FROM COHERENCE TOWARDS COMMITMENT :

CHANGES AND CHALLENGES IN ZAMBIA'S

NUTRITION POLICY ENVIRONMENT

Jody Harris, Scott Drimie, Terry Roopnaraine, Namukolo Covic

Micronutrient Forum 2016

Research design.

Objective: To understand what has driven change in nutrition since 1990

Quantitative:

Drivers of stunting change

• Data:

• DHS datasets 2002, 2007, 2014

• Analysis:

• Descriptive statistics

• Linear regression

Qualitative: Policy process

• Data:

• 67 in-depth interviews

• 14 focus groups

• Social network mapping

• Document and budget review

• Analysis:

• Coding (open and to frameworks)

• Framework analysis for key themes

• Triangulation among sources

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Changes in nutrition outcomes

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0

10

20

30

40

50

60

Underweight Stunting Wasting Chld overweight Femaleundeweight

Femaleoverweight and

obesity

%

1992 1996 2002 2007 2014

Context

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To fully assess nutrition change drivers, future data collection should combine health and agricultural factors, and collect dietary data from different sections of the population. (Gillespie et al 2012 “data disconnect”)

Linking the under- and over-nutrition agendas might be a useful way to gain traction that is lacking on undernutrition, while heading off an impending overnutrition crisis. (Popkin 2004 “Nutrition transition”)

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Agenda setting

Policy coherence

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Millennium Development Goals, 2000

Zambia Vision 2030, GRZ 2006

Zambia Poverty Reduction Strategy Paper, IMF 2007

Zambia Sixth National Development Plan, GRZ 2011

Nutrition Agriculture Health Education Social protection Water and sanitation

SUN Framework for Action 2010

CAADP agreementWorld Health Assembly

agreement

National Food and Nutrition Policy 2006

National Agriculture Policy 2004-15

National Health Policy 1992

National School Health and Nutrition Policy 2006

National Food and Nutrition Strategic Plan

2011-15

MAL Strategic Plan 2013-16 (“Budget Strategy”)

National Health Strategic Plan 2011-16

Social Protection Framework 2013

WASH Framework 2006

1000 Most Critical Days Program 2013-15

Agriculture Sector Implementation Plan

Micronutrient Policy 2005-2011

School Health and Nutrition Program Guidelines 2008

National Rural / Urban Water & Sanitation Supply Programmes

National Agriculture Investment Plan 2014

Multisectoral District Plan (Mumbwa)

Agriculture Ministry Workplan (Mumbwa)

MCDMCH-DOH Workplan (Mumbwa)

Education Ministry Workplan (Mumbwa)

MCDMCH-DCW/DSP Workplan (Mumbwa)

Local Gov Ministry Workplan (Mumbwa)

100% policy agreement is neither feasible nor in fact desirable (Duraiappah and Bhardwaj 2007). Zambia has good coherence- now needs monitoring of sectoral policy to ensure that new policies do not lose their nutrition thread, and do not adversely affect nutrition outcomes.

Leadership

Social, political, institutional, economicPolitical: Permanent secretaries nutrition group, parliamentary nutrition caucusDonors: SUN Fund, DFID, Irish Aid, SIDA, USAID, EUAcademic: UNZA, IAPRI, NRDCMedia: Post, Daily MailSource: Adapted from

UNICEF 1990

Immediate causes

Underlying causes

Basic causes

Food securityMAL, MCDMCH, WFP, FAO, PAM, Java foods

Care environmentUNICEF, MOG, CWZ

Health and WASH servicesMOH, MLGH, WHO, UTH

Health statusMOH, UNICEF

DietMCDMCH, Java foods, WFP

NutritionNFNC, NAZ, CSOSUN, CARE, CWZ, PATH, REACH

If the three key nutrition institutions – NFNC, NAZ, and CSOSUN –can strengthen their capacity and deliberately align their respective roles, then together they will be a clear force for nutrition.

(Sabatier and Jenkins Smith 1993 “Advocacy coalitions”)(Pelletier 2011 “Strategic capacity”)

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0

5

10

15

20

25

30

35

40

0

20

40

60

80

100

120

140

160

180

200

2012 2013 2014

HRC score

NC score

HANCI score

HRC rank

NC rank

HANCI rank

Commitment

SUN may have bypassed the need for political attention, moving the nutrition agenda forward quickly, but also limiting broader government attention to nutrition and therefore limiting system-wide commitment.

(Heaver 2005 “attention vs. commitment”)

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Accountability

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Strengthening the capacity, influence and ability of “boundary spanning” organisations to leverage their roles can move nutrition policy and practice forward.

(Leifer and Delbecq 1978 “Boundary spanners”)

Strengthening citizens’ understanding of their rights would strengthen their voice, to improve demand for better nutrition, and to demand accountability from relevant officials.

