nutrition upstream: improving policies, programmes… · nutrition upstream improving policies,...

Nutrition UpstreamImproving Policies, Programmes, and Partnerships for Maternal and Child Nutrition in Asia

Nu

trit

ion

Up

stre

am: I

mp

rovi

ng

Pol

icie

s, P

rogr

amm

es, a

nd

Par

tner

ship

s fo

r M

ater

nal

an

d C

hil

d N

utr

itio

n in

Asi

a

Recommended citation: Ruducha, J. (2016). Nutrition Upstream. Improving Policies, Programmes, and Partnerships for Maternal and Child Nutrition in Asia. UNICEF Regional Office for South Asia. Kathmandu, Nepal.

This research was developed, conducted and authored by Jenny Ruducha, of Braintree Global Health and Boston University School of Public Health, Center for Global Health and Development. The research team included Carlyn Mann, who analyzed quantitative network data and built visual plots, and Amiya Bhatia and Renuka Pandya, who abstracted and analyzed qualitative data based on taped interviews.

This research would not have been possible without the support of the Maternal and Young Child Nutrition Security Initiative in Asia (MYCNSIA, 2011-2015) and UNICEF Nutrition teams in Bangladesh, Indonesia, Nepal and the Philippines with funding provided by the European Union. Country specific UNICEF teams included: Nepal - Stanley Chitekwe, Anirudra Sharma, Pradiumna Dahal and Sanjay Rijal; Bangladesh - Anuradha Narayan, Andrew Musyoki Sammy, Farhana Sharmin, Mohsin Ali and Ireen Akhter Chowdhury; Indonesia - Harriet Torlesse, Ninik Sri Sukotjo and Isti Rahayuni (interpreter); and the Philippines - Willibald Zeck, Aashima Garg, Maria Evelyn Carpio, Paul Zambrano and Melvin Marzan. The intellectual lead to document upstream organizational processes for maternal and child nutrition was provided by Victor M. Aguayo and Kajali Paintal from UNICEFRegional Office for South Asia.

Lastly, the research team would like to thank the 138 study participants from different government departments, United Nations agencies, donors, national and international NGOs, academia and associations. They kindly offered their time to answer survey questions and share their insights to help us understand how upstream engagement is shaping national policies, programmes and partnerships for maternal and child nutrition in Asia.

Dr. Jenny Ruducha

UNICEF Regional Offi ce South AsiaLekhnath Marg, Kathmandu 44600, Nepal

Copyright © UNICEF South AsiaPrinted in October 2016Technical lead Victor M. AguayoGraphic design Giovanna BurinatoPhotographs Dimatatac pp. 79, 86; Esteve p. 36; Estey pp. 40, 46; Ferguson pp. 38, 45, 52, 76; Lemoyne p. 75; Noorani pp. 18, 22, 29, 35; Nybo pp. 3, 4, 5, 10, 16, 23, 30; Pirozzi cover photo, pp. 6, 8, 12, 54, 57, 64, 67, 69, 71, 73.

Nutrition Upstream Improving Policies, Programmes and Partnerships for Maternal and Child Nutrition in Asia3

SummaryThe partnership between UNICEF and the European Union (EU) through the Maternal and Young Child Nutrition Security Initiative in Asia (MYCNSIA, 2011-2015) provided an opportunity to document upstream engagement for maternal and child nutrition in four countries - Bangladesh, Indonesia, Nepal and the Philippines – through 10 case studies. We used a mixed-methods approach including organizational network analysis, key informant interviews with government and non-government stakeholders, and in-depth reviews of national policy and programme frameworks:

• To document upstream engagement of country partnerships and networks for nutrition and identify good practices and areas for improvement to make upstream engagement for nutrition more effective.

• To document UNICEF’s role in national upstream engagement for nutrition and identify opportunities to strengthen UNICEF’s upstream work in policy infl uencing, strategy design, and programme scale up in Asia.

The 10 case studies included in this research show that national governments and their development partners have used global and national evidence to create a new momentum for upstream engagement for maternal and child nutrition. Most recently, the prevention of child stunting has become an effective driver for multi-partner and multi-sectoral commitment to nutrition. Governments and their nutrition partners have created multi-stakeholder partnerships, networks and platforms to accelerate progress for nutrition at the national level. These partnerships and networks have

taken different shapes in different epidemiological, political, and socio-economic contexts to ensure upstream progress for nutrition. However, two features are common to most contexts: 1) the majority of the relationships within national partnerships and networks go beyond communication to include coordination and collaboration; and 2) in most instances, organizational networks for advocacy, policy formulation, strategy development, and programme design have a high density of partners and direct relationships while organizational networks for capacity building and programme scale-up are less dense, signaling less support to implementation.

UNICEF upstream engagement for maternal and child nutrition at the national level is positively acknowledged by its national partners, who perceive UNICEF as: 1) the most infl uential partner, facilitating national governments’ commitment to global nutrition narratives, goals, and good practices; 2) the best coordinator and bridge builder with and among nutrition partners; and 3) the ‘go to’ partner for the latest research and programmatic evidence and guidance. However, nutrition partners fi nd that sometimes UNICEF country teams, which in middle income countries tend to be small, stretch themselves too thin. Partners suggest that in such settings, UNICEF should focus on its strengths - situation analysis, technical advice, policy formulation, strategy design and capacity building - to produce and sustain large scale results for maternal and child nutrition at the national level. In settings where national capacity is weak, UNICEF should also utilize its infl uence to build stronger partnerships for program scale-up with quality, while monitoring trends and progress for greater accountability.

Nutrition Upstream Improving Policies, Programmes and Partnerships for Maternal and Child Nutrition in Asia 4

RationaleOver the past decade, the global nutrition landscape has undergone unprecedented changes and has embraced the need for comprehensive approaches to respond to the global problem of maternal and child undernutrition. A common organizing theme is upstream engagement, a strategy that broadly includes the advocacy and technical support needed to design and scale up policies, strategies, and programmes for maternal and child nutrition. Upstream engagement includes emphasis on partnerships and networks within and across organizations and sectors to achieve results for nutrition.

UNICEF has long supported global, national and subnational partnerships for scaling up policies and programmes to advance children’s rights. Upstream engagement was articulated for the fi rst time in UNICEF’s medium-term Strategic Plan 2006-2013, with a cross-cutting theme on policy advocacy and partnerships for children’s rights. It continued to be further strengthened in UNICEF’s Strategic Plan 2014-2017, which outlines the importance of partnerships and networks to generate evidence about the situation of children, to bring children’s issues to the forefront of policy dialogue and programme design and implementation, and to catalyze strategic action for the realization of children’s rights, including the right to good nutrition (UNICEF, 2013).

UNICEF’s Approach to Scaling Up Nutrition Programming for Mothers and their Children (UNICEF, 2015) outlines the operationalization of the Strategic Plan 2014-2017 for maternal and child nutrition and calls for leveraging partnerships to scale up the delivery of nutrition-specifi c interventions and nutrition-sensitive development.

UNICEF’s efforts on maternal and child nutrition are part

of the global Scaling Up Nutrition (SUN) movement, which aims to bring together national governments, international donors, United Nations organizations, national and international non-governmental organizations (NGO), national civil society groups and movements, research, academia, media and the private sector to accelerate progress for maternal and child nutrition worldwide. The global direction and strategies for nutrition are further reinforced by the Sustainable Development Goals (SDGs), which build on the commitments of the Millennium Development Goals (MDGs) for reducing child undernutrition. SDGs provide a unique opportunity for effective upstream engagement and increased synergy across organizations and sectors.

The evidence base on how to make upstream engagement for nutrition more effective is still weak. With the emergence of broad-based initiatives for maternal and child nutrition, there is a need to document how to engage successfully with partners across organizations and sectors to deliver effective advocacy and communication, policy formulation and enforcement, and programme design and scale-up (Garrett and Natalicchio, 2011). The partnership between UNICEF and the European Union (EU) through the Maternal and Young Child Nutrition Security Initiative in Asia (MYCNSIA, 2011-2015) provided an opportunity to document 10 case studies of upstream engagement for nutrition in four Asian countries: Bangladesh, Indonesia, Nepal and the Philippines.

We hope that the knowledge and insights gained from this research will contribute fi lling the evidence gap about upstream engagement for nutrition in low- and middle-income countries and to document the contribution that effective partnerships and networks can make to accelerate progress towards national SDGs for nutrition.


ObjectivesThe objective of this research is two-fold:

• To document upstream engagement of country partnerships and networks for nutrition and identify good practices and areas for improvement to make upstream engagement for nutrition more effective.

• To document UNICEF’s role in national upstream engagement for nutrition and identify opportunities to strengthen UNICEF’s upstream work in advocacy, policy infl uencing, strategy design, and programme scale-up.

MethodsWe used a mixed-methods approach to document the background situation, catalytic events, progress markers, and organizational partnerships and networks involved in advancing national policies and programmes for maternal and child nutrition. We conducted qualitative interviews with government and non-government stakeholders in a neutral space to obtain and triangulate views, perspectives and experiences on the role of different partners in contributing to the upstream accomplishments. We conducted a structured Organizational Network Analysis (ONA) to understand the roles, positions and network dynamics that shaped the processes leading to the upstream achievement in each case study. Additionally, we reviewed the existing

data to collect complementary information about the key events and triggers that led to the upstream progress.

Selection of case studies. UNICEF country offi ces in Bangladesh, Indonesia, Nepal and the Philippines identifi ed recent upstream advancements in maternal and child nutrition in their respective countries in fi ve areas: 1) policy dialogue and policy development; 2) design of new programmes or re-design of existing programmes; 3) development or strengthening of organizational capacities at the national level; 4) evidence generation, including national surveys, assessments, surveillance, or data analysis; and 5) national communication and advocacy initiatives. The intention of these upstream advancements was to strengthen in-country commitment to deliver proven nutrition interventions for children and women at scale.

We identifi ed 10 case studies that cover a broad range of issues in low-income (Bangladesh and Nepal) and middle-income (Indonesia and the Philippines) countries. These include: advancing national level nutrition policies to address child stunting; strengthening the capacity and effectiveness of government systems to protect, promote and support optimal infant and young child feeding; advancing national policies and programmes for the prevention and control of micronutrient defi ciencies; or advancing national policies and programmes for the provision of therapeutic care for children with severe acute malnutrition.

Tools and techniques: In addition to the main qualitative and quantitative methods, additional tools were used to understand the overall process of upstream progress. These included:

• Desk reviews: In order to get an in-depth understanding of the background situation for each case study we conducted desk reviews of: a) relevant policy and programme documents; and b) Demographic and Health Surveys, National Nutrition Surveys and programme monitoring data.

• Policy timelines: We documented the sequence of catalytic events and processes that led to a major policy or programme development upstream. With this information we developed a visual policy timeline to document the key events along the upstream engagement pathway.

• Stakeholder mapping: for each case study we mapped the key organizations involved in the upstream development. These organizations were included in the organizational network analysis.

Identifi cation of respondents: For each of the organizations selected, we listed in order of priority for interviews up to three persons involved with the upstream development. We tailored the interviews to the information needs and the type of information that respondents were able tocontribute depending on their organization’s role in improving the nutrition policy and programme environment. In some situations, we interviewed the same respondent from a given organization to obtain information for more than one case study. In other cases we included different respondents from the same organization to document different case studies.


Data collection instruments: Instruments were developed to record observations and to document the roles and experiences of the organizations selected for each case study. The instruments had four sections: 1) basic background characteristics of the respondent; 2) Organizational Network Analysis (ONA); 3) progress markers for upstream developments; and 4) working relationship with UNICEF. The ONA followed a standard structure that included a matrix with questions about the working relationship with a given partner specifi c to the index case study. Two fi nal questions in the ONA section focused on the intensity and quality of the relationship. To get an indication of the level of prestige of organizations, respondents were asked to nominate organizations that they perceived to be the most infl uential. The fi nal question, specifi c to UNICEF, asked partners to mention the benefi ts and challenges of their partnership experience with UNICEF.

Data collection: An independent investigator (J. Ruducha) travelled to the four countries included in the research (March and April 2015) and conducted all the interviews. UNICEF staff coordinated the interview appointments but did not participate in the interviews. After describing the purpose and content of the interview and obtaining verbal consent, the ONA instrument was administered and respondents were asked a series of questions about their relationships with each of the organizations selected for the index case study.

This was followed by a qualitative semi-structured set of

questions to triangulate information on the perspectives and experiences of the key organizations involved in the upstream process. The interviews were conducted in a neutral space to facilitate an open discussion and minimize bias. Organized prompts were added to obtain information about the major markers of progress, the timing of their occurrence, who was involved, and how they led to the upstream change for nutrition. A question about lessons learned completed this line of inquiry.

Most of the interviews were conducted in English but there were a few exceptions. In Indonesia an interviewer/translator was hired and trained to conduct the interviews, due to the inclusion of many representatives of district government departments who did not speak English. However, the independent investigator was present for all the interviews to answer questions and support the interview process. To a limited extent, in Bangladesh and Nepal, a translator was made available to the independent investigator for a few interviews that had to be conducted in Bengali or Nepali.

The duration of interviews ranged from 45 to 90 minutes and most were recorded after obtaining consent from the respondent. A total of 138 interviews were conducted (Table 1). The types of organizations included government ministries and departments (39%), United Nations agencies (25%), national and international NGOs and civil society organizations (20%), donors (5%), academic institutions (4%), and civil associations (7%).


Table 1 Respondents by case study and type of organization1

GovernmentUnited Nations (UN)

INGOs, NGOsCivil Society

Donors Academia Associations Total

Nepal

1. MSNP 8 8 4 2 0 0 22

2. IYCF 5 5 6 1 0 0 17

3. CMAM 1 2 3 0 0 0 6

Total 14 15 13 3 0 0 45

Bangladesh

1. DNSO 5 3 2 2 1 0 13

2.IM-SAM 2 1 0 0 2 0 5

3. MN 5 1 2 0 1 0 9

Total 12 5 4 2 4 0 27

Indonesia

1.RAN-PG, RPJMN, SUN

8 3 1 1 1 0 14

2. IYCF 8 4 7 1 0 0 20

Total 16 7 8 2 1 0 34

Philippines

1. NSMP 8 5 2 0 0 10 25

2. EWS 3 4 0 0 0 0 7

Total 11 9 2 0 0 10 32

Total (%) 53 (39%) 35 (25%) 27 (20%) 7 (5%) 5 (4%) 10 (7%) 138

1 Refer to the list of acronyms (p. 94)

Data Management: Interviews were recorded and password protected after obtaining permission from the respondent. For the ONA component, responses were written on paper questionnaires that were only available to the independent investigator to protect confi dentiality. Information from questionnaires was entered into a structured excel format for further development of network matrices and analysis. Personal identifi ers were not entered in the computer storage system. Data was cleaned and any potential inconsistencies were double-checked with the paper-based instruments and interview recordings.

Qualitative data analysis: Recorded interviews were transcribed by two experienced qualitative analysts. Key information and non-redundant information were abstracted into a pre-designed matrix that provided a consistent system for identifi cation of themes of interest for the case studies. Based on the questions of the qualitative survey that refl ected the major areas of inquiry, we identifi ed the following thematic categories: advocacy, policies, activities, partners, government, laws, decrees and regulations, resource allocation, triggers of the change process, timeline of the change process, key events in the nutrition environment, achievements and successes, lessons learned, and working with UNICEF. The

information was analyzed and integrated into the report. This process yielded a main story that was consistent across multiple stakeholders. Differences in views or perceptions were noted and further explored to understand organizational roles and partnership dynamics.

Organizational Network Analysis (ONA): The ONA followed a systematic process aligned with the structure of the questionnaire. The fi rst question in this series was establishing whether a relationship existed between two organizations and if so, whether there was any relationship related to the index case study. Any positive response from either party formed an unconfi rmed relationship in which reciprocity was not required. Subsequently we established whether both parties knowing each other thereby forming a confi rmed relationship.

A further analysis of working relationships assessed mainly three types of interactions: advocacy, capacity building and programme planning and scale-up. Although the questions varied slightly depending on the case study, the general domains remained similar. The intensity of the relationships was measured by asking respondents to report on the increasing layers of their relationship beginning with communication, followed by coordination, collaboration and


integration. If partners did not report in concordance about the intensity of their relationship, the lower reported level was used in the analysis.

The data entered in excel fi les was constructed into distinct matrices for each of the measures developed. UCInet software was used to analyze the data. This analytic tool provides multiple network statistics and facilitates the construction of visual plots to examine the organizational relationships. The NetDraw programme was used to develop the plots. Colored nodes were used to represent the types of organizations in the network while node shapes represent the location (national, regional or district level). The size of the nodes was adjusted for betweeness or degree centrality (see defi nitions below). For measures related to most infl uential, best coordinator and having the latest evidence, a weighted degree centrality score was computed. It weighted the order of the nominations from number one to number fi ve, combining the number of nominations in addition to the rank order of the responses.

Multiple ONA measures were used in assessing the different types of networks and relationships. Below we summarize a description of each measure, how it was measured, and its signifi cance in explaining organizational dynamics.

The node or individual organizational ties include:

• Degree centrality is calculated by simply counting the number of adjacent links to or from an organization. Based solely on direct connections, it refl ects the potential power of having direct relationships (Freeman, 1979). These direct links reduce the reliance on intermediaries to access information or resources. The assumption is that more connections are better than fewer connections.

• Betweeness centrality measures the extent to which organizations fall between pairs of other organizations or individuals on the shortest paths connecting them. This measure represents potential mediation or fl ow of information or resources between organizations in the network. It is used to assess the power in networks, as an organization may control the fl ow of information and potential resources, thereby increasing dependence of others who are not directly connected in the network.

The relationship level ties include:

• Multiplexity describes multiple relationships among the same set of organizations. In the case studies, three types of relationships were investigated: advocacy, capacity building and scale-up. Therefore the multiplexity score was either 1 (if only one type of relationship existed), 2 (any combination of two relationships) or 3 (all three relationships were confi rmed)

• Intensity describes the level of interaction between different organizations or nodes. The levels of interactions in this research were classifi ed as: communication, coordination, collaboration, or integration.

Network level ties include:

• Centralization is an expression of how tightly the network structure is organized around its most central point. The general procedure involved in any measure of graph centralization is to look at the differences between the centrality scores of the most central point and those of all other points. Centralization, is the ratio of the actual sum of differences to the maximum possible sum of differences (Hanneman and Riddle, 2005)

• Density is defi ned as the sum of the ties divided by the number of possible ties (i.e. the ratio of all tie strength present to the number of possible ties). The density of a network gives us insights into such phenomena as the speed at which information diffuses among the nodes and the extent to which actors have high levels of social capital and/or social constraint (Hanneman and Riddle, 2005).

The main fi ndings from our qualitative research and organizational network analysis for each case study are presented by country in the subsequent chapters while the major fi ndings that emerge from the 10 case studies are summarized in the next section.


FindingsDespite growing consensus on what needs to happen to improve nutrition outcomes, less is known about how to make it happen. These 10 case studies spanning four Asian countries at different stages of epidemiological transition, economic growth, and social development are illustrative of the potential role of upstream engagement to deliver results for nutrition at national and sub-national scale.

Upstream engagement for nutrition aims to create an enabling policy and programme environment for nutrition

through effective partnerships and networks that share a common goal and have agreed on an appropriate distribution of roles, responsibilities, and accountabilities. This section summarizes the main fi ndings that emerge from the 10 case studies. It is divided in two parts. Firstly, we present the main fi ndings pertaining to upstream engagement at the national level to advance policies, programmes and partnerships for nutrition. Secondly, we present the main fi ndings related to UNICEF’s role in catalyzing or infl uencing national upstream engagement for nutrition with government and non-government partners.

Governments and their development partners have used global evidence and national data

to reset the momentum for nutrition. Many of the achievements described in the case studies presented in this report were catalyzed by evidence and momentum for maternal and child nutrition at the global level. The recognition of the changing epidemiological, political and programme environment for nutrition globally and nationally generated a new energy to move forward. Opportunities were seized to connect national governments with key nutrition stakeholders nationally and globally. This is illustrated, for example, by the fact that high level government leaders, including presidents and prime ministers, have endorsed the principles of the Scaling up Nutrition (SUN) movement and have agreed to incorporate these principles into national policies, strategies, programmes and plans for nutrition.

Nutrition upstream: Advancing policies, programmes and partnerships

1

The prevention of child stunting, integrated in all major national policies and programmes,

has been an effective driver for multisectoral commitment to nutrition. Governments, often through their ministries of health, are at the center of nutrition policy development and programme scale-up. Government departments, especially in the ministries of health, provide leadership in guiding national policy and programme development for the prevention of child stunting. In many countries, multisectoral nutrition policies and programmes have been developed and are being scaled up. However, multisectoral partnerships and platforms to implement these policies and programmes are not always fully operational at the national level and are often limited at the subnational level. In countries where representation from multiple sectors was included in the organizational network analysis, non-health ministries were often not integrated into platforms for generating nutrition results.

2Organizational networks for advocacy and policy infl uencing have a higher density

(more connections) than networks for strategy development and programme scale-up. Across all case studies, the organizational network analysis reveals a pattern of reduced participation of partners as upstream engagement moves from advocacy/infl uencing to strategy development and programme scale-up. In many cases, the reduced number of partnerships for scale-up is indicative of a signifi cantly lower number of partners with expertise in strategy design and programme scale-up at the national level. In other cases, it refl ects poorer coordination among partners for programme scale-up. This is frequent in contexts with many non-governmental implementing partners. When organizations work independently, without coordinating their efforts, there is a risk of duplication and redundancy, opportunities for synergy are missed, and programme effectiveness and impact are reduced.

4

Platforms to move forward the nutrition agenda at the national level have a high

degree of direct relationships among partners, particularly for advocacy and policy infl uencing. Most of the ONA plots show a high density score, which means that nutrition partners have been able to establish a high degree of relationships in the form of partnerships and networks, particularly for advocacy and policy infl uencing. The engagement of partners in direct dialogue with each other has been effective to share information and ideas, build a common vision for maternal and child nutrition in the country, create consensus for policy formulation and policy development, agree on the introduction of new interventions and innovations, and prioritize the use of organizational, human and fi nancial resources.

3


Partnerships and networks are fl uid and dynamic in responding to the changing

needs. Most of the respondents involved with the organizational network analysis knew each other. However, they selected different degrees of involvement and association in partnerships depending on the goal that was pursued by the partnership and the mandate and comparative advantage of their organization. This strategy produces effi ciency, as partners with specifi c skillsets work together in smaller groups to advocate for new ideas, formulate new policies and strategies, design or scale up programmes, build institutional/individual capacities, or solve problems together. The fi ndings of the organizational network analysis show that the positions and roles of different organizations within partnerships and networks changed over time to accommodate new goals or take advantage of the expertise of a given partner.

5

The majority of relationships within national partnerships and networks go beyond

communication and include coordination and collaboration. Integration is mainly reported by units or departments that are part of the same organization. The organizational network analysis fi ndings on multiplexity indicate that most relationships in the partnerships and networks for nutrition are built to work together for more than one upstream result. A few partners play a key role in bridging other partner organizations that do not have direct relationships with each other. Connecting partners is an important function as it contributes to communication and integrity within the network, creates a unifi ed voice for nutrition results, and accelerates progress on the implementation of policies and programmes.

6

Different forms of partnership and network dynamics have emerged in different political

and socio-economic contexts to ensure upstream progress for nutrition. In countries with lower resources and institutional capacity, nutrition partnerships and networks include a wider range of donors, bi-lateral and multi-lateral partners, and international non-governmental organizations. Conversely, in countries with transition economies, partnerships and networks for maternal and child nutrition include a larger mix of government agencies and national organizations. In countries with more decentralized political structures and decision making processes - where central governments have less control over subnational programme implementation - regional, district and other subnational platforms for leadership and coordination emerge to provide technical support, build capacity, and design and implement local solutions for programme scale-up.

7

Working relationships for upstream nutrition engagement may not be visible to

everyone and may not correspond to the offi cial roles of organizations. Much advancement in the development of a shared understanding and vision on maternal and child nutrition at the national level and the documented progress in nutrition policy development and programme scale-up has happened behind the scenes. It has frequently been related to the infl uence of one or more individuals, often in capacities that were beyond the offi cial role and responsibility of the organization (s) that these individuals were affi liated with. The organizational network analysis captures some of these dynamics and reveals how specifi c organizations have played upstream roles for nutrition that were beyond their mandate.

8


The 10 case studies illustrate the diversity of UNICEF’s upstream work for nutrition in a variety of socio-political environments. Although contexts and approaches vary, fi ve key fi ndings emerge with respect to UNICEF’s upstream work in supporting the development of national policies, programmes and partnerships for maternal and child nutrition.

UNICEF upstream: Supporting policies, programmes, and partners for nutrition

National partners for nutrition rate UNICEF as ‘the most infl uential’ partner. In most case

studies, national partners perceive UNICEF as the most infl uential member of the nutrition network, connecting and guiding national governments to global nutrition narratives, goals, and guidance. UNICEF plays an active role in facilitating government leaders to participate in international fora and commit to globally-agreed targets and evidence-based approaches to tackle malnutrition in their countries. UNICEF staff often refer to this upstream work for nutrition as ‘supporting governments to be in the lead’. The recognition by national partners of UNICEF’s ability to play an infl uential leadership role provides UNICEF with an opportunity to drive and facilitate a shared vision for maternal and child nutrition at the national and subnational levels.

1

National nutrition partners see UNICEF as the ‘best coordinator/connector’. Most national

nutrition stakeholders see UNICEF as a partner that builds bridges for coordination and collaboration with organizations at both national and international levels. Most of the organizational analysis plots indicate that UNICEF has the highest betweeness centrality and is the main connector of organizations and partners. Typically, UNICEF Nutrition programme staff connects government ministries and departments involved in nutrition with national and international partners. Its bridge-building and coordination role in advocacy, policy formulation, strategy development, capacity building and programme scale-up allows UNICEF to rally multiple partners around large and new initiatives for maternal and child nutrition such as multisectoral policies for the prevention of child stunting or innovative strategies to improve child feeding, maternal nutrition and household sanitation.

2

National partners for nutrition sometimes see UNICEF as ‘stretching itself too thin’. UNICEF

is recognized as a technical leader, a policy infl uencer, and a partnership convener. However, a good number of partners suggest that UNICEF country teams, which in middle income countries tend to be small, need to be more strategic in prioritizing their work. Partners feel that in such contexts UNICEF should continue to focus on its strengths - situation analysis, technical advice, policy formulation, strategy development, and capacity strengthening - to create and sustain large scale change for maternal and child nutrition at the national level.

4

National partners for Nutrition see UNICEF as ‘having the latest evidence’. National nutrition

partners acknowledge that technical leadership is a main sphere of UNICEF infl uence to drive advocacy, policy formulation, strategy design, capacity development and programme scale-up. UNICEF is seen as an evidence-based partner that links global evidence and upstream guidance to national and subnational programme design and scale-up so that evidence – in the form of epidemiological data, research fi ndings, proven interventions and better practices - informs policy development and programme scale-up.

3

UNICEF ‘should do more’ to support the coordination of programme scale-up with

quality. The density of networks and partnerships that support programme scale-up is signifi cantly lower than the density of networks that support policy formulation, strategy development and programme design. This translates sometimes into a cycle of ineffective implementation and lack of progress on maternal and child nutrition indicators at the national level. Sub-optimal coordination and collaboration to test innovations, strengthen capacity and scale up programmes compounded by inadequate evaluation impedes effective programming (coverage, equity and impact). Partners suggest that UNICEF should utilize its infl uence to build stronger partnerships for program scale-up with quality, while monitoring trends and progress for greater accountability.

5


Conclusions

These 10 case studies spanning four Asian countries highlight the contribution of multi-stakeholder partnerships and networks to achieving results for maternal and child nutrition in Asia. They point to four factors that are important in activating/strengthening upstream engagement for nutrition.

1. Contextual intelligence: A common theme across studies is the importance of a catalyst that initiates the process leading to a major policy or programme development. The catalyst must be able to discern opportunities and challenges in the face of complexity and uncertainty and adapt effectively to shape the nutrition environment.

2. Partnerships and networks: Multi-stakeholder and multi-sectoral networks and partnerships have enabled a dynamic environment that creates new possibilities and pathways to infl uence positively policy development, strategy design, capacity strengthening and programme scale-up and achieve results for nutrition.

3. Coordination and governance: An important task for network partners is to determine which governance structure is a good fi t while ensuring that the network structure evolves and responds to the changing needs – nationally and/or subnationally – to achieve nutrition results and impact.

4. UNICEF as a partner: UNICEF has been an effective

and trusted leader and partners. UNICEF should use its infl uential status strategically to engage national and international partners across sectors and organizations around a bolder vision for maternal and child nutrition results in Asia.

