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Story of change in nutrition Ethiopia
The document discusses a qualitative study on nutritional sensitivity in Ethiopia, exploring the establishment and operationalization of this concept across various sectors and levels. It includes insights from key informant interviews and emphasizes the importance of multisectoral coordination, challenges in implementation, and the experiences of local communities. Conclusions highlight the need for system adaptation and ongoing changes in the uptake of nutrition-sensitive initiatives.
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Story of change in nutrition Ethiopia
- 1. Stories of Changein Nutrition: Ethiopia Andrea Warren, PhD candidate June 28, 2016 Addis Ababa, Ethiopia
- 2. Introduction • Stories ofChange in Nutrition • Document experiential learning • Tracing an idea: Linear cascading case study
- 3. Study design andmethods • Flexible and adaptive qualitative study • Data sources: o over 60 qualitative key informant interviews with federal officials, international donors, NGOs, and partners, subregional agriculture, health, and social protection officials, kebele officials o 30 household interviews o Review of national strategies, program documents and evaluations
- 4. Study questions • Howis nutrition sensitivity becoming established across sectors and levels and what does it take to make ‘nutrition sensitivity’ operational? • Questions of institutional structures, capacities, practices, and attitudes • The operating systems through which it will be implemented • The conditions and perspectives of the communities that are meant to receive it.
- 5. International Federal Zone Woreda Kebele Community Federal/International: (largely) PSNP actors Woreda and zone: PSNP, agriculture, and health personnel Kebele: leaders Community: Household experiences with health, agriculture, and safety net programming
- 6. International and Federal •Multisectoral coordination, leadership, and commitment • A progressive policy environment for nutrition • How are ideas and interventions cascaded from federal to kebele level? • What are some of the real world challenges of implementing nutrition-sensitive agendas?
- 7. Zone and Woreda •Awareness of concepts and national strategies • Coherence of perspectives on nutrition–causes and outcomes • Vagueness of roles of health, ag, and social protection • Lack of enforced coordination mechanisms • Day to day challenges • Perceptions of frontline worker workloads • Limits on implementation: the state of existing platforms
- 8. Household • Engagement in programming: whatare the constraints beyond education? • Environmental barriers • Complexity of risk
- 9. Conclusions and Implications •Implications for implementation • For consideration: Change the system or adapt the programming? • Stories of change really one of ongoing change—pieces of a picture that begin to fit together when researching the uptake and adaptation of an idea and the experiences of those grappling with this idea in real time.
- 10. Acknowledgments Study participants—federal tohousehold Eskinder Wolka and Dawit Johannes, research assistants Kenaw Gebreselassie and the Transform Nutrition Team
Editor's Notes
- #3 Ethiopia’s story of change is one of ongoing change. With considerable momentum and attention to nutrition at high levels, the key to making sure that nutrition remains a priority and progress is made is for high-level attention to turn to how to make nutrition programming work throughout the country. This research therefore focused on the lower levels of government where implementation occurs, as well as among the communities who receive the programming. This research was largely concerned with how the idea nutrition sensitivity was becoming established in Ethiopia and through Ethiopia’s health extension, agriculture extension, and social protection programs. Making nutrition programming work in any setting brings up questions of capacities, practices, and attitudes. It requires a consideration of the service delivery platforms through which it will be implemented, and the conditions and perspectives of the communities that are meant to receive it.
- #4 Through case study research, we can piece together a picture of what implementing complex programs will entail and move some of the discussion around the policy agendas into questions of practice, uptake, and thinking about potential outcomes. We conducted in-depth qualitative interviews with actors at different levels, particularly implementers, to understand the challenges of implementing nutrition programming.
- #5 These were our study questions… We focused on the mid-level government actors responsible for the day to day of program implementation. We focus on this segment of the process because there is typically not enough emphasis on these actors, how they do their jobs, and how to better support the process of implementation. It is more common to see research jump from high-level rhetoric and discourse to community or individual-level outcomes without much attention to what happens in between, and thus without much attention to the actual intervention that reaches the community—this jump represents a large and important knowledge gap in improving health outcomes.
- #6 For your reference, at the top of the slide is the structure of governance in Ethiopia and below are the groups of actors included in the interview.
- #7 The actors at the international federal level form an important part of the enabling environment for nutrition policy. I will only briefly discuss this space at federal level—overall, multisectoral coordination to carry out nutrition programming remains a challenge. Other challenges include: Incentivizing sectors work together, establishing an authority for nutrition, and making sure all sectors are genuinely accountable to coordination as well as to their nutrition commitments—three issues that are fairly interlinked. Overall, however, the policy environment for nutrition is well-developed and progressive. Commitment is impressive, and given the growing wealth of research, experience, and data, momentum is likely to continue. Given all the positive work being done to build an enabling policy environment at national level, we focused on how ideas and interventions are cascaded from federal to kebele level. What are some of the real world challenges of implementing nutrition-sensitive agendas? In any country context, attention to the implementing structures—how they are supposed to operate, how they operate in practice, what resources do they have, and how is knowledge transmitted to them—will be key to moving ideas into practice.
