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VOICE FOR CHANGE PARTNERSHIP (V4CP)
PROGRAM BRIEF|June 2020Sawudatu ZAKARIAH-AKOTO and Richmond ARYEETEY
Coordinating Nutrition Partners and Programs
in Ghana
BACKGROUND
Malnutrition is a multifactorial problem; different sectors and partners are often needed to address its multiple drivers (1). Achieving optimal outcomes
requires effective coordination and coherent actions across the multiple actors involved in the nutrition landscape (2). Vertical coordination ensures systematic
harmonization of decision-making and actions across national and subnational policies, plans, resources, implementation, and monitoring mechanisms. Horizon-
tal coordination systematically integrates policies, plans, resources, implementation, and monitoring mechanisms across sectors and agencies. Horizontal coor-
dination can occur at the national and subnational levels, and may involve such diverse partners as government agencies, donors, civil society organizations
(CSOs), development partners (DPs), academia, and the private sector (Table 1).
Suboptimal coordination has been linked with inability to scale up effective interventions to address malnutrition both within Ghana and globally (2, 3).
This advocacy brief reviews coordination across sectors and governance levels in Ghana’s nutrition landscape, based on review of existing literature; describes
existing coordination mechanisms that have been operational in Ghana in the past decade or more; and highlights the gaps and challenges that need to be
addressed.
Table 1: Key sectors involved in nutrition in Ghana and their core roles
Institution/Agency Role in Nutrition
Health institutions Delivery of nutrition services, particularly nutrition-specific interventions
Agriculture institutions and partners Delivery of Food security interventions and nutrition-sensitive agricultural interventions
Educational institutions and partners Awareness creation about nutrition through delivery of school-based nutrition programs
(including curriculum and school meals)
Local government, regional and dis-
trict assemblies
Governance and leadership of nutrition-sensitive interventions at subnational levels and
key coordination of sanitation services
Academic and research institutions Research, innovation, and evaluation to inform decision-making in nutrition
Donor agencies Funding, supply of logistics, and capacity building
United Nations agencies Funding and technical support of nutrition-specific and nutrition-sensitive interventions
STAKEHOLDERS IN THE NUTRITION LANDSCAPE IN GHANA
Drawing on evidence from multiple sources and studies, including the Transform Nutrition West Africa (TNWA) Stories of Change in Nutrition study, we
find that there are many actors involved in addressing malnutrition and its drivers (3-5). A stakeholder mapping done as part of the Stories of Change (SoC)
study identified over 100 actors/stakeholders involved in the nutrition landscape in Ghana at various levels (Appendix1). These actors come from diverse sec-
tors, including government, civil society, donors, the United Nations (UN), business, and academic institutions, with government agencies making up the major-
ity. Within government, 11 ministries were identified as highly involved in nutrition policy development and program implementation. In addition to institutional
actors, there are also individual actors who serve as champions or influencers of nutrition, often in partnership with some of the listed organizational actors.
2
SUMMARY | APRIL 2010
PERCEIVED VALUE OF VARIOUS STAKEHOLDER IN NUTRITION
The Ghana Health Service (GHS) is the lead implementing agency for nutrition programs in Ghana. The GHS—especially its Nutrition Department (ND)—is
therefore considered a key institution for nutrition in the country (3-5). According to the SoC study, the ND’s capacity to engage with a wide range of partners
involved in nutrition makes it particularly important. Other highly influential actors in nutrition include the Council for Scientific and Industrial Research, the
Food and Agriculture Organization of the United Nations (FAO), Global Affairs Canada (GAC), the Global Fund, UNICEF Ghana, the University of Ghana, USAID,
and the World Bank, as well as Ghana’s Ministry of Health, Ministry of Food and Agriculture, and National Development Planning Commission. An additional 25
institutions also play critical roles.
RECOGNITION OF THE IMPORTANCE OF NUTRITION COORDINATION IN GHANA
As expressed in the National Nutrition Policy (NNP) and several other policies, the Government of Ghana recognizes multisectoral coordination as “an
overarching multi-sectoral framework for achieving optimal nutrition and reducing malnutrition among people living in Ghana.”1 Thus, the NNP seeks to
strengthen coordination mechanisms at national and subnational levels as part of effective governance and implementation of nutrition programs. To achieve
this, the NNP highlights the need to coordinate action across the various ministries, departments, and agencies (MDAs) implementing nutrition-relevant actions.
The NNP identifies specific actions to strengthen coordination, including strengthening human and institutional capacity for nutrition and related services
at all levels of the health system and provision of technical nutrition support for relevant MDAs involved in nutrition-sensitive programs. The NNP also recom-
mends that existing regional planning and coordinating units within the Regional Administration System should have coordinating responsibility across sectors.
The plan further proposes that a regional focal person be appointed to lead nutrition coordination at the regional level. A similar approach is proposed for the
district level, —that is, to appoint a district focal person to work through the district planning and coordinating units to ensure coherence across sectors. These
mechanisms have not yet been established.
