Story of change in nutrition Zambia
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A presentation given by Namukolo Covic at the Transform Nutrition regional meeting 'Using evidence to inspire action in East Africa' Nairobi, Kenya 8 June 2017.
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Story of change in nutrition Zambia
- 1. FROM COHERENCE TOWARDS COMMITMENT : CHANGES AND CHALLENGES IN ZAMBIA'S NUTRITION POLICY ENVIRONMENT Jody Harris, Scott Drimie, Terry Roopnaraine, Namukolo Covic 8 June 1917, Nairobi, Kenya
- 2. Research design. Objective:Tounderstandwhathasdrivenchangein nutritionsince1990 Quantitative: Drivers of stunting change • Data: • DHS datasets 1992, 1996, 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 2
- 3. Changes in nutrition outcomes 3 0 10 20 30 40 50 60 Underweight Stunting Wasting Chld overweight Female undeweight Female overweight and obesity % 1992 1996 2002 2007 2014
- 4. Context 4 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”)
- 5. 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”) 5 Agenda setting
- 6. Policy coherence 6 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 agreement World 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.
- 7. Leadership Social, political, institutional, economic Political: Permanent secretaries nutrition group, parliamentary nutrition caucus Donors: SUN Fund, DFID, Irish Aid, SIDA, USAID, EU Academic: UNZA, IAPRI, NRDC Media: Post, Daily MailSource: Adapted from UNICEF 1990 Immediate causes Underlying causes Basic causes Food security MAL, MCDMCH, WFP, FAO, PAM, Java foods Care environment UNICEF, MOG, CWZ Health and WASH services MOH, MLGH, WHO, UTH Health status MOH, UNICEF Diet MCDMCH, Java foods, WFP Nutrition NFNC, 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”) 7
- 8. 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”) 8
- 9. Accountability 9 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”)
- 10. Conclusions: opportunities and challenges Written policy complete and coherent Positive benefits from key interventions, insecticide treated nets, WASH 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 10
Editor's Notes
- Presenting on behalf of the study team CIFF- funding TN- making it happen
- We sought to understand the drivers of change in outcomes and policies since 1990- though of course part of what has driven change is what has happened historically, so we go back much further than that in our enquiry. There were two streams of work, one quantitative looking at drivers of stunting change using multiple rounds of DHS data, which I will summarize briefly here but not go into; and one qualitative looking at policy change using multiple qualitative sources of data collected at different levels, from national to district to community, which I will focus on in this presentation.
- Major trends in Zambia are a reduction in stunting over the past 12 years, but a concurrent increase in overweight and obesity in women. I’m not going to go into it here, in a policy process talk, but the major drivers of stunting reduction were increased bednet use for malaria reduction, and improved sanitation A potential driver of increased overweight is changing diets, and this shows calories available from different food groups in Zambia using FAO national data, with analysis over time showing the nutrient-dense foods being less available over time, and the calorie-dense ones being more available.