References

Freeman, L. C. Centrality in social networks: conceptual clarifi cation. Social Networks, 1:215-239, 1979.

Garrett, J., Natalicchio, M. (eds). 2011. Working multi-sectorally in nutrition: Principles, practices, and case studies. Washington, DC.

Hanneman, R.A., Riddle M. 2005. Introduction to social network methods. Riverside, CA: University of California, Riverside. http://faculty.ucr.edu/~hanneman/

UNICEF. 2013. The UNICEF Strategic Plan, 2014-2017.New York. http://www.unicef.org/strategicplan/fi les/2013-21-UNICEF_Strategic_Plan-ODS-English.pdf

UNICEF Programme Division. June 2015. UNICEF’s approach to scaling up nutrition for mothers and their children. Discussion paper. UNICEF, New York. http://wphna.org/wp-content/uploads/2015/10/2015-06-Scaling-Up-Nutrition-UNICEF.pdf

CASE CASE Indonesia

p.36

Bangladeshp.16

STUDIES STUDIES

Philippinesp.76

Nepalp.54

Nutrition Upstream Improving Policies, Programmes and Partnerships for Maternal and Child Nutrition in Asia 16BANGLADESH

CASE STUDIES

Bangladesh

Nutrition Upstream Improving Policies, Programmes and Partnerships for Maternal and Child Nutrition in Asia17 BANGLADESH

Case Study 1

DEVELOPING CAPACITIES OF GOVERNMENT SYSTEMS TO IMPLEMENT AND MANAGE EFFECTIVE NUTRITION PROGRAMMES: THE DISTRICT NUTRITION SUPPORT OFFICERS APPROACH

Background

Catalytic events: Progress markers, actors and outcomes

Organizational network analysis: Network linkages and key players to mainstream the DNI using the DSNO approach

Major fi ndings

Discussion and conclusions

References

Case Study 2

DEVELOPMENT OF A NATIONAL MICRONUTRIENT STRATEGY AND OPERATIONAL PLANS TO SCALE-UP THE DELIVERY OF MICRONUTRIENTS

Background

Catalytic events: Progress markers, actors and results

Organizational network analysis: Micronutrient network linkages and key players of the strategy development

Major fi ndings


References

Case Study 3

STRENGTHENING THE CAPACITY OF THE NATIONAL HEALTH SYSTEM TO DELIVER SERVICES FOR CHILDREN WITH SEVERE ACUTE MALNUTRITION

Background


Organizational network analysis: SAM management network linkages and key players

Major fi ndings


References

18

18

18

18

22

23

23

24

24

24

25

28

28

29

30

30

30

32

34

35

35


This case study explores the historical context and role of organizations and partnerships that led to the deployment of the District Nutrition Support Offi cers (DNSO). The DNSO strategy aims to develop the capacity of sub-national level programme managers on nutrition so that nutrition specifi c interventions are mainstreamed effectively. The engagement and working relationships of government, UN agencies, research institutes and donors are depicted through an organizational network analysis.

Background

In 2011, the National Nutrition Services (NNS) was established by the Bangladesh Ministry of Health and Family Welfare to mainstream direct nutrition interventions. At the national level and through six zonal offi ces, UNICEF supported the national government in the implementation and rapid scale-up of a full package of direct nutrition interventions (DNIs) throughout the country.

In 2012-2013, a nutrition capacity assessment identifi ed signifi cant human resource gaps and poor capacities in implementing a nutrition programme at the district and sub-district levels. To ensure that nutrition is mainstreamed at all levels, UNICEF began providing support to the government to (i) develop human resource capacities in nutrition, (ii) plan and monitor supplies, (iii) integrate nutrition in the health management information system to guide monitoring; and (iv) establish the standards and guidelines for all technical areas of the interventions. In response to the need for developing the capacities of subnational level health managers and workers in nutrition, the idea for District Nutrition Support Offi cers (DNSO) was born.


The mission of the DNSOs is to help scale-up and mainstream nutrition interventions in public health programmes and services across health, family planning and other allied other sectors at the district and community levels. The key role of the DNSOs is to provide technical support, facilitate intersectoral coordination, and mainstream nutrition interventions. They are tasked to work within departments of Education, Agriculture, Water, Sanitation and Hygiene (WASH), and others to integrate nutrition sensitive interventions. In addition, every quarter, the DNSOs provide support in organizing multisectoral nutrition coordination meetings, facilitate the development of a district nutrition plan of action, provide supportive supervision through fi eld visits and on-the-job training to health workers on nutrition related knowledge and skills.

Various partners were involved in the scale-up of the DNSO approach - the government, several donors and NGO partners. BRAC University School of Public Health trained this cadre of public health nutrition professionals in 2013. By 2015, 42 DNSOs had been deployed in 39 districts and 3 urban municipalities and in partnership with many national and international organizations the programme was scaled-up. On-going advocacy with the Government of Bangladesh has resulted in the recent approval of 64 nutritionist positions (a scale-up of the DNSO model) covering the entire country. The creation of the district nutritionist post in the government health system provides a stable mechanism for coordination of nutrition related services moving into the future.

Organizational network analysis: Network linkages and key players to mainstream the DNI using the DNSO approach

This section focuses on interactions and relationships between multiple partners, organizations and networks involved in conceptualizing the DNSO approach and leading to scale-up across the country.

DEVELOPING CAPACITIES OF GOVERNMENT SYSTEMS TO IMPLEMENT AND MANAGE EFFECTIVE NUTRITION PROGRAMMES: THE DISTRICT NUTRITION SUPPORT OFFICERS APPROACH

CASE STUDY

1


A total of 13 organizations were identifi ed as partners in advocacy, training and scaling-up (Table 1). The organizational relationships, networks in which these organizations work, and interactions are described through multiple plots using organizational network analysis.

Table 1 List of organizations

BRAC_U BRAC University FAO Food and Agriculture Organization

CARE CARE IPHN Institute of Public Health and Nutrition, Directorate General of Health Services

DFATD Canada Department of Foreign Assistance and Technical Development

MOH_PH & WH Public Health and WHO Wing

DGFP_Field Directorate General of Family Planning, Field Services Unit

Shushilan Shushilan (national level NGO)

DGFP_MCRAH Directorate General of Family Planning, Maternal, Child, Reproductive and Adolescent Health

UNICEF United Nations Children’s Fund, Nutrition Section

DGHS Directorate General of Health Services WHO World Health Organization, Nutrition and Food Safety Offi ce

EU European Union, Food Security Offi ce

Overall DNSO network: The overall network of organizations working on the DNSO approach for organizing and delivering more effective direct nutrition interventions has a high degree of connectivity and reciprocity (Figure 1). The confi rmed density of the network is 64.1% (100 out of 156 potential ties) and only slightly lower than the unconfi rmed results of 75.6% indicating that most organizations reciprocated that they worked together on the DNSO programme. The structure of the network is based on two main clusters of homogenous organizations connecting through a central broker. IPHN has the highest between centrality and is the main broker especially for other government bodies. CARE and Shushilan, as NGOs, are located in the government cluster of the network. CARE is connected to every government organization, EU and UNICEF, while Shushilan, as a subnational NGO is connected to mainly the implementation oriented MOHFW-Directorate General of Family Planning (DGFP) and UNICEF. Conversely, UNICEF is the next most important broker and is located at the center of non-governmental organizations including other UN agencies (WHO and FAO), Donors (EU and DFATD) and BRAC University, the sole academic institution in this network.

Working relationships: The establishment of the DNSO approach required advocacy, training and scale-up. The structure of these three types of linkages and the key players vary by the type of activity (Figures 2a, 2b and 2c). For all three activities, the density drops from 64% for the overall DNSO network to a range of 16.7% to 24.4% as some organizations become isolates and have no confi rmed working relationships.

DGFP_MCRAH

DGFP_Field

IPHN

UNICEF

DGHS

WHO

MoH_PH&WH

EU

FAO

CAREDFATD

BRAC_U

Shushilan Plot guide: node color (nodes sized by betweeness centrality)

GovernmentUNAcademicDonorCivil Society/NGO/INGO

Figure 1 Overall confi rmed DNSO network


The advocacy network (Figure 2a) for the DNSO approach resembles a “double spoke and wheel” confi guration with MOHFW-Public Health Unit (PH & WH) as the main brokers for advocacy as well as being in the center of interactions with their colleagues across different departments in the MOHFW. UNICEF forms the other “partial spoke” connecting in WHO to support the advocacy and development of the DNSO strategy. Organizations that were left out of the advocacy network include: EU, FAO, DFATD, and Shushilan.

In training and capacity building, UNICEF holds the most central position and has the highest betweeness centrality score. UNICEF is important in bringing in the academic institution (BRAC University) as well as CARE and Shushilan into this broader network. The UN effort appears decentralized as none of the UN agencies are connected with UNICEF or with each other but only work with specifi c government departments. WHO is only connecting with IPHN; and FAO with DGHS. The donors are not active partners working on the training and therefore placed as isolates and separated from the training and capacity building networks.

The center of the scale-up activities for DNSO is located within the MOHFW with the DGHS as the focal point (Figure 2c). This network has the lowest density as many organizations have not mutually acknowledged working with each other. They include WHO, FAO, CARE, DFATD and EU. The Ministry of Health’s Public Health Unit has the highest betweeness centrality because it is linking BRAC University into the scale-up and serving as a facilitator for information exchange. UNICEF is working directly with IPHN, DGHS and DGFP_MCRAH. The national representative of Shushilan is also connected to IPHN as well as DGHS Field Services Unit.

Relationship strength: An important measure of the strength of ties between organizations is multiplexity. When organizations are working on multiple activities together, then there is less probability of fragmentation. Among the connections that span the three activities (advocacy, training, and scale-up), a majority of them consist of 2 to 3 activities (Figure 3). UNICEF has the maximum ties with both IPHN and DGHS. Other government bodies also have three ties with each other but that excludes IPHN, whose strongest ties are with UNICEF. However, there are number of organizational connections that are only across 1 tie including: other UN agencies, NGOs and BRAC University. FAO, in particular would become an isolate if that one

Figure 2a DNSO: Advocacy Figure 2b DNSO: Training and capacity building

Figure 2c DNSO: Scale-up

DGFP_MCRAH

DGFP_FieldIPHN

UNICEF

DGHS

WHO

MoH_PH&WH

EUFAO CAREDFATD

BRAC_U

Shushilan

DGFP_MCRAHDGFP_Field

IPHN

UNICEF

DGHSWHOMoH_PH&WH

EU FAO

CARE

DFATD BRAC_U

Shushilan

Plot guide: node color (nodes sized by betweeness centrality)


DGFP_MCRAH

DGFP_Field

IPHN

UNICEF

DGHS

WHO

MoH_PH&WH

EUFAOCAREDFATD

BRAC_U

Shushilan


relationship with DGHS was lost. There are 2 isolates (EU and DFATD), meaning that there are no confi rmed relationships across the 3 activities.

The intensity of relationships further elucidates the degree of involvement between partners and in this case relates to the DNSO design and implementation (Figure 4). As can be viewed in the plot, the majority of relationships fall into the basic category of communication. This is followed by coordination and collaboration. Only one connection is based on the more robust relationship of integration – this is between MoH_PH & WH and DGHS, as they are both part of the MoHFW. This indicates that the strength of relationships is not as robust as it could be across all the organizations because they begin and end with the basic fi rst stage of communication. Communication usually involves exchange of information but does not include active participation in DNSO activities. However, a majority of the UNICEF relationships involve collaboration, which signals strong connections within this network.

Infl uence, coordination and evidence: In order to have a more comprehensive picture of the perceptions that different organizations had about the leadership qualities that were important for infl uencing nutrition policies and programmes in Bangladesh, they were asked to nominate other organizations in a ranked order for: a) most infl uential (Figure 5a); b) best coordinator (Figure 5b); and c) best evidence base (Figure 5c). UNICEF received the most votes in all three categories and has the highest ranking based on the positioning of the nominations. In the “most infl uential” category, there is a dispersion of nominations beyond the votes for UNICEF across many organizations, including government bodies with no one organization approaching UNICEF’s position. For “best coordinator”, FAO comes in second after UNICEF in both number of nominations and weighted ranking. In the “latest evidence” category, IPHN has the second most number of votes and ranking after UNICEF.

Figure 3 DNSO: Multiplexity Figure 4 DNSO: Relationship Intensity

DGFP_MCRAH

DGFP_Field

IPHN

UNICEF

DGHS

WHO

MoH_PH&WH

EU

FAO

CAREDFATDBRAC_UShushilan

DGFP_MCRAH

DGFP_Field

IPHN

UNICEF

DGHS

WHO

MoH_PH&WH

EU

FAO

CARE

DFATD

BRAC_U

Shushilan

Multiplexity key

1 Tie2 Ties3 Ties

Intensity plot guide

CommunicationCoordinationCollaborationIntegration

Figure 5a DNSO: Most infl uential Figure 5b DNSO: Best coordinator

MOHFWDGFP_MCRAH

DGFP_Field

IPHN

UNICEF

DGHS

WHO

MoH_PH&WH

EU

FAO

CARE

DFATD

BRAC_U

Shushilan

MOHFW

DGFP

DGFP_MCRAH

DGFP_Field

IPHN

UNICEF

DGHS

WHO

MoH_PH&WHFAO

CARE

DFATD

BRAC_U

Shushilan

Com_Clinic

EU


Major fi ndings

1. UNICEF maintains an infl uential position in the DNSO network. UNICEF’s leadership in developing and funding the DNSO approach is refl ected in their high betweeness centrality as they provide a platform for engagement of mainly non-governmental organizations into the broader network with government counterparts.

2. The DGFP and DGHS and their respective units are leading the scale-up effort. Donors, INGOs and other UN organizations, other than UNICEF completely drop out of the scale-up effort.

3. A high degree of direct overall network connectivity between partners has not led to active working relationships, especially on advocacy and scale-up. The low degree of connectivity left the majority of the work on DNSO with units of DGHS and DGFP as well as BRAC University and UNICEF.

4. Most DNSO relationships do not go beyond the level of communication. The intensity level of most relationships as described by organizational respondents was at a basic level. This fi nding is consistent with other results where many organizations were not very involved in the different processes that resulted in DNSO implementation and further scale-up.

DGFP_MCRAH

DGFP_Field

IPHN

UNICEF

DGHS

WHO

MoH_PH&WH

EU

FAO

CARE

DFATD

BRAC_U

Shushilan

Figure 5c DNSO: Best coordinator

Plot guide: node color (nodes sized by weighted degree centrality)




IPHN and UNICEF have powered the DNSO approach through the deployment of district nutrition offi cers as illustrated through the ONA. Although many organizations have been involved in an interwoven network that in one way or another was associated with the DNSO approach, the actual work of advocacy, training and scale-up was reduced to a few organizations, mainly UNICEF, government departments and selected INGOs. Further reinforcing this pattern, there are a number of organizations that are working together on only one task leaving them vulnerable to being left out of the DNSO activities. This lack of attention may be related to the perception that the DNSO approach is a UNICEF programme and there is limited understanding to what extent the programme would be sustained by the government. Additionally, partners were waiting to assess the evidence base for the DNSOs impact before being fully committed to the programme’s scale-up.

The majority of relationships fall into the category of basic communication while UNICEF maintains the most collaboration ties with most of the government agencies. Even though UNICEF has been nominated as “most infl uential”, the translation of this infl uence to attracting more support from additional organizations is limited. This is especially evident for scale-up, as most non-governmental agencies drop out of the picture and UNICEF’s engagement is aligned with two governmental organizations: IPHN and DGFP_MCRAH. This fi nding corresponds to a recent commitment by the Government of Bangladesh to scale-up the DNSO approach through the creation of 64 district nutritionist positions thereby ensuring the sustainability of nutrition services in the community without necessarily involving non-governmental organizations. As the new nutritionists get deployed around the country, the programme would benefi t from a rigorous evaluation that could provide a solid evidence base on subnational and multisectoral coordination and capacity building strategies that can have a positive impact on the quality of nutrition services and nutrition outcomes for children and women.

References

DGFP, EU, UNICEF. (2015). Endline Assessment: Nutritional Status among Women and Children in MYCINSIA Areas in Bangladesh. Dhaka: Directorate General of Family Planning, Government of the People’s Republic of Bangladesh.

UNICEF, EU. (2013). UNICEF-EU Maternal and Young Child Nutrition Security Initiative in Asia. Bangladesh. MYCNSIA Progress Report.


DEVELOPMENT OF A NATIONAL MICRONUTRIENT STRATEGY AND OPERATIONAL PLANS TO SCALE-UP THE DELIVERY OF MICRONUTRIENTS

CASE STUDY

2

This case study highlights the pathway towards the development of an integrated National Micronutrient Strategy to direct the scale-up of a micronutrient programme. The current story emerges from qualitative interviews with nine key organizations and government departments and fi ndings from a structured Organizational Network Analysis (ONA) supplemented by a review of secondary data sources.

Background

Widespread micronutrient defi ciencies exist in Bangladesh that impede the progress on key nutrition targets as confi rmed by trends on stunting and wasting. A range of short, medium and long-term approaches have been in place for addressing micronutrient defi ciencies, however Bangladesh lacked a comprehensive approach until 2015, when the National Micronutrient Strategy was developed.


The recognition and focus on the delivery of specifi c micronutrients has a long history in Bangladesh. Since 1973, there was national attention placed on vitamin A supplementation to reduce the high prevalence of vitamin A defi ciency in children and lactating women. Then in 1995, a salt iodization programme was initiated. A decade later in 2007, aided by donors and local organizations a broader discussion began about an integrated approach that led to the development of large-scale fortifi cation programmes. The Global Alliance for Improved Nutrition (GAIN) and UNICEF supported the fortifi cation of edible oil with vitamin A and the Micronutrient Initiative (MI) supported salt with iron by applying lessons learned from similar programmes in Indonesia and Vietnam. By 2008, nutrition education and micronutrient supplementation and fortifi cation was being aligned with the National Food Policy (2006) and the plan of action (2008-2015). To address the lack of micronutrient data at the national level, the government requested a micronutrient survey in 2009 and it was completed in 2011.

In addition to supplementation, to reach a wider population and address vitamin A defi ciency, the Ministry of Industries (MoI), UNICEF and GAIN began an oil fortifi cation initiative in 2010 with a goal of fortifying palm, soybean and rice bran oil with vitamin A. UNICEF conducted a needs assessment and facilitated the signing of an MOU between the 16 functional oil refi neries and MoI. MoI chaired the Project Steering Committee that was the main implementing body, which included Bangladesh Small Cottage Industries Corporation (BSCIC), Ministry of Planning, and MoHFW. The Project implementation Committee was also chaired by MoI and IPHN played a central role in project management. A technical committee for micronutrients was established with representation from IPHN, MoHFW, Dhaka University, Micronutrient Initiative, icddr,b, UNICEF and other international organizations and research institutes. The incremental cost of fortifi cation was 0.22 paise per liter and was absorbed by consumers purchasing oil. Fortifi ed oil was provided nationwide in 2011 and by 2013, oil fortifi cation legislation endorsed by parliament, mandated that all refi neries fortify oil.

One respondent described the challenge of bringing refi neries together, engaging the refi nery association and regulating the quality of oil. However, the fi rst phase of fortifi cation led to 63% national coverage of the total oil purchasing market, and increased awareness of the availability and benefi ts of fortifi ed oil. The high vitamin A coverage and strong government ownership of micronutrient supplementation created a policy environment that was conducive to bringing partners together. Having each sector identify nutrition as crucial created increasing investments and resources for nutrition.

In parallel to an expanded fortifi cation programme, improved food policies led to the integration of nutrition interventions and indicators in the results framework. The goal of the 2006 National Food Policy was to diversify food in order to produce access to safe and nutritious foods, and ensure adequate nutrition for mothers and children. This followed earlier efforts in 1997 when the National Food and Nutrition Policy supported by FAO and WHO was adopted. This led to the emergence of the national multisectoral plan of action with the Bangladesh National Nutrition Council taking responsibility for working across Ministries.

After more than two decades of the government of Bangladesh and organizations working in narrowly focused partnerships, a more far-reaching technical committee on micronutrients was convened by IPHN to develop the National Micronutrient Strategy. REACH, FAO, UNICEF, WHO, DFID, GAIN, MI and WFP played an important role in this phase of development. UNICEF supported IPHN to be the key driver for this initiative and bring all organizations to the table for consensus building.


These processes led to the formulation of the ten-year National Strategy for the Prevention and Control of Micronutrient Defi ciencies in Bangladesh (2015-2024), which was endorsed by Ministry of Health and Family Welfare in March 2015.

Micronutrient policy timeline

2004: Government procures its own Vitamin A capsules

2007: Fortifi cation programs begin

2010: Plan developed for direct nutrition and nutrition sensitive interventions

2011-2012: National Micronutrient Survey

2013: National Edible Oil Fortifi cation Law 2013 endorsed

2015: Food policy approved

2006: National Food Policy

2015: National Strategy on Prevention and Control of Micronutrient Defi ciency

2007: National Strategy for Anemia Prevention and Control

2008: National Food Policy Plan of Action

2010: Food Security and Nutrition Country investment plan

2013: Breast milk substitute (BMS) Act endorsed

Organizational network analysis: Micronutrient network linkages and key players of the strategy development

The key members of the micronutrient network selected for the study include nine organizations: fi ve government departments including Institute of Public Health and Nutrition (IPHN) and its implementing arm the National Nutrition Services (NNS), Directorate General of Family Planning Field Services Unit (DGFP_Field) and Maternal, Child, Reproductive and Adolescent Health (DGFP_MCRAH), and the Ministry of Industries (MoI); two INGOs, the Global Alliance for Improved Nutrition (GAIN) and Micronutrient Initiative (MI); icddr,b and UNICEF.

Overall micronutrient network: The level of direct connectivity between organizations or density is quite high at 77.8% (56 out of 72 confi rmed ties). There are two clusters, the governmental organizations and the non-governmental organizations representing UNICEF, a research organization, and INGOs. The main brokers that infl uence communication across the network are IPHN and its unit NNS. They function as a bridge between DGFP and the non-governmental organizations. The DGFP, Field Services Unit is only connected to three government bodies: DGFP_MCRAH, IPHN and NNS. UNICEF is on the outer edge of the network having direct connection to six out of eight other organizations. They did not have a confi rmed direct relationship with DGFP_Field and DGFP_MCRAH.

Working relationships: A further analysis presents the different focal activities that these organizations engage in to advocate, develop and scale-up the implementation of the Micronutrient Strategy. It reveals varied network structures but consistency is maintained in the principal vehicles for bridging information exchange across the networks. Micronutrient advocacy and the design of the National Micronutrient Survey (Figure 7a) have a very low density of 22.2 % (only 16 out 72 potential ties are

pre 2010 2010-2016

Figure 6 Overall confi rmed micronutrient network

DGFP_MCRAH

DGFP_Field

IPHN

UNICEF

NNS

MI

icddr_b

MoI

GAIN


GovernmentUNDonorCivil Society/NGO/INGO


confi rmed) with four government organizations excluded from the plot. Only DGFP_MCRAH is part of the survey development and advocacy network connecting directly with MI and GAIN to icddr,b and UNICEF. Therefore MI and GAIN have the largest nodes, or betweeness centrality as they control the communication between groups that do not have a direct channel for the advocacy to happen. Most of the advocacy ties are between UNICEF, icddr,b, MI and GAIN, who are all connected to each other.

The Micronutrient Initiative is central to the design of the Micronutrient Strategy and plan of action (Figure 7b). However, the NNS and IPHN as well as GAIN all have the same betweeness centrality score and together serve as a passageway for information to UNICEF, icddr,b and DGFP_MCRAH who are on the periphery of the network. The isolates who did not receive mutual confi rmation get reduced to two government bodies: DGFP, Field Services Unit and Ministry of Industries.

The scale-up network for IFA or fortifi cation of edible oil has two distinct clusters or working groups (Figure 7c). The Ministry of Industries and GAIN are in one cluster, while MI, NNS, DGFP_MCRAH are in the other cluster with UNICEF and IPHN playing an important role of connecting the two clusters. DGFP_Field is only connected to DGFP_MCRAH.

Figure 7a Micronutrient advocacy Figure 7b Micronutrient strategy design

Figure 7c Micronutrient scale-up



Relationship strength: The multiplexity or number of different types of ties between organizations is based on three working connections (Figure 8). UNICEF has a mix of two and three ties creating a robust relationship with associated organizations, especially with GAIN and MI spanning all three types of activities to address micronutrient defi ciency in Bangladesh. The Ministry of Industries is connected through one type of relationship, which is at risk for sustained engagement once that activity ends.

The strength or intensity of the relationship was measured by asking respondents to categorize their working relationships along a continuum starting from the most basic communication, leading through coordination and collaboration and ending with the highest level of integration (Figure 9). The micronutrient network is very stable as most respondents chose to classify their connections as “collaboration”. UNICEF has four collaboration ties with GAIN, MoI, IPHN and NNS and three

DGFP_FieldIPHNNNSMoI

DGFP_MCRAH

UNICEF

MI

icddr_b

GAIN

DGFP_FieldMoI

DGFP_MCRAH

IPHN

UNICEF

NNS

MI

icddr_b

GAIN

DGFP_MCRAH

DGFP_Field

IPHN

UNICEF

NNS

MI

icddr_bMoI

GAIN


Figure 8 Micronutrients multiplexity Figure 9 Micronutrients intensity

DGFP_MCRAH

DGFP_Field IPHN

UNICEF

NNS

MI

icddr_b

MoI

GAIN

DGFP_MCRAH

DGFP_Field

IPHN

UNICEF NNS

MI

icddr_b

MoI

GAIN

Multiplexity key

1 Relationship2 Relationships3 Relationships



Figure 10a Micronutrients: Most infl uential Figure 10b Micronutrients: Best coordinator

MOHFW

DGFP_MCRAH

DGFP_Field

IPHN

UNICEF

NNS

MI

icddr_b

MoI GAIN

MOHFW

DGFP_MCRAH

DGFP_Field

IPHN

UNICEF

NNS

MI

icddr_b

MoIGAIN

coordination relationships with MI, icddr,b and DGFP_MCRAH. The DGFP_Field Services is integrated with DGFP_ MCRAH but only communicates with two other MOHFW counterparts: IPHN and NNS, which are located within DGHS.

Infl uence, coordination and evidence: As a measure of the perceived leadership roles of different organizations, respondents were asked to nominate: the most infl uential, best coordinator and the organization that provides the latest evidence for the development of nutrition policies and programmes. The order of the nominations was weighted to create scores that can provide a window into the value that is ascribed to organizations. The MOHFW is considered the most infl uential followed by NNS and UNICEF (Figure 10a). Outside of the specifi c departments within MOHFW, the MOHFW itself received 5 votes, with two being outside of that Ministry that included MI and GAIN.

The nominations for best coordinator fall into two clusters in which different patterns emerge: seven organizations in one cluster and two organizations alone in another grouping (Figure 10b). IPHN and UNICEF are ranked as the best coordinators in this network. DGFP_MCRAH and NNS are a separate entity as NNS nominates DGFP_MCRAH as best coordinator. For providing the latest evidence (Figure 10c), UNICEF had the most number of votes as well as the highest ranked score. The next highest ranking was for NNS. The star-like pattern of the network indicates that reliance and exchange of knowledge is very centralized with limited exchange between different organizations who rely on UNICEF and NNS for being up-to-date on technical and programmatic country and global level knowledge resources.


Figure 10c Micronutrients: Latest evidence

Major fi ndings

1. The Institute of Public Health Nutrition and National Nutrition Services are the main connectors of partners in the over-all Micronutrient Network. The important role of IPHN and their NNS unit in the DGHS are validated by the ONA. They have the highest betweeness centrality by connecting the DGFP with the broader group of non-governmental partners. Interview respondents also asserted that IPHN was instrumental in promoting and forming the committee structure to de-velop the micronutrient strategy.

2. There is a lack of consensus on a programmatic approach to micronutrients among partners. Respondents highlighted the importance of a dietary approach in addressing micronutrient defi ciencies and others discussed the importance of using research, evidence and advocacy to determine the balance between food-based interventions and supplementation. Others emphasized how interventions to improve exclusive breastfeeding were necessary. Further, one respondent discussed how a focus on child protection and safeguarding children could be integrated into programmes and UNICEF could play a key role in connecting health and child protection programmes. Finally, one respondent felt the government should move from supplementation to fortifi cation. This clearly highlights the lack of consensus and a unifi ed vision on this issue.

3. Multisectoral and intragovernmental collaboration is limited. The need to collaborate was seen as a key lesson learned, especially since different stakeholders often had multiple approaches to nutrition programming. Further collaboration could address the vertical nature of micronutrient programmes and integrate them with other nutrition programmes. The DGFP and DGHS portrayed their relationship as basic communication that did not include coordination or collaboration on mi-cronutrients. One respondent suggested that the government predominantly runs micronutrient programmes and further partnerships to improve implementation would be benefi cial. Working with oil refi neries highlighted the importance of mak-ing businesses aware of fortifi cation and ensuring price does not become a barrier to access.