EXISTING COORDINATION MECHANISMS
Horizontal Coordination
There have been multiple national-level coordination mechanisms for nutrition policy and programming in Ghana—most notably, the National Nutrition
Partners Coordination Committee (NANUPACC), convened by the director of the GHS ND, and the Scaling Up Nutrition (SUN) Cross-Sectoral Planning Group
(CSPG), was coordinated by the National Development Planning Committee (NDPC) and led by a national SUN focal person. Both mechanisms operated con-
vened stakeholders from academia, the government, and UN agencies to contribute to policy and program planning. In-depth interviews with key stakeholders
suggest that the formation of the SUN CSPG in 2011 stifled the activities of the NANUPACC and eventually resulted in the SUN CSPG replacing the NANUPACC as
the main coordination mechanism for nutrition in Ghana.
It is unclear when the NANUPACC was established and whether it still exists. It has been reported that the NANUPACC was an informal entity (3) that
convened partners on an ad hoc basis. Stakeholder interviews indicate that the NANUPACC stopped activities sometime in 2011, when Ghana joined the Scaling
Up Nutrition (SUN) Movement. That was when the multi-stakeholder platform, (the CSPG) for SUN was established. After about two years of intense activity
that resulted in the finalization of the NNP, the SUN CSPG also became functionally inactive. In 2014, the NDPC established a SUN technical working group, even
though the CSPG had not been disbanded. When the SUN CSPG focal person’s term expired in 2017, the NDPC did not appoint a replacement, between 2017
and 2019, further limiting the functionality of the SUN technical working group.
In addition to the NANUPACC and SUN CSPG, there are other mechanisms that exist to ensure coherence among multiple agencies within sectors as well as ad
hoc or standing coordination mechanisms for addressing specific nutrition issues within sectors (Table 2). All these mechanisms have contributed to important
gains in nutrition programming in Ghana. At the national level, the SUN CSPG was crucial in the finalization and validation of the NNP and in facilitating the
development of a long-term national food and nutrition security policy.
Regional and district-level coordination of nutrition
At the subnational level, nutrition programs are led primarily by nutrition officers from the regional and district health administrations. Regional nutrition
officers exercise responsibility over district nutrition officers and report to the GHS ND director, as well as to the Regional Director of Health Services. District
nutrition officers manage nutrition programming at district and subdistrict levels and report to regional nutrition officers and the District Director of Health
Services. Limited subnational-level evidence suggests that at the district level, there is limited coordination of nutrition activities across sectors (6).
The main barriers to subnational coordination of nutrition actions include incomplete decentralization of governance, limited funding, low awareness of
the scale of malnutrition, and non-prioritization of nutrition across agencies outside the health sector (3, 6). Incomplete decentralization has been identified as a
hinderance to coordination, as it limits evidence sharing, leading to suboptimal formulation and implementation of nutrition policies and programs. Incomplete
decentralization also limits capacity for institutionalizing intersectoral engagements. The result is that interactions are often ad hoc and informal.
1 Ministry of Health. 2016. National Nutrition Policy, Ghana.
3
SUMMARY | APRIL 2010
Table 2: Coordination mechanisms relevant for nutrition at national level in Ghana
Coordination mechanism Purpose Convening/Lead agency
Ghana Coalition of Civil Society Organizations for SUN Nutrition prioritization through SUN Movement Hunger Alliance, Ghana
SUN Academic Platform Evidence-informed decision making and capacity building University of Ghana
SUN Development Partners Group Funding and technical support United Nations/UNICEF
Other development partner groups for health, educa-
tion, agriculture, water, and sanitation
Sector-specific objectives with beneficial overlaps for nutri-
tion
National Child Health Coordinating Body Child health program planning GHS, Director-General
Micronutrient Task Team Addressing anemia GHS Nutrition Department
National Salt Iodization Committee Supporting and promoting iodized salt availability and use Ministry of Trade and Industry
Infant and Young Child Feeding (IYCF) Task Team Promoting optimal infant and young child feeding GHS Nutrition Department
National Food Fortification Alliance Promoting use of fortified foods Ghana Standards Authority
Severe Acute Malnutrition Technical Committee Prevention and treatment of acute malnutrition GHS
HIV/AIDS Nutrition Assessment and Counselling and
Support (NACS) Technical Working Group
Prevention and treatment of malnutrition among HIV-in-
fected persons
National AIDS Control Program
Codex Alimentarius2 Sub-Committee on Food and Nu-
trition
Establishing food standards Food and Drugs Authority
School Feeding Programme Steering Committee Implementation of school feeding program FDA
FDA Food Safety Committee Food safety promotion FDA
FDA Communications Sub-Committee FDA
FDA Monitoring and Evaluation Sub-Committee FDA
FDA Technical Advisory Committee on Nutrition FDA
Two case studies illustrate opportunities for initiating subnational coordination of nutrition. The first is from 2018 on the facilitative role of the Ghana
Trade and Livelihoods Coalition (GTLC) in Poyentanga, in Wa West District (6). In this community, which previously had no formal nutrition coordination mecha-
nism, GTLC stimulated the formation of a cross-sectoral committee. The committee has representatives from government agencies (health, education, and
agriculture), assembly members, chiefs, other identified community leaders, and mother-to-mother support groups. It now coordinates efforts across sectors to
improve nutrition service delivery and to advocate for increased budget allocation to nutrition.
