STORIES OF CHANGE IN NUTRITION: THE CASE OF ZAMBIA Jody Harris, Scott Drimie, Terry Roopnaraine, Namukolo Covic, Derek Headey SIG meeting, Washington DC November 2015
STORIES OF CHANGE IN NUTRITION:
THE CASE OF ZAMBIA
Jody Harris, Scott Drimie, Terry Roopnaraine,
Namukolo Covic, Derek Headey
SIG meeting, Washington DC
November 2015
Nutrition policy processes- literature review
• Some have called for nutrition research to engage with political economy (Pinstrup-
Anderson 1993; Berg 1987; Gillespie 2003), but call was largely ignored at the time
• Recent (~5-10 years) more widespread understanding in the literature that action is
aided or constrained by the ‘enabling environment’, defined as political and policy
processes (Gillespie, Haddad et al. 2013)
• Several key case studies assessing elements of these issues for nutrition (Benson 2008;
Natalicchio 2009; Menon/Hoey/Pelletier 2011; Garrett 2012)
• Literature tends to use policy frameworks to structure research (particularly Shiffman 2007
agenda setting; Heaver 2005 commitment), but few links to political or social science theory.
• Nutrition is slightly behind similar health systems research in its sophistication (eg. Walt
and Gilson 1994; Gilson et al 2008)
• Call for more, and more nuanced, nutrition policy research, including attention to power
structures (Nisbett et al. 2014)
Stories of Change initiative
Goal: To improve the formulation and implementation of nutrition-relevant policy
and action by producing a set of documented experiences of how undernutrition
has been addressed, in different contexts.
Change Challenge
Commitment
Coordination
Community
International level:• How has understanding of nutrition evolved internationally? †
• How has this informed and affected national policy and programs? †
National level:• How has nutrition arrived on the national policy agenda?• What characterises the broader enabling environment for nutrition?• What has driven change in stunting prevalence in Zambia? *
Local level• How is action for nutrition understood and implemented at local level?• How do national and international processes affect this?
Community level:• How have communities and individuals experienced changes in
nutrition services? *• How is nutrition perceived to have changed in rural communities? *
SUN level:• How is the SUN movement playing out in this context?• How does this apply to other SUN countries? *• What can we learn from patterns across different countries? *
*Stories of Change study only† PhD study only
Interviews with long-standing international nutrition expertsHistorical literature review
Interviews with international nutrition actors with explicit links to Zambian nutrition policy and practice
Quantitative assessment of drivers of undernutrition change
Interviews with Zambian national nutrition policy actorsReview of Zambian policies and program documents in
various nutrition-relevant sectorsSocial network mapping of national actors and interactions
Interviews with local nutrition implementation actorsSocial network mapping of local actors and interactions.
Focus group interviews with community members Interviews with community leaders
Data collection timeline
Policy document gathering Legend:
Netmap interviews International
Theory of change for coordination work National
Key informant interivews District
Policy document gathering Community
Key informant interviews
Key informant interviews
Netmap interviews
Key informant interviews
Netmap interviews
Focus groups
2011 2012 2013 2014 2015 2016
Analysis
Analysis stage Example analyses Steps in analysis
First stage: Descriptive
TimelinesNarratives Actor analysesSummarizing
Creating timelines of key events Describing key narratives Mapping key actors Coding data to original frameworks/ open coding
Second stage: Thematic
Patterns in the data Mapping to themesLooking across respondent types