4. The implementation and scale-up consists of groups working in silos. The degree of direct relationships across the mi-cronutrient scale-up network is limited as organizations work with only two or three others in their own respective and separated corners of a rectangle network structure. UNICEF along with IPHN and DGFP_MCRAH act as connectors for communication between the different silos.

5. UNICEF is a highly valued partner in micronutrient policy and action, but it is not refl ected in the ONA micronutrient networks. UNICEF was voted, together with IPHN as the best coordinator and provider of access to the latest evidence. However, the ONA results revealed that UNICEF has strong relationships with many partners but is not playing a central role nor a bridging role with other organizations on micronutrient nutrition issues.


The development of a ten-year National Strategy for the Prevention and Control of Micronutrient Defi ciencies is a major success for Bangladesh after decades of stand-alone programmes and approaches. The selection of key non-governmental

MOHFW

DGFP_MCRAH

DGFP_Field IPHN

UNICEF

NNS

MI

icddr_b

MoI

GAIN

Plot guide: node color (node sized by weighted degree centrality)



organizations for the qualitative interviews and ONA is not entirely consistent with the additional organizations that were identifi ed to be important in micronutrient strategy development by case study respondents. The organizations not included in the Micronutrient Case Study include: FAO, WHO, DFID, USAID, WFP and World Bank.

Among the nine organizations that were included in the study, the level of organizational interchange is limited and to some degree fragmented as many organizations do not have direct relationships with each other and drop out of some of the major activities. There is even an absence of a direct linkage between some departments within the MoHFW. The lack of strong coordination and collaboration ties is further refl ected in the ONA intensity plot as DGFP and DGHS characterize their relationship as basic communication on micronutrients.

IPHN and its main technical unit, NNS play an important role in bridging the relationship gap as they effectively manage their leadership position in nutrition in Bangladesh. Even though UNICEF has received votes by other partners for being the best coordinator along with IPHN, this status is not substantiated by the ONA results. The limited role of UNICEF in the micronutrient network is not in line with the high degree of prestige and potential infl uence that UNICEF garners but seems not to be actively using. The most important position of UNICEF in the micronutrient network is to bring the Ministry of Industries and different departments within the Ministry of Health and Family Welfare together for scale-up. It may be possible that UNICEF is leveraging its position of infl uence indirectly or may be working in ways that are not captured by the interview questions and ONA instrument.

The Micronutrient Initiative and GAIN are playing a major role in the micronutrient network whose advocacy efforts were directed at DGFP_MCRAH supported by UNICEF and icddr,b. They also had major roles in strategy development along with IPHN and NNS by securing relationships with many partners and linking in organizations that were not directly connected. The Ministry of Industries, a major player in oil fortifi cation and the only non-Health Ministry that was interviewed, did not acknowledge participating in the formulation of the Micronutrient Strategy. However, as explained by UNICEF, the Bangladesh Small Cottage Industries Corporation (BSCIC) is the implementing agency for Universal Salt Iodization (USI) programme and has been designated by the Ministry of Industries to be part of the micronutrient strategy development. This absence of ties in the ONA signals a lack of communication between the MoI and BSCIC, even though one is representing the other in major national policy development forums.

The degree of intersectoral and multisectoral collaboration was an important talking point in the interviews. Respondents highlighted that there were insuffi cient resources to support collaboration, and indicated that multiple mandates make collaboration occasionally challenging. In addition to the work required to build national level networks, establishing strong district level links between partners and donors was also considered an obstacle to effective implementation. A further issue that may affect the rollout of the strategy is the uncertainty in forecasting oil prices that could limit the scope of oil fortifi cation. Finally, both implementation capacity and the ability to monitor micronutrient programmes were described as challenging. Overcoming these major obstacles and developing active and engaged partnerships at all levels to implement the micronutrient strategy can change the future growth trajectory of Bangladesh.

References

IPHN, DGHS, MoHFW. (2015). National Strategy on Prevention and Control of Micronutrient Defi ciencies, Bangladesh (2015-2024). Final Draft. Dhaka: Ministry of Health and Family Welfare, Government of the People’s Republic of Bangladesh.

Food Planning and Monitoring Unit (2008). National Food Policy Plan of Action (2008-2015). Dhaka: Ministry of Food and Disaster Management, Government of the People’s Republic of Bangladesh.

Ministry of Food and Disaster Management (2006). National Food Policy. Dhaka: Ministry of Food and Disaster Management, Government of the People’s Republic of Bangladesh.


This case study traces the series of steps and leaps taken in the development of a national consciousness and related actions to address and deliver services to children with severe acute malnutrition (SAM). The stories charting the history and key milestones in addressing child malnutrition in the community and scaling-up facility based management of SAM were elicited from different organizations and are compiled below. This is followed by an Organizational Network Analysis (ONA) to uncover the underlying dynamics that infl uence coordination between partners that work on strengthening the health system to deliver community and facility based services.

Background

Severe acute malnutrition is a life threatening condition requiring urgent treatment. In Bangladesh, malnutrition is a public health problem with 14% of under-fi ve children wasted. Among these, 3% of the children are severely malnourished. Despite having national guidelines on the management of SAM, detection and treatment of children with SAM has remained low. In light of this lack of progress, UNICEF and the Ministry of Health and Family Welfare (MOHFW) through the Institute of Public Health Nutrition (IPHN) took steps to address the delivery of services. This incremental process has led to the scale-up of in-patient management of SAM from around 5 government facilities in 2013 to about 134 by mid-2015.


The scale-up of services for the management of SAM emerged as a response to the low availability and access to treatment services and the high burden of SAM across the country. Despite the existence of national guidelines for the management of SAM developed in 2008, respondents described the lack of focus and interest in hospital-based provision of SAM services. At the other end of the spectrum, there is also no national programme for Community Based Management of Acute Malnutrition (CMAM). To address these shortcomings, some respondents highlighted that NGOs located in certain areas were providing the majority of community-based SAM treatment without sustained engagement from the national health service delivery system.

“We realized that the management of SAM was not happening in any of the facilities. At that point in time we had less than fi ve facilities doing SAM in the entire country. We looked at bottlenecks, what needs to be done and after that we started moving ahead in supporting facilities to mainstream management of SAM.” (UNICEF)

Initially, efforts to manage children with SAM began in tertiary facilities with trainings provided for health workers in 2012. Facilities were expected to use local recipes to constitute therapeutic diets to feed severely malnourished children. Due to challenges related to local preparation of the diets, the management of SAM did not take off. The government allowed the issuance of packaged therapeutic diets in 2013. This provided the impetus to scale-up SAM treatment to 134 facilities across 64 districts by the end of 2014. Two beds for children with SAM were assigned at the sub-district level and four beds at the district or medical college level. A year later, in 2015, approximately 4500 children were being reached through 134 facilities. Although this is still a small percentage of the children affected, one respondent described the contribution the SAM programme was making through training physicians and linking community screenings to in-patient care. This resulted in strengthening the health system to respond to SAM, and slowly increasing the coverage of SAM interventions.

One of the key bottlenecks to SAM management was the limited capacity of health workers. To address this gap, over 1000 health workers have been trained on in-patient management of SAM. This has been achieved through a partnership with Action Contre la Faim (ACF). The training was carried out in over 100 hospitals and was skills-based, as opposed to the traditional

STRENGTHENING THE CAPACITY OF THE NATIONAL HEALTH SYSTEM TO DELIVER SERVICES FOR CHILDREN WITH SEVERE ACUTE MALNUTRITION

CASE STUDY

3


lecture methods. The District Nutrition Support Offi cers (DNSOs) also played an important role in supporting facilities to improve the quality of SAM services and management of record keeping systems.

“We have been able to scale-up and have the management of SAM opening in many hospitals once we had the DNSOs on the ground...they are able to interact with the health workers on a daily basis, infl uencing them, motivating them.” (UNICEF)

Following the mainstreaming of SAM management in MOHFW facilities, tools were developed to capture data and support transmission and management of information at the national level. Consequently, a database was established at IPHN to collate the SAM related data as a fi rst step towards integration into the National Health Information System (HMIS). Although the HMIS included nutrition indicators, SAM was not initially included and the parallel system that was created to track and measure SAM is now being mainstreamed. By the end of 2015, online SAM reporting through the District Health Information System (DHIS2) has been introduced and test runs are currently ongoing. Inclusion of SAM indicators in the DHIS2 tool will allow real time reporting. Additionally, this will provide the opportunity to analyze and use the data for planning purposes by accessing and aggregating the data from sub-national to national levels. Reporting has also improved over time. In 2014, very few facilities were reporting data, but by August 2015, 113 facilities out of 134 targeted facilities were reporting routine data and further efforts were being made to increase the reporting rate.

Currently community clinics are screening children and referring them to sub-district (Upazilla) or higher-level hospitals where in-patient management is taking place. There was a sense that a strong community-based management of acute malnutrition (CMAM) would complement the facility-based programme. CMAM guidelines were developed in 2011 to outline community-level care for SAM. Several respondents argued that community screenings, treatment and awareness were areas that needed additional focus to meaningfully address the burden of SAM. CMAM guidelines provided a foundation for community health workers and complemented the existing National Guideline for the Management of Severely Malnourished Children in Bangladesh (2008). One respondent linked the ideas that SAM was a problem of weak community screening and case detection and therefore fewer referrals were generated. In 2014, the community clinic staff and Family Welfare Assistants (FWAs) in 44 sub-districts were trained to screen and detect children with SAM during home visits and refer them to health facilities. IPHN developed the CMAM training module in collaboration with icddr,b based on WHO guidelines. Almost 50 organizations were involved in the development of these training modules for physicians, nurses, and fi eld staff. There are plans and training protocols to now reach all 480 sub-districts. Community prevention, treatment and referral services together with enhanced facility based services, would usher in the next phase of a comprehensive prevention and treatment model – the standard Community Based Management of Acute Malnutrition (CMAM).

A central part of the CMAM protocol is using Nutrition Treatment (NT), previously referred to as Ready to Use Therapeutic Food (RUTF), to treat uncomplicated SAM cases in children. Children and parents visit the outreach center to receive NT and nutrition counselling. However, the importation of NT is banned in Bangladesh and local production is yet to commence with debates on the use of NT ongoing for years now. Proponents of the food-based approach oppose the use of NT since according to them, it would displace natural foods among under-fi ve children and that it is not sustainable in the long run. There is also a school of thought that believes that the most sustainable way is to produce NT in the country using locally available food ingredients. Some NGOs are importing NT for small area based SAM management programmes. In 2015, two formulations of RUTF using locally available ingredients have been tested and their effi cacy found to be comparable to the international gold standard. Local alternatives are also being explored, tested and considered. In the words of one respondent, “right now the government has no approval or no plan to import RUTF.” This is an important policy level discussion that will determine the types of community-based services available to children with SAM.

Policy timeline

2008: SAM guidelines developed

2011: CMAM guidelines developed

2012: SAM strategy developed 2013: scale up of SAM management in district and sub district hospitals

2012: SAM program begins in tertiary hospitals

2013: UNICEF supports GoB to include ten direct nutrition indicators in the HMIS System

2011: SAM training manual developed

2012: Training on CMAM and SAM for community clininc staff and FWAs

pre 2010 2010-2014


Organizational network analysis: SAM management network linkages and key players

The national level network of key organizations involved in the development of community and facility-based management of SAM include: two government bodies - the Institute of Public Health Nutrition within the Ministry of Health and Family Welfare’s Directorate General of Health Services with an implementation focus through the Community Clinics; two research organizations International Centre for Diarhoea Disease Research Bangladesh (icddr,b) and the NGO - Center for Women and Child Health (CWCH) and UNICEF’s Nutrition Section.

Overall SAM management network: Consisting of only fi ve organizations, the density or extent to which all possible combinations of connections are realized (20 ties) are high at 90%. Conversely this network is decentralized, as most organizations are directly connected to each other and do not rely on a central point for coordination (Figure 11). The only missing direct connection is between CWCH and Community Clinics – a potential platform to deliver services at the community level. CWCH is involved in supporting the delivery of facility-based SAM services while Community Clinics constitute a rural delivery system that reach households. The fact that the other three organizations are connected to both CWCH and GOB health facilities and serve as an important channel for information exchange between them, is well illustrated in the larger and equal node size of UNICEF, IPHN and icddr,b.

Working relationships: A further assessment of the ways in which these organizations work together is presented in Figures 12a, 12b and 12c. In infl uencing SAM management policy, IPHN is working with all other organizations in the network as well as connecting the research and NGO institutions and UNICEF. IPHN then becomes the hub of the scale-up effort and infl uences the communication between the different actors including icddr,b and the CWCH, UNICEF and Community Clinics. CWCH and icddr,b would be isolated from the scale-up activity if they did not work with IPHN. For health system support, UNICEF is the main communication hub between CWCH and the rest of the network.

Relationship strength: UNICEF, IPHN and GOB Community Clinics have the highest possible multiplexity as they form the core group working on all three components of SAM management (Figure 13). IPHN and Community Clinics work with other groups in two areas while UNICEF’s relationship with both academic institutions is only across one domain, that is, health systems support. For measuring the intensity of relationships, IPHN has four collaboration and one coordination ties (Figure 14). The rest of the linkages are balanced between coordination and collaboration. Only one relationship between CWCH and icddr,b stands at the communication level.

Infl uence, coordination and evidence: To understand individual perceptions about organizations with the most infl uence, leadership in bringing partners together and provision of technical knowhow to support the development of evidence based policies and programmes, organizations were asked to nominate organizations in a ranked manner for these three roles. The order of the rank was weighted and is refl ected in the size of the nodes in the respective plots. UNICEF received the top nomination for most infl uential (Figure 5a) and best coordinator (Figure 5b) closely followed by IPHN. For the latest evidence on nutrition, icddr,b and the UNICEF both had the highest number of votes (2), but icddr,b had a slightly higher weighted score as refl ected in their node size.

Figure 11 Whole SAM management network

icddr_b

CWCH

IPHN

UNICEF

Com_Clinic


GovernmentUNResearch organization


Figure 12a SAM management: Policy infl uence Figure 12b SAM management: Health system support

Figure 12c SAM management: Scale-up

Figure 13 SAM management: Multiplexity Figure 14 SAM management: Intensity of relationships

icddr_b

CWCHIPHN

UNICEF

Com_Clinic

icddr_b

CWCH

IPHN

UNICEF Com_Clinic

icddr_b

CWCH

IPHN

UNICEF

Com_Clinic



icddr_b

CWCH

IPHN

UNICEF

Com_Clinic

icddr_b

CWCH

IPHN

UNICEF

Com_Clinic

Multiplexity key





Major fi ndings

1. IPHN is at the center of SAM management advocacy and scale-up of interventions. IPHN is the center of the government of Bangladesh’s effort to develop effective SAM programmes and implement them. This role is supported by the ONA results.

2. UNICEF is a main connector in health systems strengthening. UNICEF provides a mechanism for strengthening the ca-pacity of the government to deliver both facility and community based services through the development and activation of training programmes and provision of technical support.

3. UNICEF is highly valued by partners as the best coordinator and most infl uential for progress in developing SAM man-agement programmes. UNICEF is using its infl uential position to “support the government to take the lead.”

4. The limited number of key organizations working on SAM management is not suffi cient to address the size of Bangla-desh’s malnutrition problem. It is unclear whether the government with the support of UNICEF can deliver an integrated package of SAM services to cover the needs of the entire country. There are other organizations in Bangladesh that can be mobilized into a more multisectoral and expanded development partner network to create a comprehensive and coordinat-ed approach to service delivery across the continuum of preventive care and treatment.

5. The community-based approach requires additional strengthening. Given the focus on facility-based care, one respondent expressed concern that mainstreaming may restrict nutrition interventions to only facilities and not the community. Others felt a focus on community-based approaches required strengthening, with a parallel commitment to prevention, advocacy, behavior change and communication. Strengthening community based care requires increasing awareness and improves case detection. One respondent described how “this is a hidden problem and if we increase the screening we will fi nd many cases.” (Government).

6. The lack of access to Nutrition Treatment (NT) and ways to treat SAM is challenging. Although a local alternative is being explored, the funding environment to develop and test other products or approaches for SAM is challenging. One respon-dent highlighted the importance of bringing stakeholders together with divergent approaches to NT.

Figure 15a SAM management: Most Infl uential Figure 15b SAM management: Best coordinator

Figure 15c SAM management: Latest evidence

icddr_b

CWCH

DGHS IPHN

UNICEF

Com_Clinicicddr_b

CWCH

IPHN

UNICEF

Com_Clinic

icddr_bCWCH

IPHN UNICEF

Com_ClinicPlot guide: node color (nodes sized by weighted degree centrality)




Despite the limited size of the SAM network, its members have been able to work together to increase access to SAM management through community clinics and government hospitals. The next step will be to move the treatment of SAM from a facility-based approach to a continuum of care that goes beyond community treatment into prevention. UNICEF and IPHN may be positioned to take a more proactive role as they were the most infl uential and displayed leadership across many activities. The Government of Bangladesh Community Clinics work across three domains with UNICEF and IPHN and serve as a vehicle to subnational implementation.

Important in-roads were established in the policy and programme environment for an integrated approach to SAM. IPHN has fully embraced the concept of providing a continuum of SAM services and is making important changes in the delivery systems of the country. Along with health systems strengthening support from UNICEF, the policies will need to move to the next level by scaling-up training of health personnel in facilities as well as utilizing the far reach of Community Clinics to roll-out early detection of SAM and preventive services. However, to tackle the country’s high levels of “hidden” malnutrition and to maintain fully functional facilities that have the skills, expertise and products to treat SAM, will require further expansion and collaboration with partners and the resources and creative solutions that they can generate.

References

IPHN, DGHS, MoHFW. (2008). National Guidelines of the Management of Severely Malnourished Children in Bangladesh. Dhaka: Ministry of Health and Family Welfare, Government of the People’s Republic of Bangladesh.

IPHN, DGHS, MoHFW. (2011). National Guidelines for Community Based Management of Acute Malnutrition in Bangladesh. Dhaka: Ministry of Health and Family Welfare, Government of the People’s Republic of Bangladesh.

Levinson, F. James, and Yarlini Balarajan. (2013). Addressing Malnutrition Multisectorally: What have we learned from recent international experience? New York: UNICEF Nutrition Working Paper, UNICEF and MDG Achievement Fund.

Nutrition Upstream Improving Policies, Programmes and Partnerships for Maternal and Child Nutrition in Asia 36INDONESIA

IndonesiaCASE STUDIES

Nutrition Upstream Improving Policies, Programmes and Partnerships for Maternal and Child Nutrition in Asia37 INDONESIA

Case Study 1

IMPROVED GOVERNANCE AND ACCOUNTABILITY FOR NUTRITION: LESSONS LEARNT FROM A DECENTRALIZED SETTING AND IMPLICATIONS FOR SCALING UP NUTRITION INTERVENTIONS

Background


Organizational network analysis: Policy network linkages and key players

Major fi ndings


References

Case Study 2

ENHANCING THE EFFECTIVENESS OF THE INFANT AND YOUNG CHILD FEEDING PROGRAMME (IYCF) BY STRENGTHENING COMMUNITY-BASED COUNSELLING SERVICES

Background


Organizational network analysis: IYCF network linkages and key players

Major fi ndings


References

38

38

39

40

44

44

45

46

46

46

48

52

53

53


This case study describes the nutrition policy accomplishments and development of national plans in Indonesia from the early 2000s to the present, with a focus on the years 2011-15. It details efforts made by the Indonesian government, UNICEF, and other partners to improve nutrition outcomes through new and updated policy and planning instruments: 1) SUN, adapting the Scaling Up Nutrition global principles into local policies, plans and programmes; 2) RPJMN, the national medium-term development plan; and 3) RAN-PG, the national food and nutrition plan. Organizational Network Analysis (ONA) establishes the roles and positioning of partnerships in the overall nutrition policy and planning environment as well as delves into the specifi c working relationships that include: evidence generation, drafting the documents, and roll-out of policies and plans at the subnational level.

Background

Policies and programmes to tackle nutrition problems have a long history in Indonesia but coverage of the major evidence-based interventions recommended by the 2013 Lancet nutrition series for maternal and child undernutrition remains low. This trend parallels the static prevalence of malnutrition that has remained unchanged since 2007 and is high compared to other less prosperous countries in Southeast Asia and sub-Saharan Africa. The lack of progress on nutrition despite Indonesia’s impressive economic growth continues to be a concern. Some of the key underlying reasons for a lack of improvement in nutrition may be related to the changes in accountability following decentralization and the lack of capacity at the subnational level for programme design, planning, monitoring and implementation.

In 2011, the government disseminated its third National Plan of Action on Food and Nutrition (RAN-PG) for the years 2011-15. For the fi rst time this plan recognized stunting as a signifi cant nutrition problem in the country and included a target to reduce the stunting prevalence by fi ve percentage points. However, the actions in the plan focused largely on the health and agriculture sectors alone. In contradiction to the policy intention, the health sector chose to exclude stunting as a target in its own sector strategic plan because it felt it could not alone be held accountable for stunting reduction in the country.

Several other important events for nutrition policy improvements occurred during the subsequent fi ve years. Indonesia’s involvement in the global SUN Movement created a momentum for a more integrated and expanded multisectoral approach to nutrition planning and governance. During the same time period, Indonesia was also in a cyclic process of developing key

IMPROVED GOVERNANCE AND ACCOUNTABILITY FOR NUTRITION: LESSONS LEARNT FROM A DECENTRALIZED SETTING AND IMPLICATIONS FOR SCALING UP NUTRITION INTERVENTIONS

CASE STUDY

1


nutrition and development plans and policies including the RPJMN for 2015-9 followed by the fourth RAN-PG. Utilizing the vibrant national platform created through the SUN Movement, along with support of major partners, stunting was selected as a major development indicator in the RPJMN 2015-19 signaling progress for the nation as well as an accountability mechanism for multiple ministries and departments.

Catalytic events: Progress markers, actors, and outcomes

The catalytic event that set Indonesia on a fast track policy trajectory is the decision to join the global SUN Movement. UNICEF provided support for the Ministry of Development Planning (Bappenas) to attend a global meeting on nutrition in September 2011. By November 2011, the Minister of Health sent a letter of intent to David Nabarro, Special Representative of the UN Secretary-General for Food Security and Nutrition and Coordinator of the SUN Movement, to join SUN as an “early riser country.”

The launch of the SUN movement took place in two stages: a “soft” launch and a “grand” launch. During the soft launch in September 2012, Indonesia’s SUN Policy Framework and SUN Implementation Guidelines were released. The Policy Framework recognizes: a) the need for multisectoral action to address undernutrition beyond health and agriculture; b) the importance of concentrating efforts and resources during the fi rst 1000 days of life; and c) identifi es targets for improvement in fi ve nutrition indicators, namely, stunting, wasting, anaemia, low-birth weight, overweight and exclusive breastfeeding. In May 2013, Presidential Decree number 42/2013 entitled the “National Movement to Accelerate Nutrition Improvement within the Framework of the First 1000 Days of Life”, was issued. It provides the regulatory framework to operationalize scaling-up nutrition efforts in the country, including the specifi cation of multisectoral coordination mechanisms. A few months later, in October 2013, the President presided over the grand launch of Indonesia’s National SUN Movement.

The second key event involved the development of the country’s 2015-19 National Medium-Term Development Plan (RPJMN). UNICEF supported the development of a background study on nutrition with various stakeholders to inform the integration of nutrition into the RPJMN, including action plans for multiple sectors. Child stunting was included for the fi rst time as a main development indicator, refl ecting both the close relationship between stunting and development, as well as the recognition that improvements in nutrition are contingent on progress across multiple ministries: Health, Water and Sanitation, Early Childhood Development, Agriculture, Social Protection and others.

The third key event involved the development of the country’s fourth and latest National Plan of Action on Food and Nutrition, the RAN-PG (2015-19). This plan is in-line with the RPJMN, and refl ects SUN concepts as well as the 2012 World Health Assembly Targets, the Sustainable Development Goals and the outcomes of the second International Conference on Nutrition. It incorporates the principles of the double burden of malnutrition (undernutrition and overnutrition) and articulates the role of all key sectors in accelerating nutrition improvement in the country. It also outlines a better mechanism for roll-out of the national plan at the provincial and district levels.

A timeline of key events that occurred in the development of the three policies and plans that can have a synergistic effect on nutrition is presented below.

Policy timeline

2012: Policy framework and implementa-tion guidelines for SUN developed

2013: Presidential Decree on the national SUN Movement

2014: UNICEF appointed donor convener for SUN

2011: Indonesia joins global SUN movement

2012: Soft launch of the national SUN movement

2012: Soft launch of the national SUN movement

2014: RPJMN developed with stunting as the main development indicator 2011: Third RAN-

PG begins2012: Food law passed

2015: New RPJMN begins

2009/2010: Global SUN preparation initiated

2011-2012: President of Indonesia instructs provincial governors to develop their own food and nutrition plans

2013-2014: UNICEF conducts background study to analyze nutrition situation in Indonesia for RPJMN

2015: Fourth RAN-PG developed and begins

2015pre 2010 and 2010 2011 2012 2013 2014

SUN

RAN-PG

RPJMN


Organizational network analysis: Policy network linkages and key players

Since 2011, Indonesia has accelerated its focus on macro level nutrition policies and plans, and pursued strategies in alignment with global evidence-based nutrition movements to produce a better environment for improving health and nutrition outcomes for women, infants and children. To further the understanding of Indonesia’s development of nutrition policies and programmes through the various policy vehicles that are either nutrition specifi c or more broadly development focused, thirteen key organizations have been interviewed. They include government agencies at the national and district levels, UN bodies, civil society organizations and donors. They were asked about their partnerships and broader networks that paved the way to the adaptation of the SUN policy, integration of nutrition into the RPJMN, including the elevation of stunting as a main development indicator, and building up the RAN-PG to include the latest global evidence.

Table 1 Organizations included in interviews and ONA

Acad Academic Institution MOH_N Ministry of Health, Nutrition Directorate

BPD_Kla Bappeda Klaten (District Planning Offi ce), Social and Cultural Services

Par_Kla Parliamentarian, Klaten

BPN Bappenas (Ministry of Development Planning) PMK Coordinating Ministry of Human Development and Culture

DFAT Australia’s Department of Foreign Affairs and Trade (formerly AusAID)

SUN Scaling Up Nutrition Secretariat

GKIA Gerakan Nasional Kesehatan Ibu dan Anak/Maternal, Newborn and Child Health Movement (Indonesia)

UNICEF United Nations Fund for Children, Nutrition Unit

HSRT Health Sector Review Team WFP World Food Programme

MCA-I Millennium Challenge Account Indonesia WHO World Health Organization

Overall network for SUN, RPJMN and RAN-PG: Figure 1 presents a summary measure of confi rmed organizations involved in all the three major policies that have highlighted Indonesia’s commitment to improving nutrition in the country. The density, or degree to which organizations are connected to each other is high (61.5% or 112 ties out of 182 possible ties). The Government of Indonesia’s Bappenas and Ministry of Health, Nutrition Directorate are most central to the network. By sizing the organizational nodes according to betweeness centrality, or the extent to which organizations link or bring in other organizations, who do not have direct connections into the network, the brokerage role of organizations can be assessed. UNICEF serves as the major broker in the policy nexus. It has an especially important function of connecting the district level Bappeda planning department into the national policy dialogue as well as the organizations that lie of the periphery of the network. The Health System Review Team (HSRT), which was instrumental in coordinating the analysis of health and nutrition data that contributed to the design of the RPJMN, also has an important brokerage role in this system as evidenced by the second largest node or betweeness centrality.


Working relationships: To capture the specifi c ways that organizations work together in the process of developing and drafting the policy and plans as well as generating the evidence to produce country specifi c goals, strategies, and interventions, policy and plan specifi c plots are presented below. Figure 2a examines the evidence generation network for RAN-PG. The Ministry of Health holds a central position but Bappenas and the SUN Secretariat are important brokers for bringing in WFP and MCA-I into the network and thus have larger nodes signifying a higher betweeness centrality. The network structure for drafting the RAN-PG document (Figure 2b) is close to a double spoke and wheel confi guration with the Ministry of Health at the center of engagement with other national level government departments and teams. UNICEF has a strong bond with the Ministry of Health and maintains ties with the other UN agencies (WHO and WFP) as well as facilitates the inclusion of district level Bappeda into the national dialogue. There are a number of organizations that are not connected to the documentation and policy drafting process (located to the left of the plot and include: MCA-I, DFAT, GKIA and Parliamentarian from Klaten).