The second case is from Upper Manya Krobo District, where the Nutrition Links project has stimulated the formation of a district coordination team focused on
addressing nutrition (7). Nutrition Links was implemented between 2014 and 2018 to increase capacity of local agencies to improve health, agriculture, and
private sector services that influence child and maternal nutrition. The project facilitated the creation of a cross-sectoral committee of stakeholders comprising
the District Assembly, Department of Agriculture, Department of Education, Health Administration, and the Upper Manya Kro Rural Bank (8). Nutrition Links
generated data to create awareness of the scale of malnutrition in the district. It also facilitated regular meetings of the committee for training, decision making,
and joint review of progress on cross-sectoral action. These two case studies demonstrate the capacity and opportunities for initiating cross-sectoral mecha-
nisms for nutrition at sub-regional levels in Ghana. Because both cases were initiated by projects that have ended, there is limited evidence on the sustainability
of these initiatives.
COORDINATION OF NUTRITION PROGRAMS IN GHANA
Existing coordination mechanisms have contributed to achieving important gains in nutrition programming in Ghana. At the national level, the SUN CSPG
was crucial in the finalization and validation of the NNP(9), the Cost of Hunger in Africa Report (10), and the national long-term food and nutrition security pol-
icy. Within and across sectors, various coordination mechanisms have been reported to contribute to a number of programs including the school feeding pro-
gram, which receives technical support from the national School Feeding Programme Steering Committee. On the other hand, there are instances of programs
that have stagnated or been impeded by the poor functioning of coordination mechanisms. For example, lack of consensus within the SUN CSPG is partly why a
national action plan for nutrition has not be developed. Similarly, a recent stakeholder analysis shows that the inability of the National Breastfeeding Authority
to meet frequently is one if the key gaps for national capacity to scale up effective breastfeeding interventions (11).
2 Codex Alimentarius is a collection of internationally recognized standards, codes of practice, guidelines, and other recommendations relating to
foods, food production, and food safety.
4
SUMMARY | APRIL 2010
SOURCES OF FUNDING FOR COORDINATION OF NUTRITION PROGRAMS AND CHALLENGES
Coordination mechanisms are mainly funded by development partners and donor agencies. Between 2011 and 2015, the work of the SUN CSPG was sup-
ported by the UN Development Assistance Framework (UNDAF) as well as by UN REACH, a support mechanism that aimed to assist countries with a high burden
of child and maternal undernutrition to accelerate the scale-up of food and nutrition actions. There is no evidence of funding mechanisms for NANUPACC or for
subnational coordination.
CONFLICT OF INTEREST
There is limited evidence of conflict of interest (COI) across sectors. There is a high level of shared interest and ownership of outcomes around the NNP,
along with suspicion of the private sector’s intentions because of its profit focus. At the outset of establishing the SUN CSPG, initial COI challenges were ad-
dressed through cross-sectoral training on COI. There is, however, no national COI framework to guide nutrition partners involved in coordination mechanisms.
SUSTAINABILITY OF COORDINATION MECHANISMS
A key challenge to sustainable functioning of nutrition coordination mechanisms is funding. Individual agencies and coordination mechanisms depend
heavily on donor funding for nutrition activities. Thus, coordination mechanisms come alive when there is donor funding and tend to dwindle or die when donor
funds become unavailable.
CHALLENGES TO NUTRITION COORDINATION IN GHANA
Evidence from multiple sources identified key challenges for nutrition policy and program coordination:
1. There are multiple agencies involved in nutrition policy and programming, but their engagement lacks effective organization. This limits their ability to
leverage the power of their networks. There is limited appreciation of the role that different sectors and agencies can play to address malnutrition.
Malnutrition is predominantly considered a health issue rather than a human development issue. Consequently, there is low prioritization of nutrition
in the programs and budgets of non-health sectors and agencies.
2. There is limited nutrition competence in terms of number and distribution of personnel with nutrition training across sectors and agencies. Further,
the GHS Nutrition Department has limited capacity and power to lead and coordinate multiple sectors to address nutrition. The ND also lacks tech-
nical capacity to coordinate the input and activities of other key stakeholders.
3. The two main national-level coordination mechanisms are functionally inactive. It is unclear whether NANUPACC is still in existence, and the SUN
CSPG only meets on an ad hoc basis. A SUN focal point has not been appointed since 2017. As a consequence, there is limited importance given to
nutrition when making decisions on human development priorities. In particular, there is limited engagement between government agencies and
CSOs, researchers, and business. (12). Although the private sector is always indicated in national nutrition coordination frameworks, it is difficult to
locate their participation in nutrition actions, especially at subnational level. Partial decentralization of governance limits engagement of partners at
the subnational level on nutrition programming
4. Budgeting and expenditure on nutrition-related actions tend to be uncoordinated. Nutrition budgets are often subsumed under ministerial budgets.