- Big-picture contextual factors: Large-scale weather patterns such as the current El Niño, Fluctuating global commodity prices (copper makes up 80% of Zambia’s Forex), Global food industry reach (supermarkets, agri-business), Increased wealth with socio-economic inequality- Zambia is one of the most unequal countries in the world. So lots of big-picture changes going on in Zambia, but difficult to assess them all… Conclusion (unsurprising!)…
- This is a timeline showing nutrition-relevant policies and events from Zambia’s independence in 1964 to present day Zambia appears to have followed most of the main international paradigms in its policy and program approach, and there was a sense in the interviews of Zambia’s nutrition community to some extent being buffeted by international priorities, and the subsequent funding and support for certain issues Recently, the focus swung towards current international narratives of stunting, and nutrition-specific/sensitive interventions, and therefore multisectorality On one particular issue, that of nutrition-related chronic disease, there is frustration that this can't be comprehensively addressed because donors are not interested in funding overnutrition projects. conclusion…
- This is an overview of current nutrition-related policy in different sectors, which we read and assessed for nutrition relevance Each column represents a different policy domain such as nutrition, health, agriculture and education. Each begins at a higher level reflecting a broader policy followed by a strategy that may be translated into sub-regional plans. Based on our analysis, there has been increasing coherence in written policy through each of the major domains pertaining to nutrition. This, in turn, has converged into multi-sectoral district nutrition plans that give substance to the main nutrition program in Zambia, the 1000 days program. There is clearly deliberate and methodical action across different domains of policy as sectors come under review and their strategies are revised. This process is far from finished, but the language of nutrition is being incorporated into other sectoral policy. Conclusion… The literature on policy coherence says that…
- This is a list of key nutrition-relevant organizations in Zambia, mapped to the UNICEF framework. These are also the organizations from which we interviewed our research respondents. A key organisational leader is the National Food and Nutrition Commission, NFNC, the nutrition arm of government under the Ministry of Health. In terms of international leadership, the Scaling Up Nutrition movement has had multiple roles in Zambia: Financing through the SUN Fund. Advocacy through support of the SUN Civil Society Organisation (CSOSUN). A leadership triad has emerged including government, through NFNC, nutrition professionals through the Nutrition Association of Zambia, and civil society through CSOSUN Conclusion…
- This graph shows HANCI, hunger and nutrition commitment index, scores for Zambia. Zambia’s scores for the nutrition commitment index have fallen since 2012, and Zambia is falling in the country rankings for nutrition commitment as other countries out-perform it What do we mean by commitment? … Firstly, Commitment means different things: Political attention in high-level speeches and decrees; vs political commitment such as writing policy and setting targets; vs system commitment such as allocation of resources. … Secondly, Commitment to hunger reduction is not the same as commitment to nutrition: In Zambia, the politics of hunger are front-and-center, with maize security and mealie-meal prices high on the agenda, but nutrition has been notably absent from high-level policy discourses. … Thirdly, ‘Government’ itself is not monolithic, but rather comprises different sections with different roles, mandates, interests and actors, and the commitment of different parts of government to nutrition – for instance technical vs financial arms - is likely to vary. Conclusions… Indicators for the Nutrition Commitment Index include: … Presence of a budget for nutrition (Zambia scores moderately in 2014, having a sectoral budget for nutrition but not separate budget lines); … enshrining of key infant feeding legislation in law (Zambia scores highly on this, as aspects- though not all- of the International Code of Marketing of Breastmilk Substitutes are in law); … and enactment of nutrition-related policies and programs (Zambia scores highly on many of these; it scores less well for instance on population access to improved water and sanitation).
- This is a social network map using the Netmap method, showing key actors in national nutrition policy; their influence shown by the size of their bubble; and any links of ‘accountability’ between them. The network map can approximately be seen in two halves: National in the top-left, and international in the bottom-right. Only seven actors are linked to both ‘sides’ of the network: In the center are NFNC and CSOSUN, clear hubs for nutrition, but all of their accountability connections are outwards, meaning they must try to please multiple different actors. They were not assigned high influence by respondents, and their control over the issue clearly does not match the multiple and central roles assigned to them. They can be seen as ‘boundary spanning’ organizations, with many masters and little power. Another key observation is that the network map appears to be capturing several forms of accountability, including financial accountability through funding contracts; institutional accountability in terms of management authority; and political accountability through the processes of democracy . Conclusions (2)…
- Written policy for nutrition is strong and up-to-date in Zambia, and is coherent both within the nutrition sector and across other relevant sectors. From the interviews and Netmap, we see that the nutrition agenda is currently split to some extent between national and international interests, which often but not always align. This split makes the sector vulnerable, and key boundary spanning actors pulled in many directions likely find it difficult to follow a coherent agenda. The predominance of international institutions in funding and agenda-setting, even more coherently recently through SUN, has to some extent bypassed the need for government action, meaning that government commitment to nutrition by several metrics is now low. Strengthening the capacity of the population to call for their nutrition rights and hold government to account would increase government commitment, and strengthening the strategic capacity of boundary spanning organizations would help them to strengthen and coordinate delivery.