Even though the same organizations are also engaged in SUN and RPJMN development, the way they interact with each other varies according to the needs of the policy or plan and the type of activity undertaken (Figures 3a, 3b, 4a, 4b). This division of labor, whether it is deliberate or a result of other personal and political dynamics is important for the maintenance of organizational effi ciency. The Ministry of Health continues to be central to the network, with the SUN Secretariat also maintaining a bridging function for the drafting of Indonesia’s SUN policy. HSRT manages to connect with Bappeda Klaten for bringing in their ideas into this development process.

Figure 1 Confi rmed relationships for SUN, RPJMN and RAN-PG

BPN

PMK

SUN

HSRT

Acad

MOH_N

WFPWHO

UNICEF

MCA-I

DFAT

GKIA

BPD_Kla

Par_Kla Plot guide: node color (nodes sized by betweeness centrality)


Figure 2a RAN-PG: Evidence generation Figure 2b RAN-PG: Drafting the document

BPN

PMK

SUN

HSRT

Acad

MOH_NWFP

WHO

UNICEF

MCA-I

DFATGKIABPD_KlaPar_Kla

MCA-IDFATGKIAPar_Kla

BPN

PMK

SUN

HSRT

Acad

MOH_N

WFP

WHO

UNICEF

BPD_Kla




The translation of policies into provincial and district level action plans is presented in Figure 5. The SUN Sectretariat followed by UNICEF and Bappenas are the main brokers and enable peripheral organizations to be part of the broader process for rolling-out and scaling-up the implementation at the subnational level.

Figure 4a RPJMN: Evidence generation Figure 4b RPJMN: Drafting the document

BPNPMK

SUN

HSRT

Acad

MOH_N

WFPWHO

UNICEF

MCA-I

DFAT

GKIA

BPD_KlaPar_Kla

BPNPMK

SUN

HSRT

Acad

MOH_N

WFP

WHO

UNICEF

MCA-I

DFAT

GKIABPD_KlaPar_Kla

Figure 5 Roll-out of policies and plans at subnational level

BPN

PMK

SUN

HSRT

Acad

MOH_N

WFP

WHO

UNICEF

MCA-I

DFAT

GKIA

BPD_Kla

Par_KlaPlot guide: node color (nodes sized by betweeness centrality)


Figure 3a SUN: Evidence generation Figure 3b SUN: Drafting the document

BPN

PMK

SUN HSRT

Acad

MOH_N

WFP

WHO

UNICEF

MCA-I

DFAT

GKIA

BPD_Kla

Par_Kla

BPN

PMK

SUN

HSRT

Acad

MOH_N

WFP

WHO

UNICEFMCA-I

DFAT

GKIA

BPD_KlaPar_Kla




Relationship strength: Organizations working on nutrition policies and plans have a moderate to a high level of connectivity as most of them work on a combination of activities including: generating evidence and drafting of SUN, RPJMN and RAN-PG as well as scaling-up the implementation. MOH-Nutrition, SUN Secretariat, UNICEF, and HSRT have the highest number of strong connections. There are very few organizations that have only one tie. DFAT could possibly become an isolate given that all of the three ties are only based on one relationship type.

In measuring the intensity of the relationships, organizations were asked to identify the highest level of interactions ranging from basic communication, followed by coordination, collaboration and integration. If there was a discordant response from two partners, the lower level of connectivity was applied. As can be viewed in Figure 7, the majority of relationships were characterized by coordination (green lines) followed by collaboration (blue lines). The Ministry of Health stands out as having the highest level of integration with Bappenas, the Coordinating Ministry of Human Development and Culture (PMK) and the Health Sector Review Team that was established by Bappenas.

Infl uence, coordination and evidence: Respondents were also asked to nominate up to fi ve organizations that they considered to be the most infl uential and the best coordinator for developing nutrition policies and plans in Indonesia. Bappenas and UNICEF had the most votes (9 each) for most infl uential followed closely by the Ministry of Health (8 votes). Bappenas also had the highest number of votes for the best coordinator, refl ecting the respect and credibility established to lead the work with multiple stakeholders. UNICEF has been nominated by a range of partners as having the latest evidence on nutrition followed by the Ministry of Health. The votes were also weighted by the rank order of the nomination, which is refl ected in the size of the nodes in Figures 8a, 8b and 8c.

Figure 6 Multiplexity Figure 7 Relationship intensity

BPNPMK

SUN

HSRT

Acad

MOH_N

WFPWHO

UNICEFMCA-I

DFAT

GKIA

BPD_Kla

Par_Kla

BPN

PMK

SUN

HSRTAcad

MOH_N

WFP

WHO

UNICEF

MCA-I

DFAT

GKIA

BPD_Kla

Par_Kla

Multiplexity key




BPN

PMK

SUN

HSRT

Acad

MOH_N

WFP

WHO

UNICEF

MCA-I

DFAT

GKIA

BPD_Kla

Par_Kla

Figure 8a Most infl uential Figure 8b Best coordinator

BPN

PMK

SUN

HSRT

Acad

MOH_N

WFP

WHO

UNICEF

MCA-I

DFAT

GKIA

BPD_Kla

Par_Kla


Major Findings

1. Bappenas and the Ministry of Health are central to the development of nutrition policies and plans. As reported in the overall nutrition policy network, Bappenas and the Ministry of Health were centrally located in the ONA plot. They interact with all the government institutions that are mainly clustered together as well as civil society (GKIA), academia, the donor DFAT, and UN agencies (UNICEF, WFP and WHO).

2. UNICEF is the main connector in the overall nutrition network and provides a pathway for district level engagement. UNICEF has the highest betweeness centrality with an important role of connecting the Klaten district level planning body, Bappeda, into the national policy dialogue. This is especially important because of the absence of a sustainable direct pathway for subnational communication and involvement. “It is important to have champions at all levels and to be politically connected but [action at] the subnational level is lacking.” (Donor)

3. UNICEF connects government to global ideas and movements. The global community of nutrition leaders and advocates are engaged in generating new ideas and approaches that try to steer policies in the latest evidence-based directions to promote nutrition improvement. Exposure to these ideas can be through various channels of communication but there are no guarantees that ideas will be heard by leaders in government who have the power to act. Indonesia’s exposure to the SUN movement supported by UNICEF, was cited by most organizations as the key catalytic event that set Indonesia to place a major focus and policy action on nutrition and specifi cally stunting.

4. Subnational multisectoral linkages for scale-up are limited in practice. As noted from the interview respondents: it continues to be “a challenge to RPJMN about how to bring the multisectoral process to the provincial and district level.” (Government) For RAN-PG, a similar constraint has been identifi ed: “we need to learn how to formulate and harmonize action planning and distribute resources.” (Government) The multi-policy scale-up plot establishes the important role of UNICEF and the SUN Secretariat in implementing policies at the subnational level. UNICEF and HSRT are the only organizations directly connected to Bappeda in Klaten.

5. Bappenas has received the most nominations as the best coordinator but coordination structures are not yet fully operational. For the SUN movement and the new RAN-PG, there are no concrete and sustainable coordinating structures in place... but coordination structures are not fully operational, especially the ones that involve ministerial-level representatives.That’s why an awful lot of the [SUN] meetings tend to be more ad-hoc arrangements with trusted nutrition experts rather than using the formal coordinating structures that are too unwieldy to form on a regular basis.” (UN)

6. Developing plans at the subnational level, particularly in the context of decentralization is very diffi cult. The presidential decree to governors to develop food and nutrition plans at the provincial level was successful, and by 2012 all provinces had a plan, but this has not been replicated at district level.


The road to policy development has proven to be a non-linear and dynamic process involving multiple organizations and shifting linkages or ties based on the specifi c areas of advocacy and technical work. There appear to be three distinct components: 1) the catalytic action and advocacy to expose and connect the high levels of government to new ideas and global movements in nutrition; 2) the country specifi c dynamics, including government leadership, levels of coordination and collaboration to establish country specifi c policies; and 3) the challenges of implementation and scale-up of policies and plans of action in a decentralized setting.

Figure 8c Latest evidence

BPN

PMK

HSRT

Acad

MOH_N

WFP

WHO

UNICEF

MCA-I

DFAT

GKIASUNBPD_KlaPar_Kla




Indonesia has made great strides in embracing global nutrition norms and new ideas and translating them into policy initiatives and plans. Indonesia’s exposure to the SUN movement, supported by UNICEF, was cited by most organizations as the key catalytic event that set Indonesia on track to construct major policies and plans on nutrition and place stunting as a multisectoral indicator in the RPJMN. As expressed by a Government of Indonesia offi cial: “We work well with UNICEF. They support and push us to access the global evidence.”

UNICEF supported upstream nutrition achievements through their fl exibility, advocacy, technical skills, relationship building as well as modest but catalytic funding. This was enough to open opportunities and create a momentum for nutrition within the country’s leadership circle backed by strong partnerships with other UN organizations, donors, civil society, NGOs and academia. UNICEF has worked on the entire spectrum of policy change and implementation by building bridges to the global movements as well as to the subnational level to ensure that local ideas get some attention in the national dialogue. UNICEF stands out as a major non-governmental leader in nutrition being nominated as the most infl uential, along with Bappenas. UNICEF was a main broker in the RAN-PG and instrumental in working with both levels of government (national and district) in developing the plan, in fi rmly positioning nutrition in that plan, and in supporting the MYCNSIA districts to put the structure in place for scale-up.

The remaining challenge is how to connect national policy with district level implementation and scale-up. The current annual bottom up planning cycle establishes the needs and priorities along with resource requests but relies on the awareness, interest, drive and capacity of the local government to implement national policies. Workable models do exist, such as UNICEF’s MYCNSIA project that engaged with creating leadership and capacity at the district level and using their expertise to promote development in other districts. The challenge is translating that intensity and quality of interventions across the 500 districts of Indonesia within the current decentralized government. The missing link has been the weak authority and capacity at the provincial level. If provincial governments become fully functional, they can support the districts to plan, budget, implement and monitor. Building sustainable mechanisms to improve the capacity of districts to develop data driven action plans and a system for monitoring implementation and outcomes is at the core of what needs to be done at a large scale to leapfrog into the next stage of health and nutrition improvement.

References

(2014). Sun Movement in Indonesia. PowerPoint Presentation.

Lung’aho M, Stone-Jiménez M. (2013). UNICEF Community IYCF Counselling Package. Orientation of Master Facilitator-Trainers: Supportive Supervision/Mentoring and Monitoring Module. Draft Report. UNICEF.

Shrimpton R. (2015). A multisectoral nutrition plan for tackling the double burden of malnutrition in Indonesia 2015-2019: Some initial ideas and suggestions for consideration. Draft.

UNICEF-EU Maternal and Young Child Nutrition Security Initiative in Asia: Indonesia – Cumulative 2011-2015 Report.

Widjojo SR, Sunawang, Ljungqvist B et al. (2014). Health Sector Review: Nutrition. Kementerian PPN/Bappenas.


This case study describes the efforts undertaken to enhance the effectiveness of interventions to improve infant and young child feeding (IYCF) practices in Indonesia, with a specifi c focus on the introduction of the Community IYCF (c-IYCF) Counselling Package and the pathway to expand its implementation. The role of the Indonesian government, UNICEF, and local and international partners in c-IYCF roll-out and scale-up is viewed through an organizational network analysis lens.

Background

Despite the government of Indonesia’s efforts to protect breastfeeding practices, they continued eroding in the fi rst decade of the new millennium. Between 2002 and 2007, the percentage of children aged less than six months who were exclusively breastfed fell from 40% to 32%, and prelacteal feeding increased from 63% to 65% (IDHS, 2002 and 2007). In addition, only 37% of children aged 6-23 months were fed a “minimum acceptable diet” in 2007 (IDHS, 2007), indicating that complementary feeding practices were also suboptimal.

Despite Indonesia’s impressive community health worker (CHW) programme attached to community health posts known as Posyandu, community level access to correct information and skilled counselling on infant and young child feeding (IYCF) was still missing. Like many countries across the globe, Indonesia was utilizing the 40 hours Breastfeeding Counselling Course and 40 hours Complementary Feeding Counselling Course to train health workers to provide specialized counselling to breastfeeding women and caregivers. As of 2011, there was no system in place to provide CHWs with the necessary skills and knowledge to counsel mothers and other family members on IYCF.


With support from the UNICEF East Asia and Pacifi c Regional offi ce and Headquarters, a c-IYCF Counselling package for CHWs was introduced in Indonesia in 2011 by the Ministry of Health in partnership with Wahana Visi Indonesia, PLAN International, WHO, WFP and other NGOs. With this package, the Government of Indonesia aimed to substantially increase the access of mothers and caregivers to accurate information and skilled counselling on IYCF to improve both breastfeeding and complementary feeding.

A key catalytic event to introduce the c-IYCF Counselling Package in Indonesia occurred in September 2011, when the East-Asia and Pacifi c Regional Training on the UNICEF Community IYCF Counselling Package trained Indonesia’s fi rst cohort of

ENHANCING THE EFFECTIVENESS OF THE INFANT AND YOUNG CHILD FEED-ING PROGRAMME (IYCF) BY STRENGTHENING COMMUNITY-BASED COUN-SELLING SERVICES

CASE STUDY

2


Master Trainers. These Master Trainers included participants from the Ministry of Health, UNICEF, PLAN, WHO, WFP, Save the Children and others. Subsequently the MOH with UNICEF support adapted the global c-IYCF package to the Indonesian context in September-October 2011. Compared with the generic package, Indonesia’s adaptation gave greater prominence to maternal nutrition, the father’s role in supporting good feeding practices, micronutrient supplementation, and linkages with other health services.

A cascade training model was developed to support large scale roll-out of the package. The pool of Master Trainers trained District Facilitators who are then responsible for training health workers, village midwives and CHWs. Three sets of quality assurance measures were established to ensure that only trainee Master Trainers and Facilitators who demonstrate the necessary knowledge, skills and competencies progress to a training role. Firstly, all individuals must complete the 40 hours breastfeeding or complementary feeding counselling course before training to become a Master Trainer. Secondly, all trainee Facilitators must conduct two training courses of CHWs, with supervision from an existing Facilitator, before they can train CHWs independently. Thirdly, a report card is used throughout the entire training process to track the performance of each trainee Facilitator and assess whether they can (i) progress directly to training others, (ii) require additional coaching in order to address specifi c capacity gaps; or (iii) lack the basic knowledge, skills or competencies to progress further. In 2014, processes and tools for supportive supervision have also been developed to further reinforce the skills and knowledge of CHWs following training.

A timeline of events that led to the national scale-up is presented below. This is followed by mini-stories of the rollout of IYCF in three MYCNSIA districts (Boxes 1-3). Baseline and endline surveys were conducted in three MYCNSIA districts to measure changes in IYCF practices. The survey data show that the percentage of infants who were exclusively breastfed was 52 percent in 2011 and 72 percent in 2014 in the start-up districts; in comparison, the national percentage of exclusively breastfed infants increased from 32 to 42 percent between 2007 and 2012. In addition, complementary feeding practices were signifi cantly higher in 2014 than 2011 among children in the poorest wealth quintile.

UN agencies and NGOs were fully engaged during the development of the training package and supportive supervision processes and tools to streamline the introduction and roll-out of the package in their operational areas. Some local governments have also used their own funds to support c-IYCF training, and have frequently called upon the Master Trainers in Klaten District to provide technical expertise. In addition, UNICEF advocated for the inclusion of c-IYCF counselling in the stunting reduction programme supported by the Millennium Development Challenge (MCC) of the United States Government. The MCC will cover 64 districts in 11 provinces, and UNICEF provided technical support to plan the roll-out of training in 2014. As of December 2015, the training package has been rolled-out to 115 districts in 24 provinces with the support from local governments, UNICEF and other partners and has therefore been scaled-up far beyond MYCNSIA’s three focus districts.

IYCF timeline

2007-2009: UNICEF advocates for improving IYCF programme and introduces training package. Training scaled up by the government

2011: Comprehensive IYCF training package rolled out in partner-ship with MoH, PLAN, Provision, IYC, IME and other national level stakeholders

2012: Government re-ceives MCC (Millennium Challenge Corporation) funding to roll out IYCF

2013: Supportive supervision for IYCF rolled out

2014: UNICEF provides technical support to plan the roll-out of c-IYCF training in 64 districts in 11 provinces

2012: UNICEF ad-vocates for inclusion of c-IYCF Counseling in the MCC stunting reduction programme

2014: National scale up of IYCF

2007-2010: Develop-ment and roll-out of the 40 hours Breastfeeding Counseling Course for facility-based health workers

2011: Community IYCF Counseling Package developed, and pool of Master Trainers created

2012: UNICEF-WB partnership to model large-scale roll-out of c-IYCF training in NTB Province

2014: Design and piloting of supportive supervision processes/tools for c-IYCF

2015: Roll-out of c-IYCF training commences in MCC districts

2012-2015: Roll-out of the c-IYCF package in MYCNSIA districts and by other NGOs and UN agencies

pre 2010 and 2010 2011-2015



UNICEF and a network of organizations were involved in supporting the introduction and scale-up of community IYCF services to increase access of mothers and other family members to nutrition information and counselling. A total of 21 organizations were interviewed to highlight the role of partnerships and IYCF networks in strengthening evidence generation, developing the community IYCF counselling package and rolling it out at the subnational level.

Table 2 Organizations included in interviews and ONA

AIMI Asosiasi Ibu Menyusui Indonesia/Indonesian Breastfeeding Mothers Association

MCA-I Millennium Challenge Account-Indonesia, Health and Nutrition

DAO_Kla District Agriculture Offi ce, Food Security Offi ce Klaten

MOH_N Ministry of Health, Nutrition Directorate

DHO/CH_Kla District Health Offi ce, Community Health Division, Klaten

MOH_NCon Ministry of Health, Nutrition Directorate, Consumption Sub-Directorate

DHO_Kla District Health Offi ce, Klaten Save Save the Children

DHO_Jay District Health Offi ce Jayawijaya, Maternal Health and Nutrition Division

Selasi Sentra Laktasi Indonesia –Breastfeeding Center

DHO_Kal District Health Offi ce, Community Health Division Balikpapan Kalimantan

UNICEF United Nations Children’s Fund, Nutrition Section

DHO_Sik District Health Offi ce, Sikka, Nutrition Division WB World Bank

IKLAN_Kla Association of IYCF Counsellors, Klaten WFP World Food Programme

Box 1 Klaten District

Klaten is considered a “Centre of Excellence” for IYCF. A local policy, PERDA No. 7/2008 was passed in 2008 to promote and protect the early initiation of breastfeeding and exclusive breastfeeding. The district was an “early adapter” of the community IYCF counselling package and the fi rst district to fully scale-up the training of facilitators and cadres with a combination of UNICEF and local government funds. By 2013 the district had trained 99 facilitators, 422 facility health workers and 2260 CHWs. In addition, nine Master Trainers are based in Klaten District, and provide support to other districts that plan to roll-out the package. Supportive supervision tools and mechanisms for maintaining quality were introduced in 2014 to ensure that facilitators and cadres had access to follow-on support and guidance following training. In addition, the district introduced standard operating procedures to assess the quality of counselling provided by health workers and cadres. As a result of these training and capacity-building efforts, Klaten has created a high-quality IYCF counsellor workforce that is supporting behavior change in the community, and has catalyzed scale-up in multiple districts elsewhere in the country.

Box 2 Sikka District

In 2011, the Ministry of Health and UNICEF invited the Sikka District Health Offi ce to attend the initial Master Training on community IYCF. The roll-out of the counselling package began in 2012, and has been supported with both UNICEF and local government funds. To date, 65 facilitators, 96 facility health workers and 409 cadres have been trained. Wahana Visi Indonesia has provided technical support to the District Health Offi ce to roll-out training in three sub-districts through a partnership with UNICEF.

Box 3 Jayawijaya District

The Jayawijaya District Health Offi ce attended the Master Training on community IYCF in 2011. The roll-out of the counselling package began in 2012, and has been supported with UNICEF funds. To date, 17 facilitators, 32 facility health workers and 99 cadres have been trained. Local non-government organizations have been engaged to accelerate the roll-out of the training.


PHO_NTB Province Health Offi ce, Community Health Division, NTB

WHO World Health Organization

Plan Plan International, Health WVI World Vision International

PTSC_Kla PT SC Enterprises, Breastfeeding Counsellors

Overall network: The density of the overall network (as shown in Figure 9) is 33.3% (140 out of a possible 420 ties), that is about one-third of ties or connections between organizations actually exist. UNICEF is the main player at the national level (signifi ed by the largest node in the network) and creates a pathway to “pull in” organizations at the periphery (edges of the network) into the broader network. UNICEF also plays a central role in maintaining strong ties with district level organizations (District Health Offi ce and IKLAN, the district level association of IYCF counsellors) through the MYCNSIA model district of Klaten. The District Health Offi ce in Klaten and IKLAN are at the center of the subnational IYCF network with direct communication lines to the two other MYCNSIA districts (Sikka and Jayawijaya) as well as Kalimantan and NTB Province.

The plot below further demonstrates that UNICEF’s has established linkages with NGOs/INGOs, and other UN agencies who are at the periphery of the network. UNICEF’s extensive relationships with multiple agencies that the national and district governments creates an indirect pathway for bridging the information gap.

Figure 9 Overall IYCF Network

MOH_NCon

MOH_N

WFP

WHO

UNICEF

MCA-I

WB

WVISave

Plan

AIMI

Selasi

DHO_KlaDHO/CH_Kla

DAO_Kla

IKLAN_KlaPTSC_Kla

DHO_Jay

DHO_SikPHO_NTB

DHO_Kal

Working relationships: As Indonesia is decentralized, partnerships and support systems are required at all levels to make IYCF programmes more effective. Partnerships involving evidence generation in the form of surveys, rapid assessments or surveillance and monitoring data to ensure the appropriate adaptation of global policies, norms and tools to the Indonesia context are presented in Figure 10a. The density for evidence generation is minimal at 9% as only 38 of the potential 420 ties remain active. It appears that the network operates in multiple small groups that may work together on specifi c aspects of knowledge generation. The Ministry of Health’s Nutrition Directorate has the highest betweeness centrality as it connects national level organizations such as WHO with subnational partners. UNICEF is embedded at the center of the district level evidence generation process while IKLAN in Klaten district connects the Klaten District Health Offi ce with the Ministry of Health. There are also six organizations that drop out of the evidence generation work: WFP, Plan International, Selasi, Klaten Department of Agriculture, PTSC Enterprises and the District Health Offi ce (DHO) in Kalimantan.

The network for the development of the IYCF counselling package (Figure 10b) has a triple spoke and wheel structure. UNICEF plays a leading role overall by connecting district level governmental offi ces with national level organizations. The Ministry of Health is connected directly to Klaten district government offi ces and brings in WHO, that would otherwise be out of the network without that connection. The District Health Offi ce in Klaten forms the third hub and works with a mix of organizations including Plan, Selasi, IKLAN and the Klaten district Department of Agriculture. There are also fi ve organizational isolates that do not have any confi rmed relationships and include: WFP, Save the Children, AIMI, PTSC Enterprises, and the DHO Kalimantan.

The training implementation network (Figure 10c) is more robust with a density of 30% and consists of 128 out of a potential 420 ties. UNICEF is the main connector creating bridges between a variety of national and district level organizations. There is a logical order in how organizations chose to work together to create a critical mass for expanding the speed of training implementation to maximize the spread of IYCF tools and skills to promote better nutrition. The Klaten DHO and IKLAN are working closely with district level organizations to implement IYCF training programmes.


GovernmentUNDonorPrivate SectorCivil Society/NGO/INGO


Relationship strength: Another important measure of the strength or stability of organizational relationships in the IYCF network is multiplexity. Multiplexity establishes how many of the three types of IYCF activities exist between organizations. In Figure 11 below, the magenta lines depict that all three types of IYCF linkages exist: 1) evidence generation, 2) development of the training package, and 3) implementation of the IYCF training programme. The nodes in the plot are of equal size and have the same gray color to focus attention on the color lines that represent different levels of working partnerships. The Ministry of Health-Nutrition Directorate is connected with UNICEF, WHO and IKLAN. UNICEF constructs the strongest ties to its key MYCNSIA districts of Klaten, Sikka and Jayawijaya. However, most of the ties for IYCF span only one or two activities. Even though UNICEF has the strongest district level ties, many of the other district government bodies are only connecting through one activity that makes them vulnerable to isolation if that activity is dropped.

Most organizations characterize their relationship intensity as communication and coordination (Figure 12). There are a few integration partnerships that include: two DHO departments in Klaten along with IKLAN; World Bank and the Millennium Challenge Account-Indonesia; and the Ministry of Health (Nutrition Directorate and the Consumption Sub-Directorate). The majority of UNICEF’s relationships are collaboration.

Figure 10a IYCF: Evidence generation Figure 10b IYCF: Counselling package

Figure 10c IYCF: Implementing training

MOH_NCon

MOH_N

WFP

WHO

UNICEF

MCA-I

WB

WVISavePlan

AIMISelasi

DHO_Kla

DHO/CH_Kla

DAO_Kla

IKLAN_Kla

PTSC_Kla

DHO_Jay

DHO_Sik

PHO_NTB

DHO_Kal

MOH_NCon

MOH_N

WFP

WHO

MCA-IWB

WVI

Save

PlanAIMI

Selasi

DHO_Kla

DHO/CH_Kla

DAO_Kla

IKLAN_Kla

PTSC_Kla

DHO_Jay

DHO_Sik

PHO_NTB

DHO_Kal

UNICEF

MOH_NCon

WFP

MCA-I

WB

WVI

AIMI

PTSC_Kla

DHO_Jay

PHO_NTB

MOH_N

WHO

UNICEF

Save

Plan

Selasi

DHO_Kla

DHO/CH_Kla

DAO_Kla

IKLAN_Kla

DHO_Sik

DHO_Kal

MOH_NConMOH_N

WFP

WHO

UNICEFMCA-I

WB

WVI

Save

Plan

AIMI

Selasi

DHO_Kla

DHO/CH_Kla

DAO_Kla

IKLAN_Kla

PTSC_Kla

DHO_Jay

DHO_SikPHO_NTB

DHO_Kal

Figure 11 IYCF multiplexity



Multiplexity key

1 Tie2 Ties3 Ties


Infl uence, coordination and evidence: The important roles played by UNICEF and the Ministry of Health-Nutrition Directorate are further reinforced by their nominations for most infl uential and best coordinators for IYCF (Figures 13a and 13b). UNICEF received the most votes for most infl uential (15) and is consistently ranked the highest in order of voting, receiving a weighted degree centrality score of 60. The Ministry of Health – Nutrition Directorate received the second highest nomination (8 votes) and a weighted degree centrality score of 40.

Nominations for best coordinator are evenly divided between Ministry of Health – Nutrition Directorate and UNICEF. There was an almost equal distribution by the types of organizations that nominated them. The only exception is that DHO Klaten and Sikka voted for UNICEF while DHO Kalimantan nominated the Ministry of Health. This may refl ect the fact that UNICEF has provided direct support to both DHO Klaten and Sikka, while DHO Kalimantan has benefi ted indirectly through the DHO Klaten. UNICEF also received the most nominations for having the latest evidence on nutrition and IYCF.

Figure 12 IYCF Relationship intensity

MOH_NCon

MOH_N

WFP

WHO

UNICEF

MCA-I

WB

WVI

Plan

AIMI

Selasi

DHO_Kla

DHO/CH_Kla

DAO_Kla

IKLAN_Kla

PTSC_Kla

DHO_Jay

DHO_SikPHO_NTB

DHO_Kal

Save

Figure 13a IYCF: Most infl uential Figure 13b IYCF: Best coordinator

Figure 13c IYCF: Latest evidence

MOH_NCon

MOH_N WFP

WHO

MCA-I

WB

Save

Plan

AIMI

Selasi

DHO_Kla

DHO/CH_Kla

DAO_Kla

IKLAN_Kla

PTSC_Kla

DHO_Jay

DHO_Sik PHO_NTB

DHO_Kal

UNICEF

WVI

DHO/CH_KlaDHO_JayPHO_NTB

MOH_NCon

WHO

AIMI

Selasi

DHO_Kla

DAO_Kla

IKLAN_Kla

PTSC_Kla

MOH_N

WFP

UNICEF

MCA-I

WB

WVI

Save

PlanDHO_Sik

DHO_Kal

MOH_NCon

MOH_N

WFPWHO

UNICEF

MCA-I

WBWVI

Save

Plan

AIMI

Selasi

DHO_Kla

DHO/CH_KlaDAO_Kla

IKLAN_Kla

PTSC_Kla

DHO_Jay

DHO_Sik

PHO_NTB

DHO_Kal






Major fi ndings

1. UNICEF is at the center of IYCF development and scale-up in Indonesia. UNICEF plays a leading role in the development of the community IYCF counselling package and is working closely with District Health Offi ces to connect them with national organizations and in some cases, also with the Ministry of Health – Nutrition Directorate for coordinating IYCF activities. UNICEF has also been nominated by their partners as being the most infl uential, best coordinator (together with the Min-istry of Health-Nutrition Directorate) and technical leader by maintaining the most up-to-date evidence base on nutrition.