Apart from salaries of personnel, government funding of nutrition is extremely low.
SUGGESTED STRATEGIES TO IMPROVE COORDINATION OF NUTRITION IN GHANA
Implementing the following strategies to improve coordination of nutrition programs could contribute to better nutrition outcomes in Ghana.
1. Establish a National Food and Nutrition Commission to lead engagement and ensure coherence across all relevant sectors (government, UN, research-
ers, civil society, business). This recommendation comes out of a joint consensus of key stakeholders in nutrition in Ghana in January 2020 (see at-
tached communique by nutrition partners). Parliament and the executive branch of government have the power to make this possible. The National
Nutrition Commission (a technical agency) should work closely with a high-level inter-ministerial committee on decision-making for nutrition. Linked
to this, it is recommended that the GHS ND should be restructured so that its scope extends beyond health. At subnational levels, nutrition focal
persons should be appointed, and functional coordination mechanisms established, as indicated in the National Nutrition Policy.
2. Strengthen capacity of stakeholders across all relevant sectors and agencies. Capacity strengthening can be achieved through a combination of in-
service training and pre-service training on the determinants of malnutrition and the role that diverse programs can play to address malnutrition.
3. Parliament and the Ministry of Finance should prioritize and increase government funding for nutrition at regional, district, and community levels.
Across agencies, make clear budget lines for nutrition as part of the current outcome-based institutional budgeting system, so that nutrition budgets
are not subsumed under various agency activities and thus rendered “invisible.” In addition, nutrition-relevant government institutions should create
systems to track disbursements and expenditures related to nutrition actions to enable accurate estimation of nutrition funding.
5
SUMMARY | APRIL 2010
REFERENCES
[1] UNICEF. (1998). State of the Worlds Children 1998: Focus on Nutrition. New York: UNICEF..
[2] Gillespie S, Haddad L, Mannar V, Menon P, & Nisbett N. (2013). The politics of reducing malnutrition: building commitment and accelerating pro-
gress. Lancet , 382(9891):552-69.
[3] Pinto R.F. (2011). The Nutrition Area in Ghana Institutional Assessment. Accra, Ghana; 2011.
[4] Aryeetey R, and Atuobi-Yeboah A. (2019). Policy and program review of child stunting and anemia in Ghana. Accra.
[5] Aryeetey R, and Atuobi-Yeboah A. (2019) Stories of Change in Nutrition in Ghana Report of In-Depth Interview. Accra.
[6] Billings L, and Wullingdool E. (2019). Engaging nutrition stakeholders in Poyentanga: A Case Study on Local-Level Multisector Coordination.
SNV/IFPRI .
[7] Marquis GS, Colecraft EK, Kanlisi R, Aidam BA, Atuobi-Yeboah A, Pinto C, and R Aryeetey. (2018). An agriculture–nutrition intervention improved
children's diet and growth in a randomized trial in Ghana. Maternal & child nutrition,14(S3): e12677.
[8] Nutrition Links Project. (2017) Nutrition Integration. Accra, Ghana: University of Ghana/McGill University.
[9] Government of Ghana. (2016). National Nutrition Policy. Accra: Government of Ghana.
[10] National Development Planning Commission (NDPC). (2016). The Cost of Hunger in Africa (Ghana): Social and Economic Impact of Child Undernu-
trition. Accra: NDPC.
[11] Aryeetey R, Hromi-Fiedler A, Adu-Afarwuah S, Amoaful E, Ampah G, Gatiba M, et al. (2018). Pilot testing of the Becoming Breastfeeding Friendly
toolbox in Ghana. International Breastfeed J,13:30.
[12] Aberman N-L. (2020). Approaches for Leveraging Small and Medium Enterprises to Improve Nutrition: Net-Map Assessment of Actors and Activi-
ties in Ghana. Accra: SNV/IFPRI.
About the Authors
Richmond Aryeetey is Associate Professor with the University of Ghana School of Public Health. Sawudatu Zakariah-Akoto is a Research Fellow with the
Noguchi Memorial Institute for medical Research.
Acknowledgements
Funding for this brief was received from the Dutch Government through SNV and the Voices for Change Partnership program.
INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE
A world free of hunger and malnutrition
1201 Eye Street, NW, Washington, DC 20005 USA | T. +1-202-862-5600 | F. +1-202-862-5606 | Email: ifpri@cgiar.org | www.ifpri.org | www.ifpri.info
This publication has been prepared as an output of the Voice for Change Partnership (V4CP) program and has not been independently peer reviewed. Any
opinions expressed here belong to the author(s) and are not necessarily representative of or endorsed by IFPRI.