(Jonsson 2009 “Right to nutrition”)

Conclusions

Written policy complete and coherent

x Boundary spanners pulled in multiple directions

x International momentum has bypassed the need for national

commitment

Strengthen the capacity of boundary spanners to coordinate

delivery

Strengthen the capacity of the population to hold government

accountable for their nutrition rights

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Thank you

Summary of key issues for Zambia

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Issue Cases Population Source

Maternal mortality 440 per 100,000 National WHO 2014

Under-5 mortality 75 per 1,000 National DHS 2014

Malaria cases 4.89 million National WHO 2014

Child stunting 40% National DHS 2014

Child wasting 6% National DHS 2014

Female anaemia 42% 3 provinces NFNC 2013

Female overweight / obesity 23% National DHS 2014

Adult hypertension 49% Urban Lusaka WHO 2008

Adult glucose intolerance (diabetes) 9% Urban Lusaka WHO 2008

Adult HIV 13% National DHS 2014

Population undernourishment (hunger) 48% National FAO 2015

Population poverty 78% Rural World Bank 2014

Accountability to Community

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Nangoma mothers’ FGDShimbizhi mothers’ FGD

Nangoma men’s FGD

“We can tell them through our councilors

and Members of Parliament who

represent us” / “In a situation where we are not happy we are able

to channel our complaints through

them” / “We cant tell the government directly

but [we can communicate] through

our representatives that we elected.” “The government has poor services, just to deliver farming inputs takes them

years” / “We don’t know where to go and complain…those in the offices [in Mumbwa] are not helpful in any way”.

Nangoma mothers’ FGD

“For the NGOs, so far we can’t complain because they have

shown seriousness in the execution of duties. Our lives

would be improved or developed by the NGOs

[because of] the way they have started their programing. The government departments, the services are not good because

of the time they [take to]deliver the needed services”.

“During campaigns they promise us a lot things which they don’t

deliver, and once they are elected they go for good”

Community coordination

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Nangoma mothers’ FGD

Nangoma men’s FGD

Nangoma mother’s

FGD

“The sector has people on

the ground who are

working as community

health volunteers (CHVs),

who are teaching women

on good feeding practice

and breastfeeding to the

women groups which are

doing farming”.

“Yes, they teach us

about nutrition and

health, at times you will

find that at one

meeting you have

different

ministries…each one

with a different story or

message”

“They [Ministries of

Agriculture and Health] work

separately” / “When people

from the Ministry of

Agriculture are holding field

days, we don’t see people

from [the Ministry of]

Health”.

Intersectoral coordination

2011 2015

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Recommendations1. Datasets do not exist to fully assess drivers of nutrition change. Important in future data collection will be combining health and agricultural

factors in datasets, and collecting dietary data from different sections of the population.

2. Working with organizations identified as boundary spanners to increase their capacity, their influence, and their ability to leverage their complex roles is clearly one important intervention for moving nutrition policy and practice forward.

3. If the three key nutrition institutions – NFNC, NAZ, and CSOSUN – can strengthen their capacity to undertake and deliberately align their respective roles – strategy, professional support, and advocacy – then together they will be a clear force for nutrition going forward.

4. It will be important to explore the opportune placement of NAZ, including membership from across sectors and stakeholders, to foster inter-sectoral alignment.

5. An important tension is between a reticence to single out individuals publicly for either praise or blame, and recent public calls for nutrition champions to be identified. This tendency may be an important barrier to recognition and cultivation of strong leadership, and will be an important point for the Zambian nutrition community to bring to the fore of future discussions

6. There are many unfulfilled expectations in the Zambian nutrition community, tensions between expectations and capacity. These tensions need to be acknowledged and discussed if they are to be resolved.

7. It is important to distinguish between different parts of government when talking about commitment. Technical parts of government are working on a range of different initiatives to improve nutrition, but the financial and executive arms must be encouraged in supporting these efforts with political attentions and funds.

8. Many of the big successes underpinning nutrition changes have been externally funded. The international community should see the focus on nutrition as a long-term commitment to building systems and engagement- but in creating sustainability must be flexible in its approach to defining objectives and disbursing funds.

9. The financial arms of government can contribute by exploring mechanisms that would promote targeted resource mobilization for nutrition, as part of commitments to nutrition made during election time

10. Government can help in other ways as well, in particular by making sure that the policy environment affecting nutrition is coherent and up to date, and that basic services are functioning

11. Strengthening communities’ understanding of their rights and of commitments made would make their voice more powerful, leading to awareness creation at community level to improve demand for better nutrition, but also to demand accountability from the relevant officials. Clarity is needed on which advocacy roles fall to which organizations if advocacy is to be coherent. Smaller civil society organizations closer to communities should be supported to make clear advocacy plans if grassroots demand for nutrition is to be generated

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