware of one another's plans. Several government stakeholders in both countries emphasized the need for joint planning, budgeting, and collaboration among sectors, departments within a sector, and nongovernmental partners to synchronize resources for nutrition.

 Discussions during planning are limited to whether the budget ceiling should be increased/ decreased instead of the importance and usefulness of the program.
– National government stakeholder, Nepal

 [The Office of the Prime Minister and the National Planning Authority] can form a more strategic collaboration to work with the sectors at the time of planning, to put key items about nutrition in the plan then defend the items. There are several mechanisms and critical points that nutrition can be defended in the budget process.
– National government stakeholder, Uganda

 MSNP is a multi-sectoral plan that involves the involvement of multiple sectors; therefore NPC should allot special time to bring in all the different concerned ministries together to discuss how to fulfill the gaps. […] There should be extensive discussions for need identification and resource allocation.
– National government stakeholder, Nepal

3. Improve vertical coordination between national and subnational coordination structures. Noting significant challenges in coordinating between levels, stakeholders in Uganda suggested coordinated monitoring and reporting of UNAP targets at the highest level. Several stakeholders in Uganda and Nepal suggested that the ministries, departments and other partners at the national level must have a systematic and effective mechanism to connect the district-level and VDC-level coordination structures with the national-level coordination structures. They also emphasized the urgent need to make coordination committees at the district and lower levels more functional. They felt that the national level should provide technical support to the district nutrition coordination platforms and other district departments to facilitate better planning, budgeting, implementation, and monitoring of multi-sectoral nutrition strategies.

 The central level needs to go down to the district level and look at the DNCC [district nutrition coordination committee] and provide them with a plan because that's really where this is going to be implemented.
– National CSO stakeholder, Uganda

4. Foster engagement of the private sector and academia in the NNAP coordination structure and clearly define their roles. The private sector can play an important role in leveraging financial support for nutrition activities. Stakeholders from both countries called for the formation of formal coordination platforms to engage the private sector, discuss potential partnerships, and agree on roles and responsibilities. They also suggested identifying nutrition champions from the private sector and regularly inviting private sector organizations/individuals to coordination meetings in order to improve their technical knowledge about nutrition and ongoing initiatives.

Similarly, academia can also play an important role in research and technical support for nutrition. The coordinating platform for academia in Nepal needs to be formally recognized, while in Uganda it must be established in order to facilitate regular conversations on academia's roles and contributions to NNAPs.

 [We are] positive to undertake anything that they work on MSNP as long as their roles are defined. Government should provide clear categorical role for the private sector.
– National private sector stakeholder, Nepal

 Leverage private sector to co-fund and support public relations and social change, and academia to develop and promote context-specific evidence for nutrition activities.
– National government stakeholder, Uganda

Conclusions

Our findings indicate that the governments of Nepal and Uganda and their partners have made positive progress toward multi-sectoral coordination for nutrition work, and that NNAPs have been influential in fostering such coordination. However, both countries continue to face challenges related to high-level coordination for nutrition activities, horizontal coordination between different sectors, vertical coordination between different levels of stakeholders, and partnerships with the private sector, academia, CSOs, and NGOs. While experiences vary by country, ministry, and donor, we believe these findings and recommendations regarding multi-sectoral coordination of NNAPs in Nepal and Uganda are relevant to many other countries planning and implementing multi-sectorally.