© 2020 International Food Policy Research Institute (IFPRI). This publication is licensed for use under a Creative Commons Attribution 4.0 International
License (CC BY 4.0). To view this license, visit https://creativecommons.org/licenses/by/4.0.

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Coordinating nutrition partners and programs in Ghana

  • 1. VOICE FOR CHANGE PARTNERSHIP (V4CP) PROGRAM BRIEF|June 2020Sawudatu ZAKARIAH-AKOTO and Richmond ARYEETEY Coordinating Nutrition Partners and Programs in Ghana BACKGROUND Malnutrition is a multifactorial problem; different sectors and partners are often needed to address its multiple drivers (1). Achieving optimal outcomes requires effective coordination and coherent actions across the multiple actors involved in the nutrition landscape (2). Vertical coordination ensures systematic harmonization of decision-making and actions across national and subnational policies, plans, resources, implementation, and monitoring mechanisms. Horizon- tal coordination systematically integrates policies, plans, resources, implementation, and monitoring mechanisms across sectors and agencies. Horizontal coor- dination can occur at the national and subnational levels, and may involve such diverse partners as government agencies, donors, civil society organizations (CSOs), development partners (DPs), academia, and the private sector (Table 1). Suboptimal coordination has been linked with inability to scale up effective interventions to address malnutrition both within Ghana and globally (2, 3). This advocacy brief reviews coordination across sectors and governance levels in Ghana’s nutrition landscape, based on review of existing literature; describes existing coordination mechanisms that have been operational in Ghana in the past decade or more; and highlights the gaps and challenges that need to be addressed. Table 1: Key sectors involved in nutrition in Ghana and their core roles Institution/Agency Role in Nutrition Health institutions Delivery of nutrition services, particularly nutrition-specific interventions Agriculture institutions and partners Delivery of Food security interventions and nutrition-sensitive agricultural interventions Educational institutions and partners Awareness creation about nutrition through delivery of school-based nutrition programs (including curriculum and school meals) Local government, regional and dis- trict assemblies Governance and leadership of nutrition-sensitive interventions at subnational levels and key coordination of sanitation services Academic and research institutions Research, innovation, and evaluation to inform decision-making in nutrition Donor agencies Funding, supply of logistics, and capacity building United Nations agencies Funding and technical support of nutrition-specific and nutrition-sensitive interventions STAKEHOLDERS IN THE NUTRITION LANDSCAPE IN GHANA Drawing on evidence from multiple sources and studies, including the Transform Nutrition West Africa (TNWA) Stories of Change in Nutrition study, we find that there are many actors involved in addressing malnutrition and its drivers (3-5). A stakeholder mapping done as part of the Stories of Change (SoC) study identified over 100 actors/stakeholders involved in the nutrition landscape in Ghana at various levels (Appendix1). These actors come from diverse sec- tors, including government, civil society, donors, the United Nations (UN), business, and academic institutions, with government agencies making up the major- ity. Within government, 11 ministries were identified as highly involved in nutrition policy development and program implementation. In addition to institutional actors, there are also individual actors who serve as champions or influencers of nutrition, often in partnership with some of the listed organizational actors.
  • 2. 2 SUMMARY | APRIL 2010 PERCEIVED VALUE OF VARIOUS STAKEHOLDER IN NUTRITION The Ghana Health Service (GHS) is the lead implementing agency for nutrition programs in Ghana. The GHS—especially its Nutrition Department (ND)—is therefore considered a key institution for nutrition in the country (3-5). According to the SoC study, the ND’s capacity to engage with a wide range of partners involved in nutrition makes it particularly important. Other highly influential actors in nutrition include the Council for Scientific and Industrial Research, the Food and Agriculture Organization of the United Nations (FAO), Global Affairs Canada (GAC), the Global Fund, UNICEF Ghana, the University of Ghana, USAID, and the World Bank, as well as Ghana’s Ministry of Health, Ministry of Food and Agriculture, and National Development Planning Commission. An additional 25 institutions also play critical roles. RECOGNITION OF THE IMPORTANCE OF NUTRITION COORDINATION IN GHANA As expressed in the National Nutrition Policy (NNP) and several other policies, the Government of Ghana recognizes multisectoral coordination as “an overarching multi-sectoral framework for achieving optimal nutrition and reducing malnutrition among people living in Ghana.”1 Thus, the NNP seeks to strengthen coordination mechanisms at national and subnational levels as part of effective governance and implementation of nutrition programs. To achieve this, the NNP highlights the need to coordinate action across the various ministries, departments, and agencies (MDAs) implementing nutrition-relevant actions. The NNP identifies specific actions to strengthen coordination, including strengthening human and institutional capacity for nutrition and related services at all levels of the health system and provision of technical nutrition support for relevant MDAs involved in nutrition-sensitive programs. The NNP also recom- mends that existing regional planning and coordinating units