2. The District Health Offi ce in Klaten is a major leader in IYCF activities in their own district and support IYCF training in other districts. The capacity development of Klaten District through the MYCNSIA programme, has enhanced the role of DHO in generating evidence for IYCF development for the counselling package. As a “Centre of Excellence” or model district, they developed a pool of Master Trainers that have provided support to other districts to introduce and roll-out the IYCF counselling package.

3. The quality of IYCF training is variable. Interview respondents noted that there are multiple reasons for a lack of consis-tent quality of training. One source of variability in the IYCF training package roll-out stems from uptake of the higher-level courses by facility-based health workers. The 40 hours Breastfeeding Counselling Course has been extensively rolled out (much of this occurred before MYCNSIA), but the 40 hours Complementary Feeding Counselling Course has been adopted to a lesser extent. It is essential for health workers to have expertise in breastfeeding and complementary feeding if they are to have the knowledge and skills to train and supervise cadres on community IYCF.

4. Lack of clear accountability of provinces and districts to roll-out community IYCF is affecting the pace of scale-up. The Ministry of Health has not provided clear instructions or expectations on the pace of roll-out of community IYCF by provinc-es and districts. This has meant that many provinces and districts have yet to take action to initiate roll-out. In this context, the role of UNICEF and other development partners is to advocate for the allocation of government resources and the pro-vision of technical support to leverage the roll-out and scale-up of the programme.

“[G]iven the decentralized context, we need to really work at the subnational level, and with the district government, to make sure that there are... suffi cient commitment and resources allocated, to do...quality roll-out of this package to reach all cadres, to reach more villages.” (INGO)

5. Supportive supervision is a necessary but not suffi cient component to ensure quality of IYCF counselling. It is diffi cult to implement a large-scale supportive supervision system within a large health system that has other human resource challeng-es to address such as the incentive structure and career ladder of the workforce. Even though the supportive supervision


system is designed to provide oversight over the counsellors, variation in the motivation of cadres to deliver counselling at home is also dependent on the level of oversight and monitoring by village midwife. Building in other human resource man-agement and monitoring reforms are needed to attain the goal of promoting quality home visits at critical times in the growth trajectory of the child.

“I think a couple of lessons learned...rely very much on the supportive supervision mechanism, so, and that is the big challenge in Indonesia - how to put... this package is in the health system, and having appropriate and qualitative supervision in place, ... so that all the counselling is happening [with] quality. So that is the main challenge.” (INGO)


UNICEF is a major conduit for driving IYCF programming through evidence generation, development of the counselling package and support for the implementation of training and scale-up. Together with the Ministry of Health - Directorate of Nutrition, and the Klaten District Health Offi ce they were able to develop improved and locally relevant IYCF training modules for cadres and lead the training scale-up process. By pulling in other national and district level partners, other ideas, and resources were generated for a collective national and subnational support for the programme.

As discussed previously, UNICEF supported the roll-out of the IYCF training package in three MYCNSIA focus districts (Klaten, Sikka, and Jayawijaya) plus two additional districts that were added subsequently (Pemalang and Brebes). Klaten, in particular, has reached a high level of capacity and recognition as a leader in training and is a well-respected partner of the Ministry of Health, UNICEF and other districts in Indonesia.

Lessons have been learned from introducing and rolling out the community IYCF package in different contexts, and it is encouraging that local governments are allocating their own fi nancial resources to support scale-up without donor support. With diminishing donor support for development assistance, it is critical that the government’s own resources are mobilized for the long-term sustainability of community IYCF counselling services. IYCF counselling is now included as one of the priority activities in the annual guidelines for use of Biaya Operational Kesehatan (BOK) funds since 2013. These funds are utilized by health centres (Puskesmas) and Posyandus to expand IYCF counselling. The development of technical and coordination capacity at the provincial level to support the introduction and roll-out of community IYCF at district level is essential as it not feasible for the central Ministry of Health, or development partners, to support over 500 widely dispersed districts.

UNICEF has also facilitated scale-up of the community IYCF and Maternal Nutrition Counselling package using mechanisms outside of the MYCNSIA project. For example, UNICEF partnered with the World Bank to support an initiative of the Indonesian government to enhance the nutrition portion of the PNPM Generasi programme, an incentivized community block grant programme. As part of this programme, facilitators, health workers, and community-based workers are trained on the IYCF and Maternal Nutrition Counselling package. The government will now scale-up this intervention, together with supportive supervision on community IYCF, through the Community-based Stunting Reduction Programme supported by the MCC in 64 districts in 11 provinces with technical guidance from UNICEF.

“Where we’ve had the most success is working with the government, World Bank, and MCC group during the of the stunting reduction programme to ensure that IYCF was the cornerstone of the programme at community level. We were able to infl uence them to adopt the community IYCF package for large scale roll-out, as well as the supportive supervision model, which they’ve just taken board recently. We’re also working with [MCA-I] to strengthen the WASH component of the community IYCF package.” (UNICEF)

Building on the UNICEF and Ministry of Health partnership and trust imbued by other organizations, they have the mandate to coordinate a broader set of multisectoral partnerships both inside and outside the government and linkages to subnational implementers. Further integrating IYCF within the multisectoral policy developments, as outlined in the other Indonesia Case Study can produce accelerated momentum to improve nutrition services and outcomes.

References

Lung’aho M, Stone-Jiménez M. (2013). UNICEF Community IYCF Counselling Package. Orientation of Master Facilitator-Trainers: Supportive Supervision/Mentoring and Monitoring Module. Draft Report. UNICEF.

Statistics Indonesia, National Family Planning Coordinating Board, Ministry of Health, and ORC Macro. (2008) Indonesia Demographic Health Survey – 2007. Jakarta, Indonesia and Calverton, MD.

Statistics Indonesia, National Family Planning Coordinating Board, Ministry of Health, and ORC Macro. (2003) Indonesia Demographic Health Survey – 2002-2003. Jakarta, Indonesia and Calverton, MD.

UNICEF-EU Maternal and Young Child Nutrition Security Initiative in Asia: Indonesia – Cumulative 2011-2015 Report.

Nutrition Upstream Improving Policies, Programmes and Partnerships for Maternal and Child Nutrition in Asia 54NEPAL

NepalCASE STUDIES

Nutrition Upstream Improving Policies, Programmes and Partnerships for Maternal and Child Nutrition in Asia55 NEPAL

Case Study 1

ACCELERATING REDUCTION IN CHILD STUNTING THROUGH A MULTISECTORAL NUTRITION PLAN (MSNP): THE ROLE OF PARTNERSHIPS

Background


Organizational network analysis: MSNP policy network linkages and key players

Major Findings


References

Case Study 2

POLICIES, PROGRAMMES AND COMMUNICATION HELP TO ACCELERATE PROGRESS IN INFANT AND YOUNG CHILD FEEDING

Background



Major fi ndings


References

Case Study 3

SCALING UP SERVICES FOR CHILDREN WITH SEVERE ACUTE MALNUTRITION: ROLE OF GOVERNMENT AND DEVELOPMENT PARTNERS

Background


Organizational network analysis: CMAM network linkages and key players

Major fi ndings


References

56

56

56

58

62

63

63

64

64

65

65

68

69

69

70

70

70

71

74

75

75


This case study describes the development and implementation of Nepal’s Multisectoral Nutrition Plan (MSNP) using an interdisciplinary and multiple stakeholder approach to scale-up essential nutrition interventions that can address the high levels of child undernutrition. The involvement of different national and international partners in the process is analyzed and their specifi c contributions are detailed.

Background

The Government of Nepal’s national priority is to address chronic undernutrition. Under the leadership of the National Planning Commission (NPC), the Government of Nepal worked in partnership with six government sectors and development partners to design the MSNP. The long-term vision of the MSNP is to accelerate efforts to reduce the high burden of child stunting through a multiple stakeholder platform that can deliver both nutrition-specifi c and nutrition-sensitive interventions. In order to achieve the long term vision of the MSNP at both national and subnational levels, the government intends to: (1) Improve policies, programmes and establish a multisectoral coordination mechanism; (2) Promote implementation and utilization of nutrition-specifi c and nutrition-sensitive services; (3) Strengthen the capacity of programme managers and service providers; and (4) Monitor multisectoral nutrition information to assess progress. The MSNP action plan lists a package of strategic objectives and interventions by sector, which is to be implemented over a period of fi ve years.

The key milestones along the MSNP development pathway are outlined in the policy timeline (below).

Policy timeline

2009: Nutrition Assessment Gap Report (NAGA) released and disseminated

NAGA endorsed by NPC

MSNP development initiated

MSNP endorsed by the cabinet

MSNP implemented in six districts

MSNP launched by PM of Nepal

National Nutrition and Food Security Secretariat established

Ministry of Finance allocates funds for MSNP

MSNP communica-tion strategy developed

MSNP scale- up to over 40 districts planned

National Nutrition Seminar

Nutrition Technical Committee established


In 2006, survey data showed that nearly half of Nepalese children were stunted (DHS, 2006). Concern about the high rates of stunting drove discussions between the Ministry of Health (MoH), UNICEF, WHO, USAID and other development partners. This resulted in a formation of a committee to design and conduct a Nutrition Assessment and Gap Analysis (NAGA). The NAGA report highlighted that nutrition was a multisectoral issue beyond the capacity of a single ministry to solve. Moreover, in addition to nutrition-specifi c interventions, the need for integrating nutrition-sensitive interventions into existing development programmes was underscored to address the multidimensional determinants of stunting. Recognizing the fi ndings of the NAGA report, a collaborative process was initiated by a consortium of development partners to identify the roles and responsibilities of different sectors in addressing nutrition.

“I’ve never worked on an issue where all the donors spoke the same language” (Donor).

Prior to MSNP, nutrition programming in Nepal was driven by the health sector, with little engagement from other sectors. The Nutrition Section under the Child Health Division in the Ministry of Health and Population was a small unit that implemented a few projects in select areas. This highlighted that nutrition was not a focus for the Government of Nepal despite the high burden of child stunting. A respondent described how previous conversations about improving nutrition had little traction and how an attempt was made by the National Planning Commission in the 1980s to form a food security committee:

ACCELERATING REDUCTION IN CHILD STUNTING THROUGH A MULTISECTORAL NUTRITION PLAN (MSNP): THE ROLE OF PARTNERSHIPS

CASE STUDY

1

2016pre 2010 2010 2012 2013 20142011 2015


“The idea of a multisectoral approach was implemented in the 1980s and was discontinued. In 2009–2010, there was an exercise of a Nutrition Assessment and Gap Analysis and a group of experts developed a report which resulted in the MSNP and pointed out the need for a multisectoral approach to improve nutrition.” (INGO)

Respondents almost unanimously identifi ed the contribution of the NAGA report as the foundation for multisectoral planning, programming and fi nancing: “Thinking in a multisector way is essential to address the challenges of malnutrition in Nepal” (UN). What ensued was a process of persuasion backed up by the fi ndings in the NAGA, the global SUN movement and the increasing attention to child stunting.

“There was an isolated nutrition agenda…people thought it belonged to the health sector and they needed convincing.” (NGO)

“It took a lot of effort to justify why a multisector nutrition plan was needed. This happened in 2012 and then there was endorsement.” (UN)

In 2011, the Government of Nepal convened a task force to create a multisectoral nutrition policy and a plan. The architects were working with global evidence on nutrition interventions, the NAGA report, and sector-specifi c reviews, which were prepared by the technical reference groups for each sector. With the technical lead by UNICEF, these efforts led to the development of a Multisectoral Nutrition Plan.

“If we put effort we can bring all the actors together…each sector has realized that their sectoral contribution is essential to address malnutrition - this realization is the most important.” (UN)

Several respondents highlighted that with the MSNP there was a need to think differently and “out of the box” of traditional vertical programmes, and ensure that a process was in place so that the design and implementation of the plan occurred in a multisectoral manner at national and subnational (district level).

Key government ministries including Agriculture, Education, Finance, Information and Communication, Local Development, and Health and Urban Development were led by the National Planning Commission (NPC) to develop the multisectoral nutrition action plan. Different components of the plan were formulated by a series of committees and were centrally coordinated by the National Nutrition and Food Security Steering Committee. Technical support to this committee was provided by the joint UN initiative - Renewed Efforts against Child Hunger and Undernutrition (REACH). The National Nutrition and Food Security Steering Committee was the nodal body to provide technical assistance to each ministry especially in the areas of capacity building, information management, communication and advocacy.

In addition to developing a plan of action for implementing the MSNP, all the key ministries coordinated to ensure effective programme implementation that included: high coverage of essential nutrition interventions (both nutrition-specifi c and nutrition-sensitive), provision of quality services and periodic monitoring of progress through a joint MIS system. At the subnational level, the MSNP worked to strengthen programme implementation and governance for nutrition in the district through the Village Development Committee (VDC): “in the absence of local government, the local development offi cer (LDO)


and the Village Development Committees (VDCs) are responsible for government efforts at local level” (Government). At the district level, nutrition and food security steering committees were formed and led by the chair of the District Development Committee who coordinated implementation, monitored progress, and managed programme bottlenecks.

Thus, with the MSNP a new nutrition architecture was established at all administrative levels in 2012. With the endorsement by the Cabinet Council of Ministers, the implementation of the MSNP was initiated in six districts in 2013, with a goal of adding ten districts in 2016, and 12 districts in 2017. The aim is to reach a total of 28 districts with UNICEF’s support. Other large nutrition projects, like the USAID-funded Suaahara project and the World Bank funded Golden 1000 days project are implementing their project activities in line with the MSNP; thus ensuring that the foundation of an MSNP programme is being positioned across the country. By 2017, the Government of Nepal has a plan to expand the MSNP and reach all 75 districts of the coutnry.

Organizational network analysis: Network linkages and key players

We interviewed representatives of 22 organizations to understand the MSNP policy dialogue, action plan development, implementation process, and document the organizational dynamics and contributory role of each organization (Table 1). These included 8 government organizations, 4 technical departments, 4 UN agencies, 2 donors, and 4 organizations representing civil society, and national and international NGOs. An organizational network analysis was conducted to measure organizational linkages, and identify key actors in the multiple stages of MSNP development.

Table 1 MSNP network organizations and their acronyms

CSA_Nut Civil Society Alliance for Nutrition NPC National Planning Commission

EU European Union Save Save the Children

FAO Food and Agriculture Organization Suaahara Suaahara Project, USAID

HKI Helen Keller International UNICEF_CFLG UNICEF, Child Friendly Local Governance

MoAD Ministry of Agriculture Development UNICEF_Edu UNICEF, Education

MoE Ministry of Education UNICEF_Nut UNICEF, Nutrition

MoFALD Ministry of Federal Affairs and Local Development UNICEF_SPEA UNICEF, Social Policy and Economic Analysis

MoHP, DHS Ministry of Health and Population, Department of Health Services

USAID US Agency for International Development

MoHP_NutCH Ministry of Health and Population, Nutrition Section, Child Health

WFP World Food Programme

MoUD Ministry of Urban Development WB World Bank

NNFSS National Nutrition Food Security Secretariat WHO World Health Organization

Overall MSNP network: In exploring the level of overall network connectivity for MSNP (Figure 1), the density (extent to which all potential connections are realized) and the degree of centralization (potential power of direct relationships) are measured. A relationship confi rmation process was carried out where organizations had to mutually affi rm their relationship with one another to be included in the analysis. The majority of the organizations confi rmed their relationship with each other and only a few organizations that did not reciprocate their relationship were dropped. Out of a possible 462 ties, 330 connections were confi rmed (density of 53.3%). Due to a high density, the centralization is at an average of 51.4%, highlighting that the network has a high number of connections and is not dependent on a few organizations to serve as intermediaries for information exchange.

UNICEF’s Nutrition Section stands out as the main broker or avenue for fostering linkages between organizations that do not have direct relationships with each other, and hence has the largest “node” or betweeness centrality. Within UNICEF, the Social Policy and Education Sections are indirectly linked to the other organizations, ministries and government bodies through the Nutrition Section for all MSNP activities.

The Nepal National Food Security Secretariat (NNFSS), the government body facilitating MSNP implementation for the National Planning Commission (NPC) is located at the center of the network. NNFSS is a focal point for having direct


relationship with most organization types in the network. The organizations also tend to cluster together, with the government bodies on the right side, the UN organizations on the bottom left side of the plot and the donors and NGOs centered towards the middle of the plot (with a few exceptions). These homogenous groups work essentially through NNFSS and UNICEF who serve as key communication hubs or transmitters of information throughout the network.

The Ministry of Health and Population, Department of Health Services, Child Health Division, Nutrition Section, is more integrated with all categories of organizations, including UN agencies, donors and international NGOs, and is positioned closely to the NNFSS. The Ministry of Agriculture Development is a conduit for connecting non-health sector ministries such as the Ministries of Education, Federal Affairs and Local Development, and Urban Development, which are on the periphery of the network but are key contributors to the intersectoral architecture of MSNP. Save the Children, Helen Keller International and the Suaahara Project are more embedded with the Government of Nepal side of the network while continuing to maintain ties with others.

MoHP_NutCH

WFP

Suaahara

MoHP, DHS

NNFSS

NPC

MoFALD

MoUD

MoE

CSA_Nut

USAID

FAO

WHO

HKI

MoAD

Save

EU

WB

UNICEF_SPEAUNICEF_Edu

UNICEF_Nut

UNICEF_CFLG

Figure 1 Confi rmed MSNP whole network


GovernmentUNDonorCivil Society/INGO/Private

Working relationships: The road to MSNP started with advocacy for a multisectoral collaboration to address child stunting with a package of nutrition-specifi c and nutrition-sensitive interventions. This led to a policy dialogue and the development of a Multisectoral Nutrition Plan, and was followed by strategic planning, development of an implementation plan and scale-up (Figures 2a-c). The density of relationships and centralization are the highest for advocacy and in a step-down manner are reduced for strategic planning, programme implementation and scale-up. The central broker, having the highest betweeness centrality and the highest number of direct connections in all three types of linkages is the UNICEF-Nutrition Section. UNICEF is a high performer and has a lot of direct infl uence with a variety of organizations in addition to creating bridges between organizations to enable the transmission of ideas and work to foster a common understanding.

Although the structure of the networks appears similar, there are distinct ways in which the organizations are positioned to fulfi ll different roles and responsibilities. In the advocacy and policy infl uence arena, the NPC plays a central role in a dense network of government departments and INGOs (Figure 2a). UN agencies tend to work in partnership with UNICEF as the main focal point for advocacy. The linkages in the UN cluster are slightly less dense, and NNFSS plays a central role primarily supported by UNICEF-Nutrition. The donors, USAID and EU are on the periphery while the projects and INGOs that they fund are located within the inner circle of government partners highlighting that donors do not have direct working relationships with INGOs/NGOs on MSNP.

In moving the MSNP policy development to the strategic planning stage, NNFSS and NPC are central to the network (Figure 2b). UNICEF continues to be a conduit for the government bodies as well as other UNICEF programmes and UN agencies. The Ministry of Health and Population, Department of Health Services under which the Child Health Division (Nutrition Section) is located, has direct relationships with multisectoral ministries (MoUD, MoE, MoAD) and the MSNP coordinating structure (NNFSS) under the authority of the NPC. USAID is closely connected to their grantees as well as the MoHP, Nutrition and Child Health. This government department also holds a central position with UN agencies (WFP, WB and WHO) and INGOs but is on the periphery of the government departments. This highlights that the government bodies do not interact mainly among themselves but connect with each other through UNICEF or other UN agencies.


For MSNP scale-up, there is a reorganization of UN agencies and INGOs that surround different combinations of government departments and support them in the scale-up effort. UN agencies, other than UNICEF, include the World Bank, WHO, and FAO and reciprocate relationships with NPC and NNFSS but not necessarily the other ministries, except the Ministry of Health and Population. Save the Children, Suaahara, Helen Keller International and Civil Society Alliance are working more directly with other ministries representing other sectors. UNICEF-Nutrition is working with almost everyone on scale-up and has facilitated the inclusion of other UNICEF programmes and INGOs/NGOs for a more effi cient services delivery network.

Relationship strength: In examining the strength of relationships, multiplexity and relationship intensity are analyzed. Multiplexity measures the total number of possible working relationships among organizations. Each respondent was asked to identify three types of working relationships with each organization that they engaged in. These included: advocacy and policy infl uencing, strategic planning, and scale-up. The majority of relationships are for all three ties (magenta lines in Figure 3) signifying a very robust network that involves most organizations working together in all the key three activities in the MSNP process.

The level of intensity of relationships is presented in Figure 4. The color of the lines depicts the strength of the ties. The most basic relationship is communication (grey) and only a few organizations are at this fi rst stage of developing a relationship. The majority of relationships are based on coordination (green) followed by collaboration (blue). Most of the collaboration occurs between NPC, NNFSS, different ministries and UNICEF-Nutrition. The most intensive relationships moving to the integration stage (red) include: a) UNICEF-Nutrition with Ministries of Health and Population and Urban Development; b) NPC with NNFSS; c) NNFSS with WFP; d) Ministry of Health and Population, Department of Health Services together with its Child Health Division, Nutrition Section; e) Save the Children with Suaahara and Civil Society Alliance for Nutrition; f) Civil Society Alliance with Helen Keller International; and g) USAID with Suaahara (a project funded by USAID).

Figure 2a MSNP: Policy dialogue and development Figure 2b MSNP: Strategic planning

Figure 2c MSNP: Scale-up

MoHP_NutCH

WFP

Suaahara

MoHP, DHS

NNFSSNPC

MoFALD

MoUD

MoE

CSA_Nut

USAID

FAO

WHO

HKI

MoAD

Save WB

UNICEF_SPEA

UNICEF_Edu

UNICEF_Nut

UNICEF_CFLG

EU

MoHP_NutCH

WFP

Suaahara

MoHP, DHS

NNFSS

NPC

MoFALD

MoUD

MoE

CSA_Nut

USAID

FAO WHO

HKI

MoADSave

EU

WB

UNICEF_SPEA

UNICEF_Edu

UNICEF_NutUNICEF_CFLG

MoHP_NutCH

WFP

Suaahara

MoHP, DHSNNFSS

NPC

MoFALD

MoUD

MoE

CSA_Nut

USAID FAO

WHO

HKI

MoAD

Save

EU WB

UNICEF_SPEA

UNICEF_Edu UNICEF_Nut

UNICEF_CFLG


GovernmentUNDonorCivil Society/NGO/Private


Figure 3 MSNP: Multiplexity Figure 4 MSNP: Relationship intensity

Multiplexity key

1 Tie2 Ties3 Ties



Figure 5a MSNP: Most infl uential Figure 5b MSNP: Best coordinator

MoHP

MoHP_NutCH

WFP

Suaahara

MoHP, DHS

NNFSS

NPCMoFALD

MoUD

MoECSA_Nut

USAID

FAO

WHO

HKI

MoAD

Save

EU

WB

UNICEF_SPEA

UNICEF_Edu

UNICEF_Nut

UNICEF_CFLG

UNICEF

MoHP

MoHP_NutCH

WFP

Suaahara

MoHP, DHS

NNFSS

MoFALD

MoUD

MoE

CSA_Nut

USAID

FAO

WHO

HKI

MoAD

SaveEU

WB

UNICEF

UNICEF_SPEA

UNICEF_Edu

UNICEF_Nut

UNICEF_CFLG NPC

Infl uence, coordination and evidence: Organizations were also asked to nominate each other for being the most infl uential, best coordinator and having the latest evidence for MNSP. The following defi nitions were applied: (1) most infl uential - organizations whose views, ideas, and/or research have been most listened to and have had the greatest impact; (2) best coordinator - organizations who have the respect and credibility from other organizations to work effectively with multiple stakeholders; and (3) latest evidence - organizations that are providing the latest evidence-base on nutrition for developing nutrition policies, programmes, guidelines, training materials or capacity building of the nutrition workforce. For each type of measure, each organization was asked to list up to fi ve organizations in order of importance. A weighting scheme was used to emphasize the level of importance assigned to each nomination and the size of the nodes refl ects this analytic process. It should be noted that organizations may not have specifi cally stated the exact department of an organization they were referring to, but based on the combined results, we assume that the broad UNICEF nomination refers to UNICEF-Nutrition and the Ministry of Health and Population refers to the Department of Health Services, Child Health Division, Nutrition Section.

The National Planning Commission has the highest degree centrality score based on the weighting procedure and has the highest number of votes followed by UNICEF for both being the most infl uential and the best coordinator. The Ministry of Health and Population has a very close third position for being the most infl uential in MSNP development. In examining the distribution of type of organizations that nominated NPC or MoHP as opposed to UNICEF, government bodies were most likely to vote for NPC and MoHP while donors, INGOs and other UN agencies emphasized UNICEF (Figures 5a and 5b). However for evidence generation, UNICEF had the most votes from all organizations irrespective of whether they were governmental, donors or INGOs (Figure 5c).

MoHP_NutCH

WFP

Suaahara

MoHP, DHS

NNFSS

NPC

MoFALD

MoUD

MoE

CSA_Nut

USAID

FAO

WHO

HKI

MoAD

Save

EU

WB

UNICEF_SPEA

UNICEF_Edu

UNICEF_Nut

UNICEF_CFLG

MoHP_NutCH

WFP

MoHP, DHS

MoFALD

MoUD

MoE

CSA_Nut

USAID

WHO

MoAD

WBUNICEF_SPEA

SuaaharaNNFSS

NPC

FAO

HKI

EU

UNICEF_Edu UNICEF_Nut

UNICEF_CFLG

Save


Major fi ndings

Designing MSNP resulted in a vast number of lessons learned in advocacy, policy development, and the operationalization of national plans. MSNP fundamentally changed the approach to addressing child undernutrition in Nepal. The MSNP established a multisectoral programming environment characterised by cooperative goal defi nition, a high degree of participation by partners and stakeholders, supportive leadership, and strong integration of policy and planning.

“We need to address the core determinants of malnutrition. These will be similar to the social determinations to health which means reducing inequality and the systems and processes that produce inequality...be it fi nancial, social or other forms of marginalization...I think that’s the most important thing we have learned.” (UN)

The MSNP major fi ndings are summarized below.

1. The National Planning Commission commands the center stage of multisectoral policy and programme work. The respondents in interviews and ONA plots highlighted the central role of the National Planning Commission. This reinforces the leadership role of government in the multisectoral process and the commitment to address child stunting in Nepal.

“We have learned how to work together to make a difference in the local planning process. If you want to get nutrition to be owned and for people to know about it, the only way is to not have a project approach but to build the government’s structures. If we strengthen the architecture we will have greater accountability and commitment of national and local stakeholders as well as political leaders.” (UN)

“The leadership role of the government, particularly under the Child Health Division and the NPC...they had full ownership of this since day one…if that wasn’t there, even if the donors spoke the same language, it [MSNP] would not have happened.” (Donor)

2. The high degree of direct relationships among organizations has created a platform for strong coordination and collaboration. As depicted by the ONA relationship intensity measure, there was a high degree of direct relationships among organizations. This created a platform for strong coordination and collaboration, highlighting that the formal NPC and NNFSS coordination structures are functional and effective for multisectoral policy development.

“Coordination is important between government and donors and partners - there are formal structures, but need daily and informal coordination…. All other projects that work on malnutrition and food security should be integrated and linked to MSNP.” (INGO)

One respondent highlighted the importance of joint ownership: “there has to be a common identity to bring all the sectors together. There is a logo and everyone working on nutrition uses this.” (UN)

3. Ministries, other than the Ministry of Health and Population, have limited direct connections among themselves or with other non-government organizations for MSNP. ONA results demonstrate that the Ministry of Health and Population is integrated with a range of donors, UN agencies and INGOs. However, other ministries such as Education, Federal Affairs and Local Development (MoFALD) and Urban Development do not always have direct relationships with each other and sometimes rely on the Ministry of Agriculture Development as an intermediary in communicating with others on MSNP activities. The Government of Nepal has been channeling a lot of additional funds for MSNP through MoFALD and as refl ected in MoFALD’s multiple linkages with other government departments except MoHP.

Figure 5c MSNP & IYCF: Latest evidence

MoHP

MoHP_NutCH

WFP

Suaahara

MoHP, DHS

NNFSS

NPCMoFALD

MoUD

MoECSA_Nut

USAID

FAO

WHO

HKI

MoAD

Save

EU

WB

UNICEF

UNICEF_SPEA

UNICEF_Edu

UNICEF_Nut

UNICEF_CFLG


GovernmentUNDonorCivil Society/NGO/Private


4. UNICEF exerts direct infl uence and creates bridges for a variety of organizations. UNICEF plays a major role in bridging the gap between government and the international development community in the development of MSNP. This is further reinforced by the nomination of UNICEF as most infl uential, best coordinator and provider of the latest evidence for policy advocacy and action.