Recognizing repetitions, clusters, disagreements in the coded data
Clustering codes into broader themes Splitting responses by respondent attributes
Third stage: Theoretical
Testing theory of changeIncluding broader social theory
Looking at themes across levels (international
community) Assessing assumptions in the theory of change Identifying broader social theory of relevance
1950 1960 1970 19901980 20102000
PROTEIN DEFICIENCY
M/SPLAN
NUTRITION POLICY
COMMUNITY
MICRONUTRIENT RIGHTS vsINVESTMENT
EMERGENCE OF NUTRITION SCIENCE
FOOD SHORTAGE
M/SPLAN
NUTRITION ISOLATIONISM
SPECIFIC & SENSITIVE
PROTEIN ERA
M/SPLAN
NUTRITION ISOLATIONISM
MICRO-NUTRIENT
INCREASING PRIORITY
INCREASING MOMENTUM
1
2
3
1: Jonsson 2009: International nutrition. 2: Herforth 2014: World Bank. 3: Nisbett et al 2014/Gillespie et al 2003: Nutrition policy. 4: Webb 2009/Golden 2009: Emergency nutrition. 5: Crowther et al 2007/Knaak 2006: Infant feeding. 6: Kennedy et al 2011/Kennedy 2008: Research priorities and policy. 7: Levinson and McLachlan 1999: International nutrition
Paradigms in nutrition 1950-present
PROTEIN AND STARVATION
MICRONUTRIENT
RUF / CMAM
4 TARGETED FEEDING
IYCF / BREASTFEEDING PROMOTION
LACTATIONAL PERFORMANCE; WEANING;FORMULA MILK AND MATERNAL FOOD PROVISION
5
DEFICIENCIES AND UNDERNUTRITION;DIETARY REOCMMENDATIONS
OVERWEIGHT AND NCDs; DUALBURDEN; FOOD SYSTEMS
6
7 MEDICAL PATHOLOGY; MILK POWDER;
HOME ECONOMICS
REHAB CENTRES;FOOD TECHNOLOGY
M/S PLANNING;FOOD DISTRIBUTION
INTEGRATED PROJECTS; BREASTFEEDING; SCHOOL FEEDING; FOOD COUPONS
Policy and
event timeline
1964-
1967
1968-
1971
1972-
1975
1976-
1979
1980-
1983
1984-
1987
1988-
1991
1992-
1995
1996-
1999
2000-
2003
2004-
2007
2008-
2011
2012-
2015
1964 Independence Legend:
1967 National Food and Nutrition Act, estabilshes NFNC in 1967 Policy or legislation
1972 Food and drugs act National event
1972 Food reserve act International event
1975 NFNA amended
1972 Goitre study Sources:
1978 Salt iodation legislation [not enforced] - "History" and "policy windows"
1978 Margarine fortification legislation (Vitamin A) themes of national interveiws
ANC supplementation for pregnant women - Harris and Drimie, policy review 2012
1985 Vitamin A study - Mucha, Zambia nutrition landscape 2014
1987 NFNC review (damning) - Haggblade et al, micronutrient policy review 2015
1990 Vitamin A supplementation begins - www.zambialaws.com
1991 Beginning of economic reforms
1991/2 drought
1992 Program Against Malnutrition formed
1992 international conference on nutrition
1992 Zambia plan of action on nutrition 1994-2004 [never enacted]
1992 Zambia started work on national nutrition policy
1994 Salt iodation mandatory
HIV epidemic links to nutrition
1998 Sugar fortification mandatory (Vitamin A)
2003 PROFILES tool used for advocacy and awareness-raising
2003 PRSP- mentioned nutrition for poverty reduction
2003 Biofortified sweet potato released
2005-2011 National micronutrient policy
2005-2010 NFNC strategic plan
2006 National food and nutrition policy
2006 Maize fortification plan [vetoed by government]
2008 Lancet series provided key evidence
2009 National nutrition symposium
2009 Financial scandal; donor reductions
2011 National nutrition forum
2010 Zambia signed on as an early riser SUN country
2011 National election and re-ordering of the health sector
2011-15 NFNSP
2012 Biofortified maize released
2012 SUN Fund established
2013-2015 1000 MCDP
2013 Nutrition for Growth event, London
2014 Multi-sectoral district plans [7 districts]
2015 5 key line ministries have nutrition budget lines added
2015 Review of 1975 NFNC Act
2015 CAADP results framework includes nutrition
1964-
1967
1968-
1971
1972-
1975
1976-
1979
1980-
1983
1984-
1987
1988-
1991
1992-
1995
1996-
1999
2000-
2003
2004-
2007
2008-
2011
2012-
2015
1964 Independence Legend:
1967 National Food and Nutrition Act, estabilshes NFNC in 1967 Policy or legislation
1972 Food and drugs act National event