within the Regional Administration System should have coordinating responsibility across sectors. The plan further proposes that a regional focal person be appointed to lead nutrition coordination at the regional level. A similar approach is proposed for the district level, —that is, to appoint a district focal person to work through the district planning and coordinating units to ensure coherence across sectors. These mechanisms have not yet been established. EXISTING COORDINATION MECHANISMS Horizontal Coordination There have been multiple national-level coordination mechanisms for nutrition policy and programming in Ghana—most notably, the National Nutrition Partners Coordination Committee (NANUPACC), convened by the director of the GHS ND, and the Scaling Up Nutrition (SUN) Cross-Sectoral Planning Group (CSPG), was coordinated by the National Development Planning Committee (NDPC) and led by a national SUN focal person. Both mechanisms operated con- vened stakeholders from academia, the government, and UN agencies to contribute to policy and program planning. In-depth interviews with key stakeholders suggest that the formation of the SUN CSPG in 2011 stifled the activities of the NANUPACC and eventually resulted in the SUN CSPG replacing the NANUPACC as the main coordination mechanism for nutrition in Ghana. It is unclear when the NANUPACC was established and whether it still exists. It has been reported that the NANUPACC was an informal entity (3) that convened partners on an ad hoc basis. Stakeholder interviews indicate that the NANUPACC stopped activities sometime in 2011, when Ghana joined the Scaling Up Nutrition (SUN) Movement. That was when the multi-stakeholder platform, (the CSPG) for SUN was established. After about two years of intense activity that resulted in the finalization of the NNP, the SUN CSPG also became functionally inactive. In 2014, the NDPC established a SUN technical working group, even though the CSPG had not been disbanded. When the SUN CSPG focal person’s term expired in 2017, the NDPC did not appoint a replacement, between 2017 and 2019, further limiting the functionality of the SUN technical working group. In addition to the NANUPACC and SUN CSPG, there are other mechanisms that exist to ensure coherence among multiple agencies within sectors as well as ad hoc or standing coordination mechanisms for addressing specific nutrition issues within sectors (Table 2). All these mechanisms have contributed to important gains in nutrition programming in Ghana. At the national level, the SUN CSPG was crucial in the finalization and validation of the NNP and in facilitating the development of a long-term national food and nutrition security policy. Regional and district-level coordination of nutrition At the subnational level, nutrition programs are led primarily by nutrition officers from the regional and district health administrations. Regional nutrition officers exercise responsibility over district nutrition officers and report to the GHS ND director, as well as to the Regional Director of Health Services. District nutrition officers manage nutrition programming at district and subdistrict levels and report to regional nutrition officers and the District Director of Health Services. Limited subnational-level evidence suggests that at the district level, there is limited coordination of nutrition activities across sectors (6). The main barriers to subnational coordination of nutrition actions include incomplete decentralization of governance, limited funding, low awareness of the scale of malnutrition, and non-prioritization of nutrition across agencies outside the health sector (3, 6). Incomplete decentralization has been identified as a hinderance to coordination, as it limits evidence sharing, leading to suboptimal formulation and implementation of nutrition policies and programs. Incomplete decentralization also limits capacity for institutionalizing intersectoral engagements. The result is that interactions are often ad hoc and informal. 1 Ministry of Health. 2016. National Nutrition Policy, Ghana.
  • 3. 3 SUMMARY | APRIL 2010 Table 2: Coordination mechanisms relevant for nutrition at national level in Ghana Coordination mechanism Purpose Convening/Lead agency Ghana Coalition of Civil Society Organizations for SUN Nutrition prioritization through SUN Movement Hunger Alliance, Ghana SUN Academic Platform Evidence-informed decision making and capacity building University of Ghana SUN Development Partners Group Funding and technical support United Nations/UNICEF Other development partner groups for health, educa- tion, agriculture, water, and sanitation Sector-specific objectives with beneficial overlaps for nutri- tion National Child Health Coordinating Body Child health program planning GHS, Director-General Micronutrient Task Team Addressing anemia GHS Nutrition Department National Salt Iodization Committee Supporting and promoting iodized salt availability and use Ministry of Trade and Industry Infant and Young Child Feeding (IYCF) Task Team Promoting optimal infant and young child feeding GHS Nutrition Department National Food Fortification Alliance Promoting use of fortified foods Ghana Standards Authority Severe Acute Malnutrition Technical Committee Prevention and treatment of acute malnutrition GHS HIV/AIDS Nutrition Assessment and Counselling and Support (NACS) Technical Working Group Prevention and treatment of malnutrition among HIV-in- fected persons National AIDS Control Program Codex Alimentarius2 Sub-Committee on Food and Nu- trition Establishing food standards Food and Drugs Authority School Feeding Programme Steering Committee Implementation of school feeding program FDA FDA Food Safety Committee Food safety promotion FDA FDA Communications Sub-Committee FDA