A consistent and complementary picture has emerged from qualitative interviews with key informants, organizational network analysis and the review of secondary data sources. As the global and national level momentum for nutrition improvement surged, the Government of Nepal in 2010 convened a task force to create the Multisectoral Nutrition Plan and designated the National Planning Commission (NPC) to take the lead in the MSNP development process. The NPC and its Secretariat, with technical help from UNICEF and other development partners, coordinated with other ministries to advance the MSNP goals. Additional support from the partners included fi nancial assistance from donors, and technical and logistical inputs from numerous working groups and technical committees.

The ONA plots reinforce the role of NPC and its partnership with UNICEF, in coordinating different ministries and development partners to establish a common mission. The prime success in the development of the Multisectoral Nutrition Plan lies in NPC’s effective coordinating structure that provides equal voice and power to all the participating ministries. This new collaborative approach and nutrition focus across the respective vertical structures and hierarchies is a major new dynamic to accelerate nutrition improvement. This mechanism avoids the challenge of having any one ministry taking charge. It also distributes the responsibility and governance across the sectors beyond the Ministry of Health and Population under the NPC umbrella.

The establishment of the National Nutrition and Food Security Secretariat in 2013, was another effective feature of the MSNP. The role of the Secretariat was to provide technical assistance to the Ministries. As we can view from ONA plots for advocacy and strategy development, NNFSS together with NPC is located at the center of the MSNP network, is linked with multiple ministries, and has a direct dynamic relationship with many other partners.

These upstream policy achievements have been central to UNICEF’s work in Nepal as a trusted leader and technical partner of the GoN and non-governmental partners alike. UNICEF-Nutrition works in the following ways: (1) plays a complementary role in linking the non-governmental organizations with one another; (2) has the most direct relationship with everyone; (3) is a link or “bridge” between those who do not have direct relationships with each other; and (4) has an important role not only in advocacy and policy infl uencing but also in programme implementation.

Although the basic MSNP platform has been effectively established, there is general agreement that “the multisector approach is challenging” and that: “many people are looking at Nepal because multisectoral approaches are the talk of the day everywhere, but it’s hard to do it.” (INGO) For example, the lack of full and direct participation of non-health sectors is a barrier to the effective implementation of the MSNP. Equal engagement and participation of all relevant sectors can lead to a more constructive dialogue and integration of individual and joint plans. These explicit processes can lead to fi nancial and human resource commitments at both national and subnational levels. The leaders of each sector need to send a fi rm directive and provide technical support to their staff to work towards the same MSNP goals with other departments.

The scale-up pathway of the MSNP story is still ongoing and implementation is continuing in six UNICEF-supported districts. There are plans for expansion in 2015-2016. Moreover other partner organizations like Suaahara and World Bank are implementing activities that are in line with MSNP. It is anticipated that all partners together with UNICEF could increase the reach to approximately 40 districts (53% of the total) in the next few years. The structure for scale-up at the subnational level has been proposed by MSNP in the form of regional, district and village level steering committees. Initial support was provided through district refresher training in six districts by UNICEF and the Government of Nepal, however it is unclear what resources are being extended to promote local multisectoral coordination, self-suffi ciency and sustainability. The ultimate success of MSNP will occur if the national level strategies and plans are implemented with the same intensity and collaboration at the subnational level

References

(2011). Nepal Nutrition Assessment and Gap Analysis Final Report.

Government of Nepal, Ministry of Health and Population. (2010). Nepal Health Sector Programme – II, 2010-2015.

Government of Nepal, National Planning Commission. (September 2012). Multisector Nutrition Plan for Accelerating the Reduction of Maternal and Child Undernutrition, 2013-2017.


POLICIES, PROGRAMMES AND COMMUNICATION HELP TO ACCELERATE PROGRESS IN INFANT AND YOUNG CHILD FEEDING

CASE STUDY

2

This case study describes the advocacy for the design and development of the Nepal Strategy for Infant and Young Child Feeding (IYCF) and programmatic efforts to execute a IYCF communication campaign to reach out to children in the fi rst 1000 days (from conception to age two). The ONA establishes the different roles and positions of organizations, partnerships and network structures involved in advocating, developing an implementation plan and scaling-up IYCF in Nepal.

Background

Evidence has demonstrated that infant and young child feeding practices (IYCF) in Nepal, particularly breastfeeding and complementary feeding (including hygiene and sanitation) are suboptimal. With other compounding factors like persistent poverty and food insecurity, IYCF practices offer families and communities ways to improve child nutrition even under many existing constraints.

With the global momentum on strengthening IYCF policies and programmes, the government of Nepal intensifi ed its

efforts to support the IYCF policy environment and programme actions to improve child nutrition. The national “Strategy for Infant and Young Child Feeding” was developed to create an enabling environment for mothers, families and other caregivers to adopt optimal infant and young child feeding practices. These guidelines also extend to emergency situations. The IYCF strategy highlights different approaches for improving feeding practices and details the roles and responsibilities of stakeholders and partners.

Following the development of an IYCF strategy, an IYCF action plan was designed, costed and implemented to ensure that the package of IYCF interventions are delivered to mothers and their children. Various partners and stakeholders were mobilized to scale-up the programme with the following objectives: (1) Raise awareness of mothers and communities by implementing a comprehensive communication package that includes behaviour change on IYCF, hygiene and sanitation practices, stimulation and responsive feeding, care of the sick child and maternal nutrition; (2) Scale-up of community-based IYCF interventions for both food secure and food insecure areas; (3) Strengthen service delivery mechanisms through capacity building of health providers on rights based approaches; (4) Communicate clear and targeted messages to address health and nutrition related taboos, beliefs and practices related to nutritious diets, child stimulation, immunization, hygiene and growth monitoring; (5) Engage and empower communities, child clubs and other networks to infl uence or reinforce social norms and cultural practices and create an environment that supports long-term sustainable change.

Policy timeline

National Nutrition Group established to improve IYCF

IYCF Master trainer training

Advocacy with MoH on First 1000 days of life

Golden 1000 day project initiated by the World Bank

MIYCN plan and communica-tion campaign developed

MIYCN plan costed

MIYCN implemented

Golden 1000 days campaign

20162010 2012 2013 20142011 2015



The Nepal Strategy for Infant and Young Child Feeding was catalyzed by high political commitment to address child undernutrition. The lack of improvements between DHS 2001 to 2006 in levels of exclusive breastfeeding, and minimum acceptable diet for mothers and their children created a national awareness of the severity of the IYCF problem across Nepal. One respondent described how the focus on IYCF was ignited because of high undernutrition even among children in the wealthier quintiles; “having suffi cient food and money was not enough to address malnutrition, other factors play a role” (UN). Thus it was felt there was a need to address the behavioral aspects of malnutrition in a comprehensive manner.

In 2011, the IYCF strategy was developed by the MoHP, Nutrition and Child Health Development Division with technical support from UNICEF. The strategy development was carried out in close collaboration with the IYCF Core Working Group in line with MSNP as many organizations participated in both activities. This led to the development of an action plan directed by the Nutrition Technical Committee (NUTECH). Then in 2014, NUTECH decided to integrate the IYCF and maternal nutrition strategies and developed the Maternal, Infant and Young Child Nutrition Plan (MIYCN). The MIYCN plan is presently being costed and implementation is expected to begin in 2016. In tandem, a roadmap was developed for a communication campaign – Golden 1000 days - which is the operationalization of the Maternal Infant and Young Child Nutrition Communication Plan developed by Nepal Health Education, Information and Communciation Centre (NHEICC), Ministry of Health and Population. The communication campaign is a 1000-day behavior change campaign on maternal and child nutrition. It targets groups and interventions along the life cycle starting with adolescence and covers contraception and the fi rst 1000 days after conception, including deworming, antenatal care, maternal food, and birth registration. Together all these initiatives are designed to accelerate progress in infant and young child feeding in Nepal.


The IYCF network of organizations consists of approximately two-thirds of the same organizations as for MSNP. The MSNP organizations that do not work on IYCF include: Ministry of Urban Development, Ministry of Agriculture, the head of the Division of Health Services, Ministry of Health and Population, FAO, WHO, EU and two UNICEF departments (Social Policy and Child Friendly Local Governance). The three additional organizations that are part of the IYCF network are UNICEF WASH and Communication for Development (C4D) Sections as well as MaxPro. A total of 17 organizations that were involved in the IYCF work in Nepal are included in the ONA analysis.

Overall IYCF network: The overall IYCF network is presented in Figure 6. The number of ties that emerge from unconfi rmed relationships to mutual acknowledgment of a working relationship on IYCF drops from 124 to 74 ties. This produces a density of 27.2% for confi rmed relationships (74 out of 272 potential ties). There are four organizations that have no confi rmed relationships including: the Ministry of Federal and Local Development, World Bank, the Civil Society Alliance for Nutrition and Helen Keller International. For example, even though organizations identifi ed working with the World Bank, the connections were not reciprocated and therefore were dropped out of the confi rmed plots. The same pattern was observed for the other unconfi rmed organizations.

The reduced density in the IYCF network conversely leads to a more centralized environment with a few organizations leading the way to IYCF policy and programme development and implementation. UNICEF-Nutrition is the main connector for government bodies, INGOs, USAID and other UNICEF departments. The Ministry of Health and Population, Nutrition Section

Figure 6 Overall IYCF network

MoHP_NutCH

WFP

Suaahara

NNFSS

NPC

MoFALD

MoE

CSA_Nut

USAID

HKI

Save

WB

UNICEF_WASH

UNICEF_C4DUNICEF_Ed

UNICEF_Nut

MaxPro Plot guide: node color (nodes sized by betweeness centrality)



plays a major role, being located in the center of the overall network. The NPC and NNFSS have a number of direct connections but are situated on the outer circle of the network. UNICEF Education and WASH programmes are indirectly connected to the IYCF network through UNICEF-Nutrition.

Working relationships: The specifi c types of working relationships for IYCF include advocacy and policy infl uencing, developing a plan of action followed by programme implementation and scale-up. UNICEF’s role continues to be important for advocacy and policy infl uencing and also for drawing in other UNICEF departments into the network (Figure 7a). Ministry of Health and Population, Child Health Division, Nutrition Section is a conduit for government activity and creates bridges for Ministry of Education with UNICEF and the donor and international NGOs. The reduced level of direct connections (with 66 out of 272 potential ties and density of 24.3%) and the strong leadership of UNICEF-Nutrition and MoHP, Nutrition Section led to a more centralized approach to IYCF advocacy. UNICEF’s C4D, Education, and WASH programmes do not have direct linkages with the network and rely on UNICEF’s Nutrition Section for communication of IYCF information with other organizations.

The network for the development of IYCF strategy and plan of action is basically the same as for advocacy (Figure 7b). UNICEF maintains its role as a broker in the network while MoHP_ Nutrition Section moves more into the center of the network with USAID repositioning to the periphery. It should be noted that MaxPro, an organization hired to help develop the IYCF Micronutrient Powder (MNP) communication strategy and IEC materials works only with UNICEF-Nutrition and Ministry of Health and Population, Nutrition Section. The IYCF scale-up plot (Figure 7c) is more of a double spoke and wheel confi guration where UNICEF-Nutrition maintains the central position with other UNICEF programmes, Civil Society, INGOs, NGOs and private organizations whereas MoHP, Nutrition Section brings together the other government bodies. The density of the network is low at 21.3% with 58 out of a potential 272 ties, which signals that the scale-up effort is centralized and there is a question about the level of participation of organizations in subnational implementation.

Figure 7a IYCF: Advocacy and policy infl uencing Figure 7b IYCF: Strategic plan of action

Figure 7c IYCF: Scale-up and communication campaign

MoHP_NutCH

WFP

Suaahara

NNFSS

NPC

MoFALD

MoE

CSA_Nut

USAID

HKI

Save

WB

UNICEF_WASH

UNICEF_C4D

UNICEF_Ed

UNICEF_Nut

MaxPro

MoHP_NutCH

WFP

Suaahara

NNFSS

NPC

MoFALD

MoECSA_Nut

USAID

HKI

Save

WB

UNICEF_WASH

UNICEF_C4D

UNICEF_Ed

UNICEF_Nut

MaxPro

MoHP_NutCH

WFP

Suaahara

NNFSS

NPC

MoFALD

MoE

CSA_Nut

USAID

HKI

Save

WB

UNICEF_WASH

UNICEF_C4DUNICEF_Ed

UNICEF_Nut

MaxPro




Relationship strength: A very strong level of working relationships is noted in the IYCF network with a majority of organizations working on all three types of IYCF activities (magenta lines in Figure 8). This is reinforced by the fact that majority of the relationships are at the level of collaboration (Figure 9, blue lines of linkages). The strength of relationships is measured by multiplexity and perceptions of the intensity of connections, or to what extent there is an increasing engagement in the IYCF work. Relationships begin with communication, build to coordination and collaboration and lastly integration. Each individual level can be thought of a being “nested” within the next higher level. For example, there cannot be coordination if basic communication does not exist and collaboration requires both communication and coordination. This logic builds through to the fi nal stage of organizational intensity through integration of resources, activities and even services.

Figure 8 IYCF: Multiplexity Figure 9 IYCF: Intensity

MoHP_NutCH

WFP

Suaahara

NNFSSNPC

MoFALD

MoE

CSA_Nut

USAID

HKI

Save

WB

UNICEF_WASH

UNICEF_C4D

UNICEF_Ed

UNICEF_Nut

MaxPro

MoHP_NutCH

WFPSuaahara

NNFSS

NPC

MoFALD

MoE

CSA_Nut

USAID

HKI

Save

WB

UNICEF_WASH

UNICEF_C4DUNICEF_EdUNICEF_Nut

MaxPro

Multiplexity key

1 Tie2 Ties3 Ties




Major fi ndings

1. UNICEF-Nutrition is the main connector for IYCF to government bodies, INGOs, USAID and other UNICEF sections. UNICEF’s position of creating linkages between different types of organizations has been consistent for the overall IYCF network as well as for specifi c work functions.

2. The Ministry of Health and Population, Department of Health Services, Child Health Division, Nutrition Section plays the central role in all IYCF activities. The Ministry maintains a unique position of connecting with other government departments as well as having direct contact with other stakeholders. MoHP’s leadership in IYCF is further reinforced by having the most votes with UNICEF for being the most infl uential and the best coordinator.

3. The Nutrition Technical Committee within the MoHP has served as an important coordinating mechanism for IYCF development. The existence of a stable mechanism for governmental and non-governmental partners to work together is a necessary condition for IYCF policy and programme implementation.

4. Embedding IYCF within the MSNP structure promotes integration and linkages with non-health sectors. The ability to maintain a multisectoral focus and integrate nutrition activities, related funding and human resource commitments within the MSNP structure has the potential for accelerating progress in nutrition. This can be seen by the fact that the partners for MSNP were mostly the same as for IYCF.

5. The overall density or level of connectivity between organizations is low. Only about 20% of the potential direct relationships were reciprocated by their respective partners. There were four organizations that did not have any connectivity to the network: Ministry of Federal Affairs and Local Development, World Bank, the Civil Society Alliance for Nutrition and Helen Keller International.

Infl uence and coordination: Organizations were also asked to nominate others according to their perceptions of which organizations had the most infl uence and who were the best coordinators in IYCF development. The nominations were ranked from one to fi ve in order of importance and subsequently weighted to refl ect the prioritization assigned by organizational respondents. Refl ecting the consistency in other ONA measures, UNICEF and MoHP had the highest weighted degree centrality as refl ected in Figures 10a and 10b. UNICEF was nominated by the majority of non-governmental organizations with the exception of Nutrition Section, CHD, MoHP (MoHP_NutCH). The MoHP nominations for most infl uential included most governmental organizations as well as a mix of other types of organizations. The pattern of nominations for MoHP as key coordinator remained the same except that only UNICEF departments (Education, C4D and Nutrition) continued to vote for MoHP and not the other development partners.

Figure 10a IYCF: Most infl uential Figure 10b IYCF: Best coordinator

MoHP

MoHP_NutCH

WFP

Suaahara

NNFSS

NPC

MoFALD

MoEUSAID

HKI

Save

WB

UNICEF

UNICEF_C4D

UNICEF_Ed

UNICEF_Nut

CSA_NutUNICEF_WASHMaxPro

MoHP

MoHP_NutCHWFP

Suaahara

NNFSS

NPC

MoFALD

MoECSA_Nut

USAID

HKI

Save

WB

UNICEF

UNICEF_WASH

UNICEF_C4D

UNICEF_Ed

UNICEF_Nut

MaxPro




6. UNICEF has created a trusted, infl uential and stable role in Nepal. This reputation and ability to work effectively with others has led to the creation of bridges for other organizations, both within and outside the UN, to consistently update and expand IYCF development.


The MSNP environment in Nepal paved the way for the successful introduction of maternal and child nutrition initiatives. The development of a multisectoral mechanism for engaging government ministries across different sectors and development partners has led to a series of opportunities for improved nutrition programming.

The Nutrition Section at the Ministry of Health and Population led the development of the IYCF strategy that started in 2011 and fi nalized in 2014 with the full support of the organizations working on IYCF. The Ministry is at the center of most of the IYCF ONA plots including overall network of relationships, strategy development and plan of action, as well as programme scale-up. UNICEF continues to be the main broker for all types of IYCF networks and is a channel for creating a dialogue and promoting information exchange among organizations that do not have direct relationships with each other.

As IYCF policy and programme development is of a technical nature, the networks are more centralized and the number of possible ties, or density levels reduced to improve effi ciency. Therefore, as depicted in the ONA fi ndings, the leadership roles played by UNICEF and MoHP to develop methods for obtaining inputs and support from other partners was an important key to IYCF strategy development. However, the low density of connections for scale-up indicate a suboptimal alignment of government and other non-governmental organizations for programme implementation. As noted in the qualitative interviews, the presence of development partners in the districts varies. Some INGOs and development partners that have a presence at the national level do not work at the district level but there is a lot of overlap of programmes and resources targeting the same districts. At the national level, there is no synchronization or equitable distribution of districts amongst the stakeholders for a more effective programme implementation – some districts get a lot of focus while many others, especially the remote districts, are not attended to. The coordination of resources and implementation across multiple sectors and the strategic alignment with development partners would accelerate nutrition improvement in Nepal.

References

(2011). Nepal Nutrition Assessment and Gap Analysis Final Report.

Government of Nepal, Ministry of Health and Population, Department of Health Services, Child Health Division. (2014). Strategy for Infant and Young Child Feeding: Final Draft.

Government of Nepal, Ministry of Health and Population, NUTEC. (2013). Strategy for Infant and Young Child Feeding.

Shrimpton, Roger and Atwood, Stephen. (2012). Nepal National and District Nutrition Capacity Assessment.


SCALING UP SERVICES FOR CHILDREN WITH SEVERE ACUTE MALNUTRITION: ROLE OF GOVERNMENT AND DEVELOPMENT PARTNERS

CASE STUDY

3

This case study describes the advocacy for developing the guidelines, designing implementation plans and scaling up the programme for the community management of acute malnutrition (CMAM) in Nepal. It also depicts the subsequent development of the programme for the integrated management of acute malnutrition (IMAM). The organizational network analysis provides a pictorial view of the CMAM networks, key players and intensity of working relationships.

Background

Wasting, a measure of acute malnutrition, has remained stagnant over the last decade in Nepal [DHS 2001: 11% and DHS 2011: 11%] and is a serious public health problem based on WHO criteria. The Ministry of Health and Population (MoHP) and UNICEF worked in partnership to reduce the mortality and morbidity risk associated with severe acute malnutrition (SAM) among children under-fi ve. The aim of the effort was to rehabilitate children with SAM to a state of health in which they are able to sustain their recovery on discharge. Policies and programmes were designed to manage children with severe acute malnutrition and prevent further deterioration and potential death. The community management of acute malnutrition (CMAM) programme started as a pilot in three districts in 2009 with the addition of two districts in 2010. After its evaluation the programme was scaled-up to an additional 6 districts in 2012-2013. The policy timeline below traces the evolution of the CMAM programme from before 2010 through the planning phase for 2016.

Policy timeline

2005: WHO guidelines on SAM and MAM

CMAM baseline survey

CMAM implemented in fi ve districts; three districts (2011) and two districts (2012)

CMAM evaluation

MSNP recommends CMAM scale-up to 35 districts

CMAM incorporated within MSNP

IMAM implementation planned in fi ve districts

2007: Workshop with partners to discuss SAM

CMAM pilot approved

CMAM scale-up written into NHSPII

2007: CMAM feasibility study

MAM program suggested


The introduction of CMAM marked a shift from providing in-patient care to children with SAM in facilities to providing treatment at the community level so that more children could be managed at home. Data from eleven districts showed that in-patient admissions were constant every year and that a large bulk of SAM children in Nepal remained untreated.

CMAM was catalyzed by a growing recognition of the lack of capacity for treatment in hospitals where an approximately 20-bed limit meant that hospitals were unable to treat the number of SAM children seeking care. By 2007, the recognition that facilities could no longer be the sole providers of care combined with the increasing use of CMAM globally, and the realization that Moderate Acute Malnutrition (MAM) cases were ignored, led to a workshop to advocate for a CMAM programme.

“In 2007 national experts said that children are really dying of acute malnutrition and we can’t rely only on nutrition rehabilitation homes which are located inside hospitals.” (INGO)

A feasibility study for CMAM was also conducted in 2007 by UNICEF and the Ministry of Health and Population in districts with a high SAM prevalence. Respondents described how the study was conducted amidst drought in the mountains and fl oods in the Terai while a health and nutrition working group was set up to respond to the fl oods. In 2008, a national meeting was held to develop the CMAM protocol and implementation framework. In this meeting the Government of Nepal approved the CMAM pilot.

2016Pre-2010 2011-2012 2013 20142010 2015


Following the training of service providers, CMAM implementation began in 2009 in three districts (Bardiya, Achham and Mugu) and by 2010 two additional districts (Kanchanpur and Jajarkot) were included. These two districts were initially supported by ACF and Concern Worldwide and later by UNICEF. UNICEF continued providing support to the fi ve pilot districts in collaboration with the national, regional and district health authorities. Local health providers (hospital and health facilities’ staff and FCHVs), NGOs and community-based organizations (e.g. women‘s groups) delivered the services directly to children and their families.

In 2011, an evaluation was conducted in the fi ve pilot districts. Scale-up of CMAM was recommended and CMAM was written into National Health Sector Programme II (NHSPII 2013–2017). Later, when the Multisectoral Nutrition Plan (MSNP) was developed, CMAM was incorporated into the MSNP. The scale-up of CMAM began in 2012 in eleven districts in accordance to the WHO protocols yet designed to meet the goals and objectives of MSNP.

In 2011, an evaluation of the CMAM pilot and the joint review conducted by the Mother and Child Health Care (MCHC) programme of MoHP, Ministry of Education (MoE), and WFP suggested that the programme should also focus on moderate acute malnutrition (MAM) cases to reduce the prevalence. This review highlighted gaps in the programme and recommended the development of national MAM guidelines. A commitment to set a higher bar through the development of the integrated management of acute malnutrition (IMAM) was also highlighted in the Strategy for Infant and Young Child Feeding (2013-2017). It called for an accelerated reduction of severe malnutrition as a high priority in Nepal’s Health Nutrition and Population Sectoral

Programme. Agencies and stakeholders began to develop the IMAM guidelines to include MAM strategies and interventions. WFP offered support to manage MAM, and thus SAM and MAM were integrated into a single guideline.

The IMAM guidelines were developed to meet the objectives of MSNP and incorporate lessons learned from the CMAM pilot. The IMAM protocol is based on the WHO treatment guilelines for inpatient management of SAM, standard CMAM protocols, WHO technical information on supplementary foods for the management of MAM and the UN and Global Nutrition Cluster guidelines for the management of MAM. The guidelines cover treatment protocols and service delivery mechanisms for children aged 6-59 months. The guidelines propose a shift to a more integrated approach in which the services for SAM and MAM management are co-located and linked to the existing health infrastructure and service delivery system.

Organizational network analysis: Network linkages and key players

We identifi ed six organizations for the CMAM Case Study. They include: UNICEF-Nutrition, Nutrition Section at the Child Health Division, Ministry of Health and Population, the World Food Programme, Action Contre Le Faim (ACF-International), the Nepal Youth Foundation and Suaahara Project led by Save the Children and Helen Keller International and funded by USAID.

Overall CMAM network: The network is small and specialized and almost everyone knew each other, with a confi rmed relationship density of 66.7% signaling that 20 out of the potential 30 ties were validated by the respondents. The shape of the overall CMAM network is a kite structure with Suaahara at the end of the kite’s tail being connected to the network through UNICEF. By creating a bridge for organizations without direct confi rmed relationships, UNICEF holds the important position of broker for the network.


Working relationships: The three specifi c types of linkages explored for CMAM include: a) involvement in advocacy to infl uence CMAM policy design (Figure 12a); b) design of an action plan including components of piloting, training and implementation (Figure 12b); and c) scale-up of the programme (Figure 12c). The structure of the networks for advocacy and components of implementation are identical except that the Suaahara Project was not involved in advocacy and is an isolate. Suaahara appears to have no outgoing ties, because it did not confi rm the two connections stated by other organizations. The Suaahara Project representative affi rmed that they were not involved in infl uencing and designing CMAM policy, but with support from UNICEF they partnered in implementation.

The roles and infl uence of the different organizations change as a result of the different activities. For advocacy, UNICEF and the Nutrition Section at the Ministry of Health and Population have the same betweeness centrality as they both bring all organizations together including the Nepal Youth Foundation. For CMAM implementation, UNICEF’s infl uence is higher as they engage with Suaahara and connect them into the CMAM implementation process. For CMAM scale-up, UNICEF is the main bridge between the World Food Programme and the Nepal Youth Foundation that provides an indirect connection between WFP and MoHP, Nutrition Section of the Ministry of Health and Population and between WFP and NYF. Suaahara is not involved in scale-up.

Figure 11 Confi rmed CMAM network

MoHP_NutCH

WFP

SuaaharaACF

NYF

UNICEF_Nut


GovernmentUNCivil Society/NGO/INGO

MoHP_NutCH

WFP

Suaahara

ACFNYF

UNICEF_Nut

Figure 12a CMAM: Advocacy Figure 12b CMAM: Implementation

Figure 12c CMAM: Scale-up

MoHP_NutCH

WFP

Suaahara

ACF

NYF

UNICEF_Nut

MoHP_NutCH

WFP

Suaahara

ACF

NYFUNICEF_Nut


GovernmentUNCivil Society/INGO/Private


Relationship strength: Among the three types of linkages described above, a majority of them are across all the types of working relationships as depicted in the multiplexity plot in Figure 13. The only organization/project that is connected only across one relationship is Suaahara. This occurs because Suaahara does not claim to have relationships with other organizations for advocacy and neither have other organizations claimed that Suaahara is involved in the implementation of the CMAM programme in a few overlapping districts where their project is being implemented. The Nutrition Section of the Ministry of Health and Population and WFP confi rmed their relationship across two different types of work activities that include advocacy, programme implementation but not scale-up.

The intensity of the relationships is very strong as the majority of organizations chose to describe their relationships as integration with UNICEF leading the way and having four out of fi ve relationships fall in this top category (Figure 14). Conversely, Suaahara is the only organization in this network where a majority of the relationships are across communication.

Figure 13 CMAM: Multiplexity Figure 14 CMAM: Relationship Intensity

MoHP_NutCH

WFPSuaahara

ACF

NYF

UNICEF_Nut

MoHP_NutCH

WFP

Suaahara ACF

NYF

UNICEF_Nut

Multiplexity key

1 Tie2 Ties3 Ties

Intensity Key



Figure 15c CMAM: Latest evidence

Plot guide: node color (nodes sized by weighted degree centrality )

GovernmentUNCivil Society/INGO/Private

Major fi ndings

1. Collaboration with partners to implement a continuum of care approaches works well. The importance of integrating nutrition promotion, prevention and treatment of children with SAM is well recognized. The partnership of UNICEF, WFP and Ministry of Health to integrate the management of SAM and MAM children through one comprehensive programme instead of vertical structures has succeeded. The new IMAM guidelines include both prevention and treatment of SAM in both facility and community-based treatment settings.

2. UNICEF continues to play a major role in forging connections between organizations. Even within a small network, some organizations are still not directly connected and rely on UNICEF for new information regarding implementation and scale-up.