1972 Food reserve act International event
1975 NFNA amended
1972 Goitre study Sources:
1978 Salt iodation legislation [not enforced] - "History" and "policy windows"
1978 Margarine fortification legislation (Vitamin A) themes of national interveiws
ANC supplementation for pregnant women - Harris and Drimie, policy review 2012
1985 Vitamin A study - Mucha, Zambia nutrition landscape 2014
1987 NFNC review (damning) - Haggblade et al, micronutrient policy review 2015
1990 Vitamin A supplementation begins - www.zambialaws.com
1991 Beginning of economic reforms
1991/2 drought
1992 Program Against Malnutrition formed
1992 international conference on nutrition
1992 Zambia plan of action on nutrition 1994-2004 [never enacted]
1992 Zambia started work on national nutrition policy
1994 Salt iodation mandatory
HIV epidemic links to nutrition
1998 Sugar fortification mandatory (Vitamin A)
2003 PROFILES tool used for advocacy and awareness-raising
2003 PRSP- mentioned nutrition for poverty reduction
2003 Biofortified sweet potato released
2005-2011 National micronutrient policy
2005-2010 NFNC strategic plan
2006 National food and nutrition policy
2006 Maize fortification plan [vetoed by government]
2008 Lancet series provided key evidence
2009 National nutrition symposium
2009 Financial scandal; donor reductions
2011 National nutrition forum
2010 Zambia signed on as an early riser SUN country
2011 National election and re-ordering of the health sector
2011-15 NFNSP
2012 Biofortified maize released
2012 SUN Fund established
2013-2015 1000 MCDP
2013 Nutrition for Growth event, London
2014 Multi-sectoral district plans [7 districts]
2015 5 key line ministries have nutrition budget lines added
2015 Review of 1975 NFNC Act
2015 CAADP results framework includes nutrition
Policy coherence- horizontal and verticalMDGs
Bu
dge
ts a
nd
res
ou
rcin
g
Zambia Poverty Reduction Strategy Paper
Zambia Vision 2030
Zambia Sixth National Development Plan
SUN agreement CAADP agreement
National Food and
Nutrition Policy 2006
National Agriculture
Policy 2004-15 National Health Policy
National Education
Policy
National Food and
Nutrition Strategic Plan
2011-15
National Agriculture
Investment Plan 2014
National Health
Strategic Plan 2006-10
National School Health
and Nutrition Policy
2006
1000 Most Critical
Days Program 2013-15
MAL Strategic Plan
2013-16 (“Budget
Strategy”)
IMAM Policy?
IYCF Policy?
Micronutrient Policy?
Social Protection
Policy?WASH Policy?
Multisectoral District
Plan (Mumbwa)
Agriculture Sector
Implementation Plan
School Health and
Nutrition Program
Guidelines 2008
Ministry Workplans
(Mumbwa)
Agriculture Ministry
Workplan (Mumbwa)
MCDMCH-DOH
Workplan (Mumbwa)
Education Ministry
Workplan (Mumbwa)
MCDMCH-DCW/DSP
Workplan (Mumbwa)
Local Gov Ministry
Workplan (Mumbwa)
Statutory Instrument No. 90 (2001): Fortification
National Code of Marketing of Breast Milk Substitutes 2006 Regulations
Employment Act CAP 268; Statutory Instruments No. 56 and 57
Social, political, institutional, economicPolitical: Permanent secretaries nutrition group, parliamentary nutrition caucusDonors: SUN Fund, DFID, Irish Aid, SIDA, USAID, EUAcademic: UNZA, IAPRI, NRDCMedia: Post, Daily Mail
Source: 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, ECF
Stakeholder mapping at national level:Zambian nutrition actors
International level:• There have been clear paradigms in international nutrition• Including intersectoral coordination / nutrition sensitivity• These have to some extent gained traction in national policy
National level:• Written policy is to some extent coherent (vertical/horizontal)• International nutrition funding encourages coordination• Coordination discourse limited to a nutrition policy elite
Local level• Multi-sectoral plans are funded directly with international funds• In one pilot district, significant progress has been made• Difficult to replicate and scale up