Making Nutrition a Development Priority in Africa: What does it take? Marcela Natalicchio Menno Mulder-Sibanda HNP Africa-The World Bank.

Making Nutrition a Development Priority in Africa: What does it take?

Marcela NatalicchioMenno Mulder-Sibanda

HNP Africa-The World Bank

Why did we conduct a PE study in nutrition in Africa?

Three Facts/One Puzzle

◦ -Malnutrition remains a critical public health issue

◦ -There is scientific evidence of workable solutions to malnutrition problems.

◦ -Yet, in many countries (in particular in Sub-Saharan Africa), it remains a low government priority.

One Hypothesis:

◦There are institutional, political obstacles to government commitment (in addition to known capacity constraints)

Comparative study (regional)

Objective- Establish: Why is nutrition not becoming a higher priority? What factors/actions promote a better positioning of nutrition?

Methodology-Conduct and compare eight case studies in Africa, with different levels of government commitment (priority) towards combat against malnutrition-Cases with highest level of commitment: Senegal, Madagascar and The Gambia-Cases with lower levels of commitment: Benin, Burkina Faso, Ghana, Tanzania and Ethiopia-Analysis of historical trajectories of government investment in nutrition policies

-----------------------x------------------x--------------------------> 1960s change 1 change 2 present

Case studies: is malnutrition a problem?

Malnutrition levels (children U-5)

Country Year Source Stunting

Benin 2006 DHS 44.7

B. Faso 2003 MICS3 44.5

Ethiopia 2005 DHS 50.7

Gambia 2006 MICS3 27.6

Ghana 2008 DHS 28.1

Madagascar 2004 DHS 52.8

Senegal 2005 DHS 20.1

Tanzania 2004 DHS 44.4

Government response/Different trajectories

-Nutrition issues have been on government agendas since Independence. In most cases, even during the colonial period. So, nutrition has had some government action.

-In fact, nutrition activities have experienced a gradual increase in the following decades due to increased availability of HR, funds from DP, better understanding of causes/solutions.

BUT, not enough attention to attract necessary resources to address alarming levels of malnutrition---> low priority cycle

Senegal, Madagascar, The Gambia (2000s): stakeholders got together to draft national policies and plans, creation of national coordination agencies (PM/president), increased budget resources, implementation of ambitious national programs with good results.

Comparative Study (regional)

Trajectories analysis

- Definition of the “outcome”: government has committed to long-term nutrition policies to reduce malnutrition. Observed through government actions/decisions. Components: 1) Discourse/policies; 2) Budget; 3) Implementation.

- Look at obstacles across time (influence of historical legacies, path dependency; are they similar?)

- Observe changes: 1. partial positive change (missed opportunity); 2. full positive change; 3. reversal.

-Factors associated with changes: agenda setting; adoption; implementation; sustainability.

Identification of changes

Observations about changes

-All case studies showed positive processes of change at some point in time, but they were truncated. They made changes in policies, sometimes creation of new institutions, but implementation did not proceed. Change was not sustained. Ex: Benin, Burkina Faso and Ghana (in response to ICN 1992) Good comparison with more sustained changes

-Issues of sustainability appear very important: lessons from The Gambia, Tanzania in particular.

So, focus was not exclusively on recent positive changes. It provided more experiences for comparison; and pointed to aspects that appear important to make them sustainable.

Obstacles: low priority cycle

Low Demand

for nutrition services

Poor institutional placement/Multiple

narratives

Fragmented support DP

Poor results/no

accountability

Low demand for nutrition services

Factors that affect low demand

Low demand for nutrition

services

Low pressure on politicians

1.Nature of problem

2. Lack of power beneficiaries

3. Info problems

4. Inadequate training

5.Lack power nutritionists

6.Low priority donors

Poor institutional placement/multiplicity of narratives

Low demand gets reflected in poor institutional placement

Lld

Low capacity/little power Fragmentation/lack of coord/rivalries

Nutrition is the business of donor-led and supported small units

Nutrition Units-small,

understaffed, underfunded

-low ranking (no access to decision-

making/budget)

Multiple narratives-Each unit different narrative

-Influence of international discourses

Limited results/little visibility/little accountability

Typical scenario

-Many small projects funded by DP (development partners)-Little coordination and overlap-Little monitoring/evaluation-Little dissemination of some good results

Little interest for political entrepreneurs to use in “portfolio of accomplishments”

Little accountability for poor results (no clear responsible)

What breaks the cycle?