3. Integration of CMAM into the MSNP programme has not been operationalized. The ONA shows that only the Ministry of Health and Population is involved in the CMAM programme. The scope of the CMAM programme was broadened and integrated into the multisectoral nutrition programme, however this was not yet demonstrated in the ONA. A multisectoral approach to SAM will result in collaboration with other sectors that directly or indirectly impact acute malnutrition like WASH, social protection, early childhood development, food security and poverty alleviation.

MoHP

MoHP_NutCH

WFP

Suaahara

ACF

NYF

UNICEF

UNICEF_Nut

Infl uence, coordination and evidence: Consistent with the major broker roles played by UNICEF-Nutrition and the Nutrition Section of the Ministry of Health and Population, organizations nominated UNICEF as the most infl uential, best coordinator and having the latest evidence on nutrition (Figures 15a, 15b, 15c). As some organizations did not specify the actual departments that they were referring to, the plots include the main organization and specifi c departments within the organization. It is then assumed that a vote for UNICEF translates to a vote for UNICEF-Nutrition.

MoHP

MoHP_NutCH

WFP

Suaahara

ACF

NYF

UNICEF

UNICEF_Nut

Figure 15a CMAM: Most infl uential Figure 15b CMAM: Best coordinator

MoHP

MoHP_NutCH

WFP

Suaahara

ACFNYF

UNICEF

UNICEF_Nut



Although CMAM was fi rst implemented in the context of an emergency response, a strong evidence base was built through the pilot programme to convince partners that it could be transitioned into a programme to manage and treat severely malnourished children at the community level in a non-emergency setting.

For developing the CMAM programme, in addition to the advocacy for policy development, all the technical stakeholders collaborated to develop treatment protocols and the implementation framework. As government recognized the results of the CMAM pilot programme, stakeholders worked towards scaling-up a comprehensive country-wide programme. UNICEF was identifi ed by the partners as being the most infl uential, best coordinator with the ability to provide the latest evidence-base for the management of SAM. Presently the CMAM programme which includes both facility and community-based management of SAM is being expanded across the country. The sustainability of this programme is highly dependent on external support. Currently all RUTF is provided by UNICEF, and although procurement was in the plan for the Government of Nepal since 2014, they were not able to do the actual procurement. Looking to the future, the delivery of a full range of SAM services will require the full commitment and activation of effective implementation potential of the Government of Nepal to ensure the availability of a range of nutrition products and well-trained human resources to prevent and reduce Severe Acute Malnutrition.

References

(2015). NEPAL Integrated Management of Acute Malnutrition (IMAM) Guideline, Draft 6.

Government of Nepal, Ministry of Health and Population. (2010). Nepal Health Sector Programme – II, 2010-2015.

UNICEF. (2012). Evaluation of Community Management of Acute Malnutrition (CMAM): A Country Case Study.

Nutrition Upstream Improving Policies, Programmes and Partnerships for Maternal and Child Nutrition in Asia 76PHILIPPINES

PhilippinesCASE STUDIES

Nutrition Upstream Improving Policies, Programmes and Partnerships for Maternal and Child Nutrition in Asia77 PHILIPPINES

Case Study 1

STRENGTHENED POLICY ENVIRONMENT TO SCALE UP EXCLUSIVE BREASTFEEDING IN THE WORKPLACE: ROLE OF GOVERNMENT AND NON-GOVERNMENTAL PARTNERS

Background


Organizational network analysis: NSMP network linkages and key players

Major fi ndings


Citations

References

Case Study 2

STRENGTHENED CAPACITY OF THE LOCAL GOVERNMENT UNITS TO SCALE UP EMERGENCY PREPAREDNESS AND EARLY WARNING SYSTEMS TO MITIGATE NUTRITION RISKS

Background


Organizational network analysis: EWS network linkages and key players

Major fi ndings


Citations

78

78

78

81

85

85

87

87

88

88

88

89

92

92

93


STRENGTHENED POLICY ENVIRONMENT TO SCALE UP EXCLUSIVE BREASTFEEDING IN THE WORKPLACE: ROLE OF GOVERNMENT AND NON-GOVERNMENTAL PARTNERS

CASE STUDY

1

This case study describes how different government agencies and stakeholders are collaborating to protect the breastfeeding culture in the Philippines. The process of developing different policy instruments and programmes to improve the environment for breastfeeding and provide support to mothers to breastfeed in the workplace is described. The case study is based on a combination of surveys and qualitative interviews with respondents from twenty-fi ve organizations and a review of secondary data. Organizational network analysis maps the relationships and partnerships that were mutually confi rmed to provide further insight into the network positions of organizations, levels of connectivity, and strength of relationships.

Background

The Philippines is positioned among nations with the lowest proportion of exclusively breastfed children. Despite the fact that there are many policies in place to support breastfeeding, only 34% of under-6 month old infants are exclusively breastfed, highlighting a critical gap in translating policies into practice. The reasons cited for replacing breastmilk with formulae include mothers’ self-perceived inability to produce suffi cient breast milk and time constraints due to work and family responsibilities. Furthermore, the use of breast milk substitutes is considered a status symbol of modernism and economic improvement, especially among mothers belonging to the lowest wealth quintile.

Two laws on infant feeding that helped to create an enabling environment for women to breastfeed are the Executive Order 51 and Republic Act (RA)-7600.

1. Executive Order No. 51, National Code of Marketing of Breastmilk Substitutes, Breastmilk Supplement and Other Relat-ed Products (“Philippines Milk Code”) (1986) Executive Order No. 51 requires that the advertising, promotion, or market-ing of infant formulae, breastmilk substitutes, and complementary infant foods be approved by an Inter-Agency Committee (IAC) consisting of the Department of Health, Department of Trade and Industry, Department of Justice and Department of Social Welfare and Development (Chiwara, 2013).

2. RA-7600, The Rooming-in and Breastfeeding Act (1992): This Act establishes a national policy of rooming-in and includes other specifi c policies to promote and foster breastfeeding practices. It also highlights the importance of developing an edu-cation campaign to enhance awareness in the community and training on lactation promotion for health workers and medical professions. Under this Act, tax incentives are provided to health facilities that comply with the Act.


Results from two surveys, the National Food and Nutrition Research Institute Survey (2008) and the Millennium Development Goals Fund (MDG-F) baseline survey (2011) revealed that rates of exclusive breastfeeding decline after mothers return to work following their maternity leave. These results were used as a basis to advocate for policies to support mothers to breastfeed in workplaces.

The Government of Philippines and its partners took an important step forward to support the endorsement of the Expanded Breastfeeding Promotion Act of 2009 (Republic Act 10028 or RA-10028). The RA-10028 mandates the establishment of lactation stations in the workplace, the granting of lactation breaks to nursing employees and the provision of breastfeeding education to all workers. The provisions of the Expanded Breastfeeding Promotion Act of 2009, helped to frame the Nutrition Security Maternity Protection (NSMP) project and its implementation. The International Labour Organization (ILO), in partnership with UNICEF and the European Union (EU) supported the implementation of NSMP through the Exclusive and Continued Breastfeeding Promotion in the Workplace Programme. The Programme developed mechanisms for promoting breastfeeding in the workplace as well as outreach strategies targeting vulnerable groups that are often not covered by maternity protection.

This programme was also designed to promote principles embedded in the ILO’s Maternity Protection Convention, 2000 (No. 183) and the Workers with Family Responsibilities Convention, 1981 (No. 156). Provision of workplace support to breastfeeding mothers is one of the core elements of Convention No. 183, which promotes maternity protection measures to ensure that women’s right to provide the best possible care for their newborns and young children does not interfere with their economic security. Expectant and nursing mothers are also expected to receive health protection at work, quality maternal


and child health care, adequate time to give birth, to recover and to nurse their children. In addition, Convention No. 156 and its accompanying Recommendation No. 165, promotes the creation of effective work-family policies so that both women and men workers can reconcile the often confl icting demands of paid work and their care responsibilities at home (Villanueva 2010; Camacho-Tajonera, 2010; Congress of the Philippines, 2009). This programme was piloted in the cities of Naga, Iloilo and Zamboanga with close partnerships between the Philippine government, employers’ and workers’ organizations (NSMP Flyer, 2014).

To facilitate better coordination for the implementation of the NSMP project, a technical working group was created and composed of the International Labour Organization (ILO), Department of Health (DOH), Department of Labor and Employment (DOLE), National Anti-Poverty Commission (NAPC), Employers Confederation of the Philippines (ECOP), Alliance of Workers in the Informal Economy/Sector (ALLWIES), Federation of Free Workers (FFW) and Trade Union Congress of the Philippines (TUCP). ECOP served as the Secretariat of the group. Its tripartite structure (equal footing for DOLE representing government, employers and workers groups) and the involvement of the Department of Health made the group an ideal platform for discussing policy issues relating to breastfeeding in the workplace. However, the need to cross sectoral boundaries led to differences in interpretation of standard roles and responsibilities.

“In the law, it says that the Department of Health should be the lead organization. The DOLE is counting on that specifi c provision in that law that ‘No, it’s not us, it’s health programme, it should be the Department of Health.’ The Department of Health will say ‘No, it’s in the workplace, we’re not allowed to... enter workplaces, because that’s the Department of Labor’s place ... At the beginning...it’s like a war room” (Labor Association)

The law was passed without much, without...enough study...purposive study, on how, or what, establishment should be exempted, how it should be implemented, things like that. And we were put on the spot to really implement it at all costs. We also have to take care of our establishments, and at the same time of course the women, so it was also a challenge to prepare these guidelines so that it would be acceptable for labor and management.” (National Government)

The Implementing Rules and Regulations (IRR) designates the Department of Health (DOH) as the lead agency to implement and enforce RA-10028, and mandates that DOH, Department of Labor and Employment (DOLE), Local Government Units (LGUs), employers, trade unions, NGOs, Bureau of Internal Revenue (BIR), Department of Trade and Industry (DTI), and


other partners are responsible for defi ning the implementation mechanisms. The DOH coordinated with these other agencies involved in implementation of RA-10028 to adopt monitoring guidelines for the law. Under the IRR, a monitoring team, both at the national and regional/provincial/city/municipal/barangay levels, is charged with tracking compliance with implementation. This includes reviewing and submitting reports on the implementation status as well as verifying, and recommending appropriate disciplinary measures for violations to the Secretary of Health.

The national RA-10028 law is further translated by local government units (LGUs) through the passage of local ordinances that cannot be more restrictive than the national law. The local ordinance is meant to resolve gray areas in the national law including local implementation of lactation stations and conditions for exemptions. It also provides authority to monitor compliance, assesses penalties for non-compliance and designates the roles and responsibilities of specifi c local offi ces in this process. The local government units also use the local ordinances to ensure that the national law covers workers in the informal sector, an important fact because the RA-10028 does not address workers in the informal sector. The Department of Interior and Local Government (DILG) Memoradum Circular MC 2011-54 “Implementation and Monitoring of the National Policy on Breastfeeding and Setting-up of Workplace Lactation Programme,” was issued in 2011 enjoining LGUs to comply with RA-10028 and to encourage them to pursue partnerships to set-up and sustain lactation management programmes for the informal sector.

“If you take a look at the profi le of business establishments in the Philippines, it’s 98-99% small industries. So you have only barely 1-2% medium and big industries that are really mandated to implement….lactation stations at the work place. That is why the role of the informal sector is important and the government in supplementing the programme at the community level.” (Labor Association)

Policy timeline

2009: RA-10028, The Expanded Breastfeeding Promotion Act of 2009

2010: The IRR describes procedures and guidelines for implementation of RA-10028.

2011: Dept. of Interior and Local Government Memorandum Circular extends implementation of RA-10028 to workers in the informal sector

2015: Department of Labor and Employment Order No. 143: guidelines described exemptions to RA-10028, including eligibility to apply and a monitoring system to check compliance with the law

2013-2015: Nutrition Security and Maternity Protection through Exclusive and Continued Breastfeeding Promotion in the Workplace (NSMP) initiated

2010-2015Pre-2010

Box 1 Implementation of Lactation Stations in Naga City

Naga City passed Ordinance 2011-032 in 2011 requiring all public and private establishments in Naga City to set up lactation stations. Importantly, it states that compliance with the ordinance is a requirement for new or renewed business licenses and permits. Naga City is the fi rst city to ratify this kind of ordinance and mandate establishments to build lactation stations.

“Not only that ...we don’t only encourage them to have their own breastfeeding corner or room, but we also train the human resource offi cers in that particular establishment, about infant and young child feeding. Like for example we give them lectures, we train them, of how to give counselling to the employees, to the clients…[T]o maintain the breastfeeding corner or the breastfeeding room, there should be a person who is really knowledgeable in counselling the employees, in counselling the clients, or customers, or whoever will go there, about breastfeeding. We want the breastfeeding really functional.” (Local Government)

In 2011, there were only a few lactation stations in place in Naga City. Since then, the local government facilitated the establishment of lactation stations in hospitals, private schools, and public elementary schools in the 27 barangays (communities) of Naga. In the public elementary schools, the school nutrition coordinator and teachers are trained on the importance of breastfeeding. Naga City also conducts quarterly monitoring visits of lactation stations.

As leaders in implementing successful breastfeeding programmes in the workplace, Naga City offi cials were invited by the National Nutrition Council and the Food and Nutrition Research Institute to share their experiences and best practices with other Local Government Units (LGUs). Now, partners including the ALLWIES, FFW, ECOP and ILO are working on scaling-up the exclusive and continued breastfeeding in the workplace programme in regions beyond the initial three focus areas (Regions 5,6 and 9).


Organizational network analysis: NSMP network linkages and key players

Organizations, their networks and patterns of relationships are assessed using organizational network analysis. The whole network structure is presented followed by specifi c working relationships, strength of the ties and measures of the value that different organizations engender based on the perceptions of other members in the network. Organizations vote for the most infl uential, best coordinator and most highly valued for possessing and supplying the latest evidence on maternal nutrition and breastfeeding in the workplace. We identifi ed 25 organizations that were involved in multiple components of promoting and implementing the Nutrition Security Maternity Protection (NSMP) project. They include a mix of government, employer and labor associations as well as UNICEF and the International Labour Organization at the national level and organizations in three cities namely - Naga, Iloilo and Zamboanga. The city level organizations were chosen because governance in the Philippines is highly decentralized and there is limited connectivity between the national and subnational level activities. Therefore organizations at the subnational level are involved in decision-making and programme scale-up.

Table 1 List of organizations in ONA

ALLWIES Alliance of Workers for Informal Sector Naga_NCCI Metro Naga Chamber of Commerce and Industry

DOLE Department of Labor and Employment NAPC National Anti-Poverty Commission

DOH Department of Health NNC National Nutrition Council

ECOP Employers Confederation of the Philippines Reg5_MYC Region 5 MYCNSIA Coordinator, Naga

FFW Federation of Free Workers Reg6_MYC Region 6 MYCNSIA Coordinator, Iloilo

ILO International Labour Organization Reg9_MYC Region 9 MYCNSIA Coordinator, Zamboanga

Ilo_Legis Iloilo Legislative Council TUCP Trade Union Congress of the Philippines

Ilo_Mall Robinson’s Mall in Iloilo UNICEF United Nations International Children’s Emergency Fund

Ilo_NNC National Nutrition Council in Iloilo Zam_CHO Zamboanga City Health Offi ce

Ilo_PCCI Philippine Chamber of Commerce and Industry of Iloilo

Zam_ECOP Zamboanga Employers Confederation of the Philippines

Naga_Legis* Naga Legislative Council Zam_Legis Zamboagna Legislative Council

Naga_Mall* SM Naga Mall Manager Zam_ZCCI* Zamboanga Chamber of Commerce and Industry

Naga_NAMASFED Naga Market Stallholder’s Federation

*It was not possible to directly interview three organizations so their relationships with other organizations are based on the reporting of their partner organizations. Since most of the national linkages were not reported by organizations, even if they had stated a relationship, the confi rmed outcome would still be the same.

NSMP whole network: The structure of the network is a mix of highly concentrated and connected national and subnational organizations from Naga and Zamboanga on the left side of the plot and a less dense set of connections with Iloilo on the upper right hand corner. The confi rmed density score is 40% [240 out of a potential 600 ties have linkages]. The Alliance of Workers for the Informal Sector (ALLWIES) is both at the center of the network and has the highest betweeness centrality by establishing information fl ow between organizations that do not have direct relationships. The Philippines Chamber of Commerce and Industry of Iloilo (Ilo_PCCI) is the second most important broker by bringing in Iloilo Mall into the broader NSMP network. The third position is occupied by the International Labour Organization (ILO) and closely followed by UNICEF. However, organizational functions in the network are varied. ILO is at the center of the national and subnational labor and employer associations while UNICEF is at the hub of the less dense part of the network working with a more heterogeneous set of actors such as their own MYCNSIA coordinators, and connecting with many (but not all) of the national and regional government departments and national level associations. The positions of most of the national and subnational government bodies are on the periphery of the network including the Department of Labor and Employment (DOLE), the Department of Health (DOH) and the National Nutrition Council (NNC). Only the Naga Legislative Council occupies a central role at the subnational level.


Working relationships: The advocacy for policies and guidelines to implement RA-10028 is comprised of national and subnational associations including the Zamboanga City Health Offi ce and Zamboanga Legislative Council (on the left side of the plot). Naga and Iloilo government departments along with UNICEF (represented by MYCNSIA coordinators for those regions) are dispersed on the right side of the network. Alliance of Workers for the Informal Sector (ALLWIES) continues to be the main broker by connecting UNICEF and the Naga and Iloilo side of the advocacy network with the major associations, Department of Labor and Employment (DOLE), and Department of Health (DOH).

For capacity building, ALLWIES continues to play the central role and is the main broker, having the largest betweeness centrality, which is twice as high as UNICEF, the second most prominent broker. UNICEF connects the regional governments in all three areas with leading national associations. All three UNICEF/MYCNSIA coordinators work with their respective legislative councils and other organizations but are not at the center of capacity building within their regions. The Iloilo section of the National Nutrition Council (NNC) has the third highest betweeness centrality score by bringing in the NNC into the capacity building network, where NNC has only one connection. The DOH is only connected to other national organizations but does not have direct linkages to the regional level.

UNICEF holds the highest betweeness centrality for NSMP scale-up, closely followed by ALLWIES and ILO. All three organizations provide an important avenue for scale-up by disseminating information to organizations that are not directly connected with each other. UNICEF is central to connecting Naga and Iloilo scale-up efforts as well as the Zamboanga City Health Offi ce to the national level while the ALLWIES focus area is Zamboanga. ILO is in the center of the national level associations but is also consistently linked to the regional legislative councils and selected other regional government departments. UNICEF does not have any direct linkages in the scale-up with national level government departments including DOLE, NNC, and DOH. The NNC continues to be involved in the NSMP scale-up network through only one connection to its own Iloilo offi ce.

Figure 1 Whole NSMP network

NNC

DOH

ILO

UNICEF

DOLE

FFW

NAPC

ECOP

TUCP

ALLWIES

Reg5_MYC

Naga_NCCI

Naga_Legis

Naga_NAMASFED

Naga Mall

Reg6_MYC

Ilo_PCCI

Ilo_Legis

Ilo_NNC

Ilo Mall

Reg9_MYC

Zam_CHO

Zam_ZCCI

Zam_Legis

Zam_ECOP


GovernmentUNAssociationsPrivate

Shape of nodes (locations)

NationalNagaIlolloZamboanga

NNC

DOH

ILO

UNICEF

DOLEFFW

NAPC

ECOP

TUCPReg5_MYC

Naga_NCCI

Naga_Legis

Naga Mall

Reg6_MYC

Ilo_PCCI

Ilo_Legis

Ilo_NNC

Ilo Mall

Reg9_MYCZam_CHO

Zam_ZCCIZam_Legis

Zam_ECOP

ALLWIES

Naga_NAMASFED

Figure 2a NSMP: Advocacy Figure 2b NSMP: Capacity building

NNC

DOH

ILO

UNICEFFFW

NAPC

ECOP

TUCP

ALLWIES

Reg5_MYC

Naga_NCCI

Naga_LegisNaga_NAMASFED

Naga Mall

Reg6_MYC

Ilo_PCCI

Ilo_Legis

Ilo_NNC

Ilo Mall

Reg9_MYC

Zam_CHO

Zam_ZCCIZam_Legis

Zam_ECOP

DOLE


Figure 2c NSMP: Scale-up

Relationship strength: If organizations are connected with each other, they tend to have ties or linkages across all three types of working relationships (magenta lines in Figure 3): advocacy, capacity building and scale-up. This demonstrates that the multiplexity measure for the overall network for Nutrition Security and Maternity Protection (NSMP) in the workplace is quite robust despite the somewhat moderate to low-density scores. Linkages across only one activity are infrequent but do include the following: NNC with NAPC and ECOP; DOLE with ILO, Naga Legislative Council, Zamboanga and Iloilo Chamber of Commerce and Industry; TUCP and Zamboanga Legislative Council.

A majority of relationships are based on collaboration (blue lines in Figure 4) followed by coordination (green lines). Many organizations on the periphery of the network also have relationships that are more committed beyond basic communication. A majority of the integration connections (in red) are among the organizations on the right-hand side of the network - mostly between Iloilo and Zamboanga regional organizations. While the left-hand side mostly consists of relationships involving collaboration among Naga regional organizations. However, a majority of the relationships among national organizations is based on coordination, except ALLWIES and ECOP who have many mutually confi rmed integration relationships. UNICEF’s relationships are all at the level of coordination.

NNC

DOH

ILOUNICEF

DOLE

FFW

NAPC

ECOP

TUCP

ALLWIES

Reg5_MYC Naga_NCCINaga_Legis

Naga_NAMASFED

Naga Mall

Reg6_MYC

Ilo_PCCI

Ilo_Legis

Ilo_NNC

Ilo Mall

Reg9_MYCZam_CHO

Zam_ZCCI

Zam_Legis

Zam_ECOP



Figure 3 NSMP: Multiplexity Figure 4 NSMP: Relationship intensity

NNC

DOH

ILO

UNICEF

DOLE

FFW

NAPC

ECOP

TUCP

ALLWIES

Reg5_MYC

Naga_NCCI

Naga_LegisNaga_NAMASFED

Naga Mall

Reg6_MYC

Ilo_PCCI

Ilo_Legis

Ilo_NNC

Ilo Mall

Reg9_MYCZam_CHO

Zam_ZCCI

Zam_Legis Zam_ECOP

NNC

DOH

ILO

UNICEF

DOLEFFW

NAPC

ECOP

ALLWIES

Reg5_MYC

Naga_NCCI

Naga_Legis

Naga_NAMASFED

Naga Mall

Reg6_MYC

Ilo_PCCI

Ilo_Legis

Ilo_NNC

Ilo Mall

Reg9_MYC

Zam_CHO

Zam_ZCCI

Zam_Legis

Zam_ECOP

TUCP



Infl uence, coordination and evidence: Figures 5a, 5b and 5c are based on nominations for the following positions – most infl uential, best coordinator and most valued for providing the latest evidence. The following defi nitions are used: 1) most infl uential is defi ned as organizations “whose views, ideas, and/or research is the most listened to and have had the greatest impact” and may include infl uence in any technical, functional or administrative area; 2) best coordinator is defi ned as organizations “working together on Nutrition Security Maternity Protection (NSMP) project who have the respect and credibility from other organizations to effectively coordinate their efforts as well as engage with multiple stakeholders”; and


3) latest evidence is defi ned as: organizations “providing or having the latest evidence-base on nutrition for developing nutrition policies, programmes, guidelines, training materials or capacity building of nutrition workforce”. For each type of relationship, organizations were asked to list up to 5 choices and order them by importance. A weighting scheme was used to create plots and size the nodes based on the weighted degree centrality measure integrating the number and ranked order of the nominations.

The Department of Labor and Employment is the most infl uential organization based on the weighted degree centrality score. DOLE is followed by the Employers Confederation of the Philippines (ECOP) that has the second highest weighted degree centrality score (27) although this is almost half of DOLE’s score (41). The next set of nominations goes equally to NAPC and ALLWIES.

There are a number of organizations that received a relatively consistent number and high ranking votes for best coordinator. Both DOH and ECOP are tied with the highest weighted degree centrality score (22). This is closely followed by DOLE (20) and ALLWIES (18).

In the nominations for most highly valued for providing the latest evidence, the Department of Health has the highest weighted degree centrality. The second highest weighted score is for the National Nutrition Council followed by UNICEF even though both have the same number of votes (5). There are six organizations that did not respond to this portion of the questionnaire, including Naga_NAMASFED, Ilo_Legis, Ilo_NNC, DOH, ALLWIES, and Reg5_MYC. Other organizations that were not included in the survey but were voted as providing the latest evidence, are WHO and LGUs with two votes each.

Figure 5a NSMP: Most infl uential Figure 5b NSMP: Best coordinator

Figure 5c NSMP: Latest evidence

NNCDOHILO

UNICEF

DOLE

FFW

NAPCECOP

TUCP

ALLWIESReg5_MYC

Naga_NCCINaga_Legis

Naga_NAMASFEDNaga Mall

Reg6_MYCIlo_PCCI

Ilo_LegisIlo_NNCIlo Mall

Reg9_MYC

Zam_CHOZam_ZCCI

Zam_Legis

Zam_ECOP

Naga_NAMASFEDNaga MallIlo_LegisZam_ZCCI

NNC

DOHILO

UNICEF

DOLE

FFW

NAPC

ECOP

TUCP

ALLWIES Reg5_MYC

Naga_NCCI

Naga_Legis

Reg6_MYC

Ilo_PCCI

Ilo_NNC

Ilo Mall

Reg9_MYC

Zam_CHO

Zam_Legis

Zam_ECOP

NNC

Reg5_MYC

Naga_NCCI

Naga_Legis

Naga_NAMASFEDNaga Mall

Reg6_MYC

Ilo_LegisIlo_NNCZam_ZCCI

DOH

ILO

UNICEF

DOLE

FFW

NAPC

ECOP

TUCP

ALLWIES

Ilo_PCCI

Ilo Mall

Reg9_MYC

Zam_CHOZam_Legis

Zam_ECOP




Major fi ndings

1. The Alliance of Workers in the Informal Sector (ALLWIES) is at the center of the Nutrition Security and Maternal Protec-tion platform and most important in creating linkages with other organizations. ALLWIES had the major brokerage role in most of the NSMP network activities except scale-up.

2. ILO functions as the hub for national and subnational labor and employer associations. ILO also connects with regional legislative councils for scale-up.

3. UNICEF is the most important broker for scale-up. UNICEF develops the linkages with regional governments to scale-up NSMP. Their overall way of functioning is at the coordination level and they do not participate in direct collaboration with their counterparts.

4. The Department of Labor and Employment (DOLE) is voted as most infl uential but their position is on the periphery of all the network plots. The DOH and DOLE have major roles to play in developing the legislation and coordinating its imple-mentation and enforcement. These roles are explicitly stated in the legislation and the implementing rules and regulations but not refl ected in the ONA.

5. The Department of Health (DOH) and Employers Confederation of the Philippines (ECOP) have the highest nominations for best coordinator. Through the Technical Working Group, ECOP coordinated labor partners (including the International Labor Organization (ILO), DOLE, Trade Union Congress of the Philippines (TUCP), and the Alliance of Workers in the Infor-mal Economy/Sector) to address their concerns and develop reasonable processes that could be implemented by a wide-range of employers. DOH was also designated as a major implementer and enforcer of RA-10028.

6. Health, labor and employment sectors are not yet in full alignment with their designated roles and responsibilities in implementing the RA-10028 legislation. The results from the qualitative interviews combined with the ONA suggest that there were differences in perceptions of major roles and which organizations held leading positions in the network analysis. The lack of clarity may contribute to delays and reduced accountability for implementation of the legislation at subnational levels. Although the Department of Health is responsible for enforcing compliance with the establishment of lactation sta-tions, it is not granted authority to access and inspect lactation stations due to labor regulations. It is the role of the Depart-ment of Labor and Employment to inspect companies and to offer exemptions to eligible establishments.


The government of the Philippines has developed a progressive policy to promote breastfeeding in the workplace. Recognizing this important opportunity, UNICEF helped to strengthen the implementation of this policy by supporting the scale-up of lactation stations for nursing mothers and encouraging optimal breastfeeding practices.

Beyond the offi cial roles designated by the legislation, ALLWIES, ILO and UNICEF were identifi ed during the ONA as keeping the NSMP network moving in the right direction. As a major representative for most of the workers in the informal sector including those working in medium, small and micro enterprises that comprise more than 98% of business activity, ALLWIES was recognized as a main driving force linking organizations together and engaging with regional partners in scaling-up breastfeeding in the workplace. Developing alternative cost-effective models to enhance the participation of small businesses was an important strategy for scaling-up.