FDA Monitoring and Evaluation Sub-Committee FDA FDA Technical Advisory Committee on Nutrition FDA Two case studies illustrate opportunities for initiating subnational coordination of nutrition. The first is from 2018 on the facilitative role of the Ghana Trade and Livelihoods Coalition (GTLC) in Poyentanga, in Wa West District (6). In this community, which previously had no formal nutrition coordination mecha- nism, GTLC stimulated the formation of a cross-sectoral committee. The committee has representatives from government agencies (health, education, and agriculture), assembly members, chiefs, other identified community leaders, and mother-to-mother support groups. It now coordinates efforts across sectors to improve nutrition service delivery and to advocate for increased budget allocation to nutrition. The second case is from Upper Manya Krobo District, where the Nutrition Links project has stimulated the formation of a district coordination team focused on addressing nutrition (7). Nutrition Links was implemented between 2014 and 2018 to increase capacity of local agencies to improve health, agriculture, and private sector services that influence child and maternal nutrition. The project facilitated the creation of a cross-sectoral committee of stakeholders comprising the District Assembly, Department of Agriculture, Department of Education, Health Administration, and the Upper Manya Kro Rural Bank (8). Nutrition Links generated data to create awareness of the scale of malnutrition in the district. It also facilitated regular meetings of the committee for training, decision making, and joint review of progress on cross-sectoral action. These two case studies demonstrate the capacity and opportunities for initiating cross-sectoral mecha- nisms for nutrition at sub-regional levels in Ghana. Because both cases were initiated by projects that have ended, there is limited evidence on the sustainability of these initiatives. COORDINATION OF NUTRITION PROGRAMS IN GHANA Existing coordination mechanisms have contributed to achieving important gains in nutrition programming in Ghana. At the national level, the SUN CSPG was crucial in the finalization and validation of the NNP(9), the Cost of Hunger in Africa Report (10), and the national long-term food and nutrition security pol- icy. Within and across sectors, various coordination mechanisms have been reported to contribute to a number of programs including the school feeding pro- gram, which receives technical support from the national School Feeding Programme Steering Committee. On the other hand, there are instances of programs that have stagnated or been impeded by the poor functioning of coordination mechanisms. For example, lack of consensus within the SUN CSPG is partly why a national action plan for nutrition has not be developed. Similarly, a recent stakeholder analysis shows that the inability of the National Breastfeeding Authority to meet frequently is one if the key gaps for national capacity to scale up effective breastfeeding interventions (11). 2 Codex Alimentarius is a collection of internationally recognized standards, codes of practice, guidelines, and other recommendations relating to foods, food production, and food safety.
  • 4. 4 SUMMARY | APRIL 2010 SOURCES OF FUNDING FOR COORDINATION OF NUTRITION PROGRAMS AND CHALLENGES Coordination mechanisms are mainly funded by development partners and donor agencies. Between 2011 and 2015, the work of the SUN CSPG was sup- ported by the UN Development Assistance Framework (UNDAF) as well as by UN REACH, a support mechanism that aimed to assist countries with a high burden of child and maternal undernutrition to accelerate the scale-up of food and nutrition actions. There is no evidence of funding mechanisms for NANUPACC or for subnational coordination. CONFLICT OF INTEREST There is limited evidence of conflict of interest (COI) across sectors. There is a high level of shared interest and ownership of outcomes around the NNP, along with suspicion of the private sector’s intentions because of its profit focus. At the outset of establishing the SUN CSPG, initial COI challenges were ad- dressed through cross-sectoral training on COI. There is, however, no national COI framework to guide nutrition partners involved in coordination mechanisms. SUSTAINABILITY OF COORDINATION MECHANISMS A key challenge to sustainable functioning of nutrition coordination mechanisms is funding. Individual agencies and coordination mechanisms depend heavily on donor funding for nutrition activities. Thus, coordination mechanisms come alive when there is donor funding and tend to dwindle or die when donor funds become unavailable. CHALLENGES TO NUTRITION COORDINATION IN GHANA Evidence from multiple sources identified key challenges for nutrition policy and program coordination: 1. There are multiple agencies involved in nutrition policy and programming, but their engagement lacks effective organization. This limits their ability to leverage the power of their networks. There is limited appreciation of the role that different sectors and agencies can play to address malnutrition. Malnutrition is predominantly considered a health issue rather than a human development issue. Consequently, there is low prioritization of nutrition in the programs and budgets of non-health sectors and agencies. 2. There is limited nutrition competence in terms of number and distribution of personnel with nutrition training across sectors and agencies. Further, the GHS Nutrition Department has limited capacity and power to lead and coordinate multiple sectors to address nutrition. The ND also lacks tech- nical capacity to coordinate the input and activities of other key stakeholders. 