- #8 Communication from higher to lower levels of government was a challenge. Nutrition sensitive agendas weren’t yet well-known at zone, and particularly woreda, level. The terminology was unfamiliar to the majority of the officials I interviewed. Several respondents in agriculture and social protection had a pretty nuanced perspective on nutrition, and they could explain their work in terms of nutrition though they were not familiar with the term itself. What was lacking was a coherent, consistent perspective on nutrition. For example, other agriculture actors were less certain of their role in addressing nutrition and less convinced that agriculture had a significant role to play. Actors in both health and agriculture thought that multisectoral coordination was likely to be challenging. Some information sharing between the two sectors was common, but both sectors were highly busy with their own work and found coordinating with other sectors challenging logistically. Both sectors seemed to lack guidance in how to conduct multisectoral planning, and noted that mechanisms to ensure accountability would be vital to making it work in future efforts. Nutrition sensitive programming will largely rely on existing service provision programs—the health extension, ag extension, and PSNP, among others—for implementation. I spoke with implememters about challenges they face in carrying out this existing programming. Many of the challenges were deeply-rooted and somewhat self-reinforcing. For example, low salaries and high workloads led to high staff turnover at all levels, including frontline workers as well as implementers and administrators. New personnel were not commonly offered the full range of trainings around the programs they were implementing. Without trainings, awareness of the programs as well as the national strategies underlying them—the NNP in particular—was low. High turnover continually eroded knowledge capacities and fostered an environment where it would be difficult for all program staff to share a coherent perspective on the causes and outcomes of nutrition and their roles in addressing it. Low awareness also points to communication gaps between levels.
- #9 Slow program uptake and a lack of education were listed by implementing actors as some of their biggest challenges, so we interviewed households in a select community to get a better sense of the ways in which the households experienced and made use of the agriculture, social protection, and health services provided. This was with the goal of understanding where ntrition-sensitive programming might fit into their lives, and what benefits or challenges they thought they might face in taking on that type of programming. Households suggested that the lack of education was less of a problem—over the years, they had received nutrition education from various sources, including the health extension program and ag extension in a few cases. They felt they largely understood nutrition issues, particularly IYCF, and didn’t perceive lack of knowledge as a barrier. Not to say that education isnt a key part of ongoing health strategies, but households spoke of constraints that made it difficult if not impossible to take on the advice and services they were already being offered. Their environment was particularly challenging—the lack of a road, degraded land, decreasing farm size, and the general roughness of the landscape—the nearest town being a 1-2 hour hike—limited a households’ ability to diversify their livelihoods, earn and save income, send their children to school, access health services, and achieve food security. They did not feel it was within their power to change much about their current way of life without a road into the area. Indeed, the impact of environmental interventions in combination with behavioral had been very impressive in this area—but the suggestion that the primary changes were environmental, which seemed to facilitate changes or adaptations in behavior, is an important one here. I’m speaking of intensive soil and water conservation efforts implemented several years ago that significantly improved soil fertility and crop yields, leading to better food security for many households, and a fairly recent government-led initiative to promote latrine use, which households now, it seems, greatly prefer to open defecation. Telling households to consume protein and a variety of fruits and vegetables meant little when they could neither afford animal-source foods nor easily grow or access fruits and vegetables.
- #10 All this to say, we can only expect nutrition programming to be as successful as its platforms, and we can expect communities to engage with it only as well as they can engage with existing programming. What will be key to making nutrition work in a given setting is setting out deliberately and explicitly to understand implementation processes as well as community conditions. if implementers have reached a certain limit where they need much more support to realign and restructure their practices, and if communities have reached a point where their environments are simply the biggest constraints on their behavior despite what they would choose otherwise, then these are the areas that are worth further, serious consideration. Accelerated progress and scaled up programming will take place, but to do so and achieve the goals of reducing stunting and undernutrition its important to try to ensure quality, even coverage, the capacities to track and monitor this programming, and the actual “fit” of the programming with the needs and constraints of communities. This is a look at some of the more systematic issues of implementation likely to be encountered, and an assessment of how national agendas align with capacities to implement them. In the interest of adapting this approach to any country context, there is likely a wealth of information from government actors and NGOs already working with these concepts at different scales. This research is meant to contribute to this conversation, provide a way of discussing these types of barriers and a framework for the emerging knowledge base around the implementation of nutrition sensitive agendas. The value in this type of exploratory qualitative research is to find new avenues for investigation and provide some grounding and context to the findings emerging through quantitative analysis.