Possible triggers: How to make it a priority?

Changing the demand-side

-Emergency situations? Natural disasters? They are windows of opportunity, but experience shows they can be short term. Danger of “food bias”

-Attaching it to demand for food. Food distribution is more politically attractive. Risk of fund diversion from other key nutrition interventions.

-Massive awareness campaigns. Not seen in cases -Starting a program that will create interest in beneficiaries—does not create enough

pressure on politicians -Signing of international treaties/Assuming international commitments(International

Nutrition Conference 1992, MDGs). It can initiate some action…but not enough in themselves.

What breaks the cycle?

Possible triggers: how to make it a priority?

Changing the supply-side-Creating a coordinating mechanism/body. In many cases, it does not

work. Several shortcomings: not enough authority, no appropriate budget, no clear mandate/leadership role, not good incentives for cooperation.

-”Champions” : advocacy and leadership. Important but limited (high turn-over; relatively limited influence)

-Implementing a successful national program with good results -Creating greater capacity to implement effective programs

What breaks the cycle?

Comparing cases (what makes a difference?)

-Making nutrition a priority is “an explicit attempt to break the elements of the low priority cycle by a coalition for reform”

-Several actions need to be taken simultaneously or in sequence (in least successful cases, some actions are missing, so priority is established but with no implementation, or unsustainable)

-Coalition for reform seeks to tackle problems of low priority cycle: a) increase demand; b) reduce fragmentation of discourse, institutions and actors; c) improve accountability; d) get DP to work in favor of long term policies

What breaks the cycle?

Agenda setting and adoption

(1) Creation of a broad based coalition for reform (leadership and vision)

(2) Developing a common narrative (and platform for cooperation)

(3) Influencing powerful actors (who needs to be on board)

(4) Contextual variables (affect chances of reform)

Breaking the cycle

Agenda Setting and Adoption

Advocacy Stakeholders’ Workshops-Finance Ministry -Consolidate coalition -President/PM office -Common narrative -DP (National Policy) -parliamentarians -Discussion on best -local authorities institutional placement Vision/Leadership

Gain support of powerful actors

Coalition for

reform

Favorable Policy Context + ‘Window of Opportunity’

Breaking the cycle

Favorable policy context -PRSP (pro-poor orientation; participation)—inscription necessary but not

sufficient -MDGs (MDG1, 4 and 5)—not all government have shown same level of

commitment -Orientation of DP towards longer-term policies (from projects to programs)

MDGs (results) and Paris Declaration (results, coordination, support for government leadership)

Window of Opportunity-Coalitions have used “windows of opportunity” to put nutrition on the agenda. Senegal, Madagascar and The Gambia have used re-negotiation (negotiation) of WB loan to do so.

Breaking the cycle

Implementation and sustainability

(1) Changing institutional arrangements (2) Ensuring results (issues of capacity) (3) Using strategic communications

(1) Better access to decision-making, resources, capacity to coordinate, and mobilize needed resources (HR, funding): ex. Coordinating agencies attached to PM/president office, with clear responsibility and resources to implement effective nationwide nutrition policies (CLM, ONN, NANA)

Breaking the cycle

Implementation and sustainability

(2) Ensuring results: they can be claimed by politicians as part of their achievements (Capacity and commitment meet here)

(3) Strategic communication: always room for issue competition (many needs/budget constraints). Strategic communication is essential to keep powerful actors interested in nutrition.

Implications for WB

Implications for WB operations?

Main lesson: “avoid actions that feed into the “low priority cycle” AND “take steps to reform”

-Based on workshop participation and results of study, Benin is on its way to “breaking the cycle”

-Supportive TTL with vision of where change needs to happen -Avoid narrow focus on “nutrition departments” and narrow/small

interventions (feeds into “low priority cycle”) -Initiate dialogue with key DP -Use different bank instruments at same time (investment + TA)

Implications for WB Operations

Implications for WB operations?

-Single it out for policy dialogue -Identify champions “across the board” (different levels of

government) -Manage “changes in the environment” in your favor and adapt

(develop possible scenarios) -Be opportunistic in getting initial funds to get action going (risk:

staying small) -Get results and communicate them! -Soft elements: getting out of the “comfort zone” : courage,

creativity, entrepreneurship, and tenacity.

Thank You!