3. The two main national-level coordination mechanisms are functionally inactive. It is unclear whether NANUPACC is still in existence, and the SUN CSPG only meets on an ad hoc basis. A SUN focal point has not been appointed since 2017. As a consequence, there is limited importance given to nutrition when making decisions on human development priorities. In particular, there is limited engagement between government agencies and CSOs, researchers, and business. (12). Although the private sector is always indicated in national nutrition coordination frameworks, it is difficult to locate their participation in nutrition actions, especially at subnational level. Partial decentralization of governance limits engagement of partners at the subnational level on nutrition programming 4. Budgeting and expenditure on nutrition-related actions tend to be uncoordinated. Nutrition budgets are often subsumed under ministerial budgets. Apart from salaries of personnel, government funding of nutrition is extremely low. SUGGESTED STRATEGIES TO IMPROVE COORDINATION OF NUTRITION IN GHANA Implementing the following strategies to improve coordination of nutrition programs could contribute to better nutrition outcomes in Ghana. 1. Establish a National Food and Nutrition Commission to lead engagement and ensure coherence across all relevant sectors (government, UN, research- ers, civil society, business). This recommendation comes out of a joint consensus of key stakeholders in nutrition in Ghana in January 2020 (see at- tached communique by nutrition partners). Parliament and the executive branch of government have the power to make this possible. The National Nutrition Commission (a technical agency) should work closely with a high-level inter-ministerial committee on decision-making for nutrition. Linked to this, it is recommended that the GHS ND should be restructured so that its scope extends beyond health. At subnational levels, nutrition focal persons should be appointed, and functional coordination mechanisms established, as indicated in the National Nutrition Policy. 2. Strengthen capacity of stakeholders across all relevant sectors and agencies. Capacity strengthening can be achieved through a combination of in- service training and pre-service training on the determinants of malnutrition and the role that diverse programs can play to address malnutrition. 3. Parliament and the Ministry of Finance should prioritize and increase government funding for nutrition at regional, district, and community levels. Across agencies, make clear budget lines for nutrition as part of the current outcome-based institutional budgeting system, so that nutrition budgets are not subsumed under various agency activities and thus rendered “invisible.” In addition, nutrition-relevant government institutions should create systems to track disbursements and expenditures related to nutrition actions to enable accurate estimation of nutrition funding.
  • 5. 5 SUMMARY | APRIL 2010 REFERENCES [1] UNICEF. (1998). State of the Worlds Children 1998: Focus on Nutrition. New York: UNICEF.. [2] Gillespie S, Haddad L, Mannar V, Menon P, & Nisbett N. (2013). The politics of reducing malnutrition: building commitment and accelerating pro- gress. Lancet , 382(9891):552-69. [3] Pinto R.F. (2011). The Nutrition Area in Ghana Institutional Assessment. Accra, Ghana; 2011. [4] Aryeetey R, and Atuobi-Yeboah A. (2019). Policy and program review of child stunting and anemia in Ghana. Accra. [5] Aryeetey R, and Atuobi-Yeboah A. (2019) Stories of Change in Nutrition in Ghana Report of In-Depth Interview. Accra. [6] Billings L, and Wullingdool E. (2019). Engaging nutrition stakeholders in Poyentanga: A Case Study on Local-Level Multisector Coordination. SNV/IFPRI . [7] Marquis GS, Colecraft EK, Kanlisi R, Aidam BA, Atuobi-Yeboah A, Pinto C, and R Aryeetey. (2018). An agriculture–nutrition intervention improved children's diet and growth in a randomized trial in Ghana. Maternal & child nutrition,14(S3): e12677. [8] Nutrition Links Project. (2017) Nutrition Integration. Accra, Ghana: University of Ghana/McGill University. [9] Government of Ghana. (2016). National Nutrition Policy. Accra: Government of Ghana. [10] National Development Planning Commission (NDPC). (2016). The Cost of Hunger in Africa (Ghana): Social and Economic Impact of Child Undernu- trition. Accra: NDPC. [11] Aryeetey R, Hromi-Fiedler A, Adu-Afarwuah S, Amoaful E, Ampah G, Gatiba M, et al. (2018). Pilot testing of the Becoming Breastfeeding Friendly toolbox in Ghana. International Breastfeed J,13:30. [12] Aberman N-L. (2020). Approaches for Leveraging Small and Medium Enterprises to Improve Nutrition: Net-Map Assessment of Actors and Activi- ties in Ghana. Accra: SNV/IFPRI. About the Authors Richmond Aryeetey is Associate Professor with the University of Ghana School of Public Health. Sawudatu Zakariah-Akoto is a Research Fellow with the Noguchi Memorial Institute for medical Research. Acknowledgements Funding for this brief was received from the Dutch Government through SNV and the Voices for Change Partnership program. INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE A world free of hunger and malnutrition 1201 Eye Street, NW, Washington, DC 20005 USA | T. +1-202-862-5600 | F. +1-202-862-5606 | Email: ifpri@cgiar.org | www.ifpri.org | www.ifpri.info This publication has been prepared as an output of the Voice for Change Partnership (V4CP) program and has not been independently peer reviewed. Any opinions expressed here belong to the author(s) and are not necessarily representative of or endorsed by IFPRI. © 2020 International Food Policy Research Institute (IFPRI). This publication is licensed for use under a Creative Commons Attribution 4.0 International License (CC BY 4.0). To view this license, visit https://creativecommons.org/licenses/by/4.0.