ILO with its commitment to workers’ rights including breastfeeding in the workplace and as the lead agency for the EU-UNICEF Maternal, Youth and Child Nutrition Security in Asia (MYCNSIA) grant for this work, was able to rally the support and be a central hub for NSMP advocacy and capacity building with employers and labor unions at the national level. By working closely with UNICEF, the ILO was able to forge new relationships between labor and the health sector that normally do not work together.

“The added value of going through UNICEF is that the ILO does not really directly work with the nutrition and health agencies like the NNC and the Department of Health. So I think – since we channeled it through UNICEF we were able to build relationship with these agencies. Because the ILO – when you fi rst think of it – ILO wouldn’t really work with these organizations. That’s, I think, the added value. It’s just very important.” (UN)

By building on existing relationships within sectors and identifying key organizations that would create the linkages between sectors, the tripartite approach became an effective tool in policy development.

“In terms of process, I think tripartism works. In order for the program to be successful, you have to ensure that all the major players and stakeholders will be part of the designing, implementation, monitoring, and evaluation of the program.” (Labor Association)


“[W]orking with non-health people you have to do an extra mile. And coordinating, and collaborating with them, spells a big difference to achieve results and impact. When I started…attending meetings and joining the...Nutrition Security Maternity Protection Technical Working Group, things really sink in better, in terms of what needs to be done. Knowing…what their needs are, DOH can actually support their gaps, their constraints, their limitations.” (National Government)

The implementation of NSMP at the regional level was led by UNICEF through their MYCNSIA regional coordinators, and partnerships comprised of ILO, ALLWIES and regional legislative councils. Many other labor and employer groups were also a big part of the picture. However, there was an important recognition of the indispensible role of local government units in rolling out the lactation stations and associated training programs for workers and the support structures that would maintain these spaces. Many respondents agreed that the support of LGUs (through local chief executive, mayor, or governor) and the presence of local champions are critical to success.

“In terms of collaboration among agency partners, like in the case of NNC, DoH, again the local government unit and even NGOs that are present in the area, if you have those organizations present, then the task of coordinating programs as well as implementing the program becomes easier. This relates to local governance because you have stakeholders that are willing and able to participate in the program.” (MYCNSIA Coordinator)

“The LGU alone cannot do the work. … We need to capacitate the LGUs... We have to integrate this program with the Department of Interior and Local Government, because of their authority... as there seems to be some kind of inherent weakness… from the Department of Health and the National Nutrition Council to enforce. Because the local government unit is directly under the Department of Interior and Local Government…[and if] they are required, by the DILG to implement it fully well because it has to be in their scorecard…for monitoring and evaluation, then they can and they will implement it accordingly. That’s the big gap that has not been answered fully well.” (MYCNSIA Coordinator)

The idea of maternity protection and the important role of creating working environments that are conducive to improving child nutrition and health with a double benefi t for improving worker productivity and reducing absenteeism is gaining much ground in the Philippines. Another major set of issues to tackle is to pay attention to the maternity leave policies and address some of the gaps. Mothers planning to return to work before 12 weeks and/or working full-time are less likely to plan to exclusively breastfeed. Longer maternity leave and/or part-time return schedules may increase the proportion of mothers who plan to exclusively breastfeed. (Mirkovic, et.al., 2014)


Additional efforts to promote breastfeeding need to continue to address the importance of social and cultural reinforcement as women are subject to confl icting messages and pressures in their dual roles as workers and mothers. In addition to the workplace, community mobilization with additional peer support and counselling is important.

“One major lesson that we learned is that nothing positive will come out of the program if you do not have the ear of the working mothers themselves.” (Labor Association)

Citations

(2013). Final MDG-F Joint Programme Narrative Report.

(2014). Nutrition Security and Maternity Protection through Exclusive and Continued Breastfeeding Promotion in the Workplace. Flyer. International Labour Organization.

(2015). Q&A on Guidelines Governing Exemption of Establishments from Setting Up Workplace Lactation Stations. Manila, Bureau of Workers with Special Concerns: Department of Labor and Employment.

About Executive Order 51. Milk Code Executive Order No. 51. http://www.milkcodephilippines.org/abouteo51.php.

Camacho-Tajonera, J. (2010). The Expanded Breastfeeding Promotion Act (RA10028): Support for Breastfeeding Mothers in the Workplace. Smartparenting.com.ph. http://www.smartparenting.com.ph/community/news/the-expanded-breastfeeding-promotion-act-ra-10028-support-for-breastfeeding-mothers-in-the-workplace.

Chiwara RM, Villate E. (2013) Final Evaluation of the Joint Programme: “Ensuring Food Security and Nutrition for Children 0-24 Months in the Philippines” (MDG-F 2030). Final Report.

Congress of the Philippines. (1991) An Act Providing Incentives to All Government and Private Health Institutions with Rooming In and Breastfeeding Practices and for Other Purposes. Metro Manila, Republic of the Philippines.

Congress of the Philippines. (2009). An Act Expanding the Promotion of Breastfeeding, Amending for the Purpose Republic Act No. 7600, Otherwise Known as “An Act Providing Incentives to all Government and Private Health Institutions with Rooming-In and Breastfeeding Practices and for Other Purposes. Metro Manila, Republic of the Philippines.

Department of Health, Offi ce of the Secretary. (2011). The Implementing Rules and Regulations of Republic Act No. 10028. Manila, Republic of the Philippines.

The International Labour Organization (ILO) Country Offi ce for the Philippines. (2014). Nutrition Security and Maternity Protection through Exclusive and Continued Breastfeeding Promotion in the Workplace (NSMP) Project: Progress Report: Nov. 2013 – Jan. 2014. International Labour Organization.

Mirkovic, KR, Perrine, CG, Scanlon, KS, Grummer-Strawn, LM (2014). Maternity Leave Duration and Full-time/Part-time Work Status Are Associated with US Mothers’ Ability to Meet Breastfeeding Intentions. Journal of Human Lactation. Vol. 30 (4), pp. 416-419.

UNICEF (EAPRO/ROSA). (2014). Maternal and Young Child Nutrition Security in Asia (MYCNSIA): An EU/UNICEF Joint Action, 2011-2015. Progress Report 2011-2013. UNICEF (EAPRO/ROSA).

UNICEF-EU Maternal and Young Child Nutrition Security Initiative in Asia: Philippines – 2011-2013 Annual Report.

Villanueva, M. (2010). GMA signs Expanded Breastfeeding Act. Manila, philstar.com. http://www.philstar.com/headlines/560464/gma-signs-expanded-breastfeeding-act.

References

Bureau of Workers with Special Concerns, Department of Labor and Employment. (2011). Employment-related Provisions of Republic Act No. 10028 and its Implementing Rules and Regulations (IRR). Manila, Bureau of Workers with Special Concerns, Department of Labor and Employment.

Bureau of Workers with Special Concerns, Department of Labor and Employment. (2012?). Accomplishments for the Year 2012. Manila, Bureau of Workers with Special Concerns, Department of Labor and Employment.

De La Torre GA, Bordado Jr. GH, Bongat JG. (2011). Ordinance No. 2011-032. Naga City.

ECOP Boardroom. (2013). Women’s Rights at Work: Employers Guideline. Makati, Employers Confederation of the Philippines.

Offi ce of the Secretary, Department of the Interior and Local Government. (2011).


STRENGTHENED CAPACITY OF THE LOCAL GOVERNMENT UNITS TO SCALE UP EMERGENCY PREPAREDNESS AND EARLY WARNING SYSTEMS TO MITIGATE NUTRITION RISKS

CASE STUDY

2

This case study describes the implementation and scale-up of an Early Warning System (EWS) for Food and Nutrition Security in the Philippines. It highlights the role of partners in advocating for an emergency preparedness plan, developing capacities at the subnational level and implementing an EWS programme so that children are delivered a package of essential nutrition interventions during emergency situations.

Background

Being affected by about 20 major disasters every year, including typhoons, fl ash fl ooding, volcanoes, and earthquakes, the Philippines is considered the third most disaster-prone country in the world. In addition to the devastating impacts of natural disasters, other calamities such as health pandemics and armed confl ict, are creating multiple social and economic vulnerabilities in affected communities. The government has established an Early Warning System (EWS) in order to issue advance warning for encouraging adequate preparation and evacuation, if needed. The Early Warning System (EWS) was then expanded to cover food and nutrition security. Under this platform, there is regular collection and analysis of specifi c food availability and accessibility indicators that describe the food security in a specifi c geographical area. The data collected through the EWS is used to predict possible food crises or health problems. This information helps the Local Governance Units (LGUs) make decisions about the food stock-ups for their respective areas.

UNICEF advocated with the national government to build additional nutrition interventions on the EWS platform. To ensure food and nutrition security for children 0-24 months, a pilot programme was established in the Ragay municipality, Camarines Sur province. The success of the pilot led to the expansion of this programme to the Bicol Region 5. Now with two effective pilots in place, the National Nutrition Council (NNC) and the Department of Social Welfare and Development (DSWD) were interested in expanding the EWS in other areas.


The Food and Agriculture Organization (FAO) served as the lead agency in the development and initial establishment of EWS. Sustained advocacy efforts helped UNICEF to pilot the EWS in Ragay Municipality, Camarines Sur Province in 2010-2011. In this pilot, the capacity of government and stakeholders was developed to implement policies and programmes on infant and young child feeding (IYCF) (MDG-F Joint Programme Narrative Report 2013). The EWS platform is intended to capacitate LGUs to utilize evidence-based programme planning and decision-making related to emergency situations. Using the food security and nutrition data to establish trends, the LGUs make predictions and broadcast information, warnings and actions. This helps to set up priorities, allocate resources, target benefi ciaries and ask for additional funds if needed. With these functions, EWS helps to fi ll a need for a comprehensive information system at the local level.

“One problem which is very common in cities and municipalities is they just collect the data but there is minimal analysis and interpretation. With that, [one] can expect little use in terms of planning. So now…EWS is promoting the use of all of this data, and


coming up with a few statements about the food security situation, what are the appropriate interventions that can be done by the local government. It’s very useful.” (National Government)

The EWS was replicated in fi ve municipalities in Camarines Sur province (Cabusao, Calabanga, Canaman, Minalabac, and Sipocot). The target municipalities are selected in a consultation meeting with government partners at the local and national levels. After target municipalities are identifi ed, a consultative workshop is held to prepare for EWS implementation to achieve fi ve objectives: (1) develop a causal framework describing food insecurity in the target municipality; (2) select a set of indicators; (3) select fi ve sentinel barangays; (4) establish an EWS team; and (5) determine a schedule for monitoring indicators (UNICEF, 2013).

The success of the EWS resulted in its expansion to other areas and subsequent plans were developed to scale-up to other regions in the country. In 2014, the National Nutrition Council (NNC), Food for Work Programme, FAO and World Food Programme (WFP) collaborated to expand the EWS to ten municipalities located across ten regions of the country. During this expansion phase, FAO took the lead in providing training and technical assistance in planning, programme implementation and scale-up.

“Any decision should be based on evidence. And EWS is one gold management tool for making right decision as to food security and nutrition. Many local governments, many areas, they just decide based on the usual programmes. But with EWS it’s a government tool actually, so that even with programmes, which are already existing, they can improve in terms of timing, better targeting. For example, many local governments would do food supplementation but they’re not doing it at the right time. With EWS they can actually adjust the timing when it is really needed by the people. In terms of livelihood it’s also a tool to help design what kind of livelihood projects are needed by the people.” (National Government)

“Particularly in our province…there’s a need for information…. We can feel there’s a problem on nutrition and also on hunger. But the thing is, we don’t have enough data to say exactly where, when, and what to do. I think [this need] is the catalyst. … So I’d say it’s actually the... nutritional and food security status of our place which prompted us to accept or embrace the system being offered by the MDG-F and FAO.” (Municipality)

Box 2 How EWS works

Indicators related to food production, climate (specifi cally, rainfall), household food insecurity, dietary diversity, nutritional status, and anthropometric measurements, are monitored every quarter. These data are collected from fi ve sentinel sites from each municipality. Volunteer health workers from the sentinel barangay, called Barangay Nutrition Scholars (BNS), conduct the surveys. BNS are appointed by local government units to monitor child nutrition status and to connect community members with nutrition service providers (Chiwara, 2013). Two rounds of training are conducted to prepare the health workers for data collection. In a household level training, three health workers from the sentinel barangays are trained to collect survey data and anthropometric measurements on the nutritional status of children 0-24 months old. Each worker collects information from 19 households in each of fi ve sentinel barangays. In a municipal level training, the local EWS team is trained on collection of specifi c secondary data on food production, food prices, and rainfall (UNICEF, 2012-13). The health workers collect the primary household data at the same time that they perform other data collection responsibilities for the municipal health and agriculture offi ces. With this method, the EWS data collection does not add an additional burden to their workload.

The data are entered into a simple Excel database, developed by FAO, which is programmed to compute a warning level specifi c to each municipality. The programme outputs a one-page description of the food security and nutrition situation in the municipality. The local EWS team (composed of unit heads) discusses the results with the local chief executive and municipal councillors, who approve recommendations from the EWS team for possible interventions. A recommended plan is then submitted to the Mayor and Municipal Council for the fi nal approval.

Organizational network analysis: EWS network linkages and key players

This section explores the overall EWS network structure and specifi c types of inter-organizational working relationships to establish an understanding of the varied roles that they occupy in the network. A total of seven key organizations were interviewed and include a mix of UN and government departments: Food and Agriculture Organization (FAO), UNICEF, and UNICEF’s MYCNSIA Coordinators for Regions 5 and 6. The National Nutrition Council and the municipal governments representing EWS project areas of Canaman and Ragay in Camarines Sur are also included.


Overall EWS network: The density of this small network is fairly high, 76.2% in which 32 out of a potential 42 ties are realized. The high number of direct ties conversely produces a low centrality score of 30%. The MYCNSIA Coordinator for Region 5 has the highest betweeness centrality and contributes to creating a bridge for MYCNSIA Coordinator from Region 6, Iloilo. UNICEF has the next highest score for also providing a pathway for linking their MYCNSIA Coordinator in Region 6 to the network.

Working relationships: Three different types of working relationships were explored: advocacy, training and scale-up. The advocacy network for the nutrition food and security surveillance system is a clear hub-and-spoke, with FAO in the center creating individual connections to the outer circle of organizations. The density score or level of connectivity for this network is 52.4% [22 out of 42 ties]. The MYCNSIA Coordinator for Region 5 has the highest betweeness centrality score mostly due to bringing in the MYCNSIA Region 6 Coordinator into the network.

The density score or level of connectivity in training to launch the EWS is slightly higher than for advocacy, 57.1% [24 out of 42 ties]. Both FAO and the municipality of Canaman have the same betweeness centrality score, and are the main brokers keeping the network together. FAO is at the center of training activities. The MYCNSIA Coordinator based in Iloilo (Region 6) is not part of the training because he did not confi rm any of the incoming ties.

In the activities related to scale-up, the density score remains the same as for training but UNICEF is now the main broker with the highest betweeness centrality score and is important in bringing Ilollo Region 6 MYCNSIA into the scale-up. UNICEF is not directly connected to Municipality Ragay or Canaman but works through the Region 5 MYCNSIA Coordinator, FAO and NNC in the scale-up of the programme. National Nutrition Council is at the center of the scale-up network.

Figure 7a EWS Advocacy Figure 7b EWS Training

NNC

UNICEFFAO

Reg5_MYCCamSur_Ragay

CamSur_Cana

Reg6_MYC

Figure 6 Overall EWS network


GovernmentUN


NationalRegion 5Region 6

NNC

UNICEF

FAOReg5_MYC

CamSur_Ragay

CamSur_Cana

Reg6_MYC

NNCUNICEF

FAO

Reg5_MYC CamSur_Ragay

CamSur_CanaReg6_MYC


Relationship strength: Many relationships are based on all three EWS activities: advocacy, training and scale-up, as refl ected in the multiplexity plot (Figure 8, magenta lines). FAO has the strongest set of ties across all three activities with four organizations, and only two activities with Region 5 MYCNSIA Coordinator. UNICEF has a working connection based on three activities with MYCNSIA Coordinator in Region 5 and one activity with MYCNSIA Coordinator in Region 6. MYCNSIA Coordinator in Region 6 is susceptible to becoming an isolate since its connection with the Region 5 Coordinator and UNICEF is only across one type of relationship. This risk also applies to NNC’s relationship with Canaman and MYCNSIA Region 5 Coordinator.

A majority of the organizations collaborate and then coordinate when they report on the intensity level of their working relationships. The municipality of Canaman, Region 5 MYCNSIA Coordinator, FAO, and NNC are organizations that mostly have collaboration relationships in the EWS network. This extends to Region 6 MYCNSIA Coordinator and FAO, reinforcing the fi nding that this network is moderately robust. Only one relationship is based on integration, and this is between the municipality of Ragay and FAO. The two relationships based on the most basic relationship type (communication) are between: 1) Region 5 MYCNSIA Coordinator and Region 6 MYCNSIA Coordinator; and 2) Region 6 MYCNSIA Coordinator and UNICEF. A majority of UNICEF’s relationships are based on coordination.

Figure 7c EWS: Scale-up

NNCUNICEF

FAO

Reg5_MYC

CamSur_Ragay

CamSur_Cana

Reg6_MYC

NNC

UNICEFFAO

Reg5_MYCCamSur_Ragay

CamSur_Cana

Reg6_MYC

NNC UNICEF

FAO

Reg5_MYC

CamSur_Ragay

CamSur_Cana

Reg6_MYC

Infl uence, coordination and evidence: The most infl uential organization in this network is the National Nutrition Council (NNC), followed by the FAO. Both of these organizations have the highest number of votes, and received the highest ranking by other organizations in the EWS network. UNICEF received only one vote by Region 5 MYCNSIA Coordinator and was ranked as 4 out of 5 for organizations that are most infl uential.

NNC has the most number of votes and highest ranking comprising the weighted degree centrality score for best coordinator, followed by the FAO (as mirrored in the most infl uential plot). UNICEF did not receive any votes for best coordinator. Local


GovernmentUN



Multiplexity key

1 Tie2 Ties3 Ties



Figure 8 EWS: Multiplexity Figure 9 EWS: Relationship Intensity


government units (LGUs) were listed as best coordinators by two organizations (but were not part of the survey and therefore not included in the plot).

The National Nutrition Council is the highest ranked organization (with only two votes) for providing the latest evidence. UNICEF is next with one vote by the NNC. FAO, and MYCNSIA Coordinators in Regions 5 and 6 did not receive any votes and did not respond to this part of the questionnaire. Another prominent organization that provides the latest evidence, but was not part of the survey, is WHO.

Major fi ndings

1. FAO is at center of the EWS advocacy and training network and is the main connector for training. The central role played by FAO as lead organization in the EWS development is supported by the ONA.

2. National Nutrition Council is rated by their partners as being the most infl uential, best coordinator and having the latest evidence. Partners recognize the importance of the government and especially NNC to be the leaders in implementing EWS in the Philippines.

3. UNICEF creates a bridge for MYCNSIA Region 6 Coordinator that has weak ties to the EWS network. UNICEF’s relationships are mostly coordination with FAO, NNC and MYCNSIA Region 5 Coordinator. Although UNICEF brings in the MYCNSIA Region 6 Coordinator, the intensity of the relationship is restricted to basic communication for scale-up.

4. The municipalities of Canaman and Ragay have the strongest working relationships with FAO. FAO’s creation of strong bonds with municipalities enabled the effective establishment of the EWS system in those communities.


The key ingredients for the establishing an effective Early Warning System in municipalities required a long-term engagement and support of multiple organizations at the national and community levels. UNICEF’s follow through with supporting this project was a good strategy for demonstrating the effectiveness in Ragay and stimulating interest for scale-up in other areas of the country.

Figure 10a EWS: Most infl uential Figure 10b EWS: Best coordinator

Figure 10c EWS: Latest evidence

NNC

UNICEFFAOReg5_MYC

CamSur_Ragay

CamSur_Cana

Reg6_MYC

NNC

UNICEF

FAO

Reg5_MYC

CamSur_Ragay

CamSur_Cana

Reg6_MYC

NNC

UNICEFFAOReg5_MYC

CamSur_Ragay

CamSur_Cana

Reg6_MYC


GovernmentUN




In addition to strong technical support from FAO and NNC, the capacity of partners on the ground, commitment of local offi cials and their willingness to collaborate are key factors that led to the successful implementation of EWS.

“If there are no people who are technically capable at the local level, it would be quite a challenge for the EWS to continue. We have tried it in Region 5 in basically six municipalities, and we can see differences from each municipality. Some would have staff available, some would have none. It’s a big factor when the Local Chief Executive (LCE) doesn’t put any focal person for agriculture, for health. … So it’s diffi cult when you don’t have the capabilities of the local staff to have their data, or to understand it, or even the equipment.” (UN)

There were some outstanding issues that need to be addressed to maintain and expand the system. The fi rst issue is the question of maintaining a high level of advocacy for the continued implementation and scale-up of the programme in a politically uncertain environment.

“Even if the Local Chief Executive is very supportive, there are other legislators at the municipal level who would be involved in deciding whether this will continue or not. The councillors, the municipal councils - you know it’s a political thing. [If] the LCE is not the same party as the municipal councillors, it’s quite hard for him to lobby for [these] kinds of programmes.” (UN)

The second component is to continue to improve the EWS analysis tool and be able to share data to compare results across multiple municipalities. Moving into the future with the prospect of nation-wide scale-up, a rigorous evaluation of EWS may be needed to provide evidence as to the benefi ts of EWS and select indicators that matter most to municipalities and their communities.

“One word critical about the EWS is the tool being used right now – the Excel-based application where they enter the data – it will show green, orange, red – that part is a struggle right now because… I suppose there’s a faster way of doing things, to put it the colored report…Also to reduce errors. Also in terms of data mapping also – I’m sure there’s a lot of things we can do better, in terms of collecting the data at the municipal level, that will make it faster for us to complete the trainings which are again dependent on the data. Finally into that application with the color code. It’s basically manual right now. That process should be further improved.” (National Government)

“We have access to it [the data that’s being collected], we use it regularly for our planning sessions. But the thing is for other municipalities, on the national level, we don’t have the data that would tell us how other municipalities [with EWS] are doing. I think that’s one area that we can improve on.” (Municipality)

Citations

(2013). Final MDG-F Joint Programme Narrative Report. (File name: MDG-F 2030 Final Narrative Report 31.07.2013)

Chiwara RM, Villate E. (2013) Final Evaluation of the Joint Programme: “Ensuring Food Security and Nutrition for Children 0-24 Months in the Philippines” (MDG-F 2030). Final Report.

(File name: Philippines_2013001_Final_report_MDGF_2030_22072013.pdf)

National Nutrition Council. (2014). Setting Up an Early Warning System (EWS) for Food and Nutrition Security. PowerPoint Presentation. Taguig City, National Nutrition Council. (Filename: EWS Expansion_Orientation_Cluster.ppt)

UNICEF. (2013). UNJP/PHI/061/CEF: Scaling-up of the Early Warning System for Food and Nutrition Security in selected Municipalities in the Philippines. Final Report.

(Filename: FAO_FINAL REPORT_Scaling-up of the EWS-FNS project_UNJP_PHI_061_CEF_23March.docx)

Memorandum Circular No. 2011 – 54. Quezon City, Republic of the Philippines.

Acronyms

Acad Academic Institution

ACF Action Contre Le Faim

AIMI Asosiasi Ibu Menyusui Indonesia (Indonesian Breastfeeding Mothers Association)

ALLWIES Alliance of Workers for Informal Sector

BIR Bureau of Internal Revenue

BNS Barangay Nutrition Scholars

BPD_Kla Bappeda Klaten (District Planning Offi ce), Social and Cultural Services

BMS Breastmilk Substitute

BPN Bappenas (Ministry of Development Planning)

BRAC_U John P. Grant School of Public Health, BRAC University

BSCIC Bangladesh Small Cottage Industries Corporation

CamSur_Cana Camaranes Sur Canaman, Philippines

CamSur_Ragay Camaranes Sur Ragay, Philippines

CHW Community Health Workers

c-IYCF Community Infant and Young Child Feeding

CMAM Community Management of Acute Malnutrition

Com_Clinic Community Clinics

CSA_Nut Civil Society Alliance for Nutrition

CWCH Center for Women and Child Health

DAO_Kla District Agriculture Offi ce, Food Security Offi ce Klaten

DFAT Australia’s Department of Foreign Affairs and Trade (formerly AusAID)

DFATD Canada Department of Foreign Assistance and Technical Development

DFID Department for International Development, United Kingdom

DGFP Directorate General of Family Planning

DGFP_Field Directorate General of Family Planning, Field Services Unit

DGFP_MCRAH Directorate General of Family Planning, Directorate General of Family Planning, Maternal, Child, Reproductive and Adolescent Health

DGHS Directorate General of Health Services

DHIS District Health Information System

DHO/CH_Kla District Health Offi ce, Community Health Division, Klaten

DHO_Kal District Health Offi ce, Community Health Division Balikpapan Kalimantan

DHO_Kla District Health Offi ce, Klaten

DHO_Jay District Health Offi ce Jayawijaya, Maternal Health and Nutrition Division

DHO_Sik District Health Offi ce, Sikka, Nutrition Division

DHS Demographic and Health Survey

DILG Department of the Interior and Local Government

DNSO District Nutrition Support Offi cer (Bangladesh)

DOLE Department of Labour and Employment

DOH Department of Health

DNI Direct Nutrition Interventions

DSWD Department of Social Welfare and Development

DTI Department of Trade and Industry

ECOP Employers Confederation of the Philippines

EU European Union

EWS Emergency Warning System

FAO Food and Agriculture Organization

FFW Federation of Free Workers

FWA Female Welfare Assistants

GAIN Global Alliance for Improved Nutrition

GKIA Gerakan Nasional Kesehatan Ibu dan Anak/Maternal, Newborn and Child Health Movement (Indonesia)

GoN Government of Nepal

GoB Government of Bangladesh

HMIS Health Management Information System

HSRT Health Sector Review Team

IAC Inter-Agency Committee

ICDDR,B International Centre for Diarhoea Disease Research Bangladesh

IDHS Indonesia Demographic Health Survey

IKLAN_Kla Association of IYCF Counselors, Klaten

ILO International Labour Organization

Ilo_Legis Iloilo Legislative Council

Ilo_Mall Robinson’s Mall in Iloilo

Ilo_MYC MYCNSIA Coordinator in Iloilo (Region 6)

Ilo_NNC National Nutrition Council in Iloilo

Ilo_PCCI Philippine Chamber of Commerce and Industry of Iloilo

IMAM Integrated Management of Acute Malnutrition

IM-SAM Integrated Management of Severe Acute Malnutrition

INGO International Non-Governmental Organization

IPHN Directorate General of Health Services, Institute of Public Health and Nutrition

IRR Implementing Rules and Regulations

IYCF Infant and Young Child Feeding

JPGSPH John P. Grant School of Public Health, Bangladesh

LCE Local Chief Executive

LGU Local Government Unit

MAM Moderate Acute Malnutrition

MCA-I Millennium Challenge Account-Indonesia, Health and Nutrition

MCC Millennium Challenge Corporation

MDG-F Millennium Development Goals - Fund

MI Micronutrient Initiative

MIYCN Maternal, Infant and Young Child Nutrition

MoAD Ministry of Agriculture Development

MoE Ministry of Education

MoFALD Ministry of Federal Affairs and Local Development

MoHP, DHS Ministry of Health and Population, Department of Health Services

MoHP_NutCH Ministry of Health and Population, Nutrition Section, Child Health

MOH_N Ministry of Health, Nutrition Directorate

MOH_NCon Ministry of Health, Nutrition Directorate, Consumption Sub-Directorate

MoI Ministry of Industries

MOHFW Ministry of Health and Family Welfare

MOH_PH & WH Ministry of Health, Public Health and WHO Wing

MoUD Ministry of Urban Development

MSNP Multisecoral Nutrition Programme (Nepal)

MYCNSIA Maternal and Young Child Nutrition Security in Asia

Naga_Legis Naga Legislative Council

Naga_Mall SM Naga Mall Manager

Naga_MYC MYCNSIA Regional Coordinator for Naga (Region 5)

Naga_NAMASFED

Naga Market Stallholder’s Federation

Naga_NCCI Metro Naga Chamber of Commerce and Industry

NAPC National Anti-Poverty Commission

NGO Non-governmental Organization

NHEICC Nepal Health Education, Information and Communciation Centre

NHSPII National Health Sector Programme II

NNFSS National Nutrition Food Security Secretariat

NPC National Planning Commission

NSMP National Security and Maternity Protection Project

NNC National Nutrition Council

NT Nutrition Treatment

NTB Nusa Tenggara Barat Province, Indonesia

NYF Nepal Youth Foundation

ONA Organizational Network Analysis

Par_Kla Parliamentarian, Klaten

PHO_NTB Province Health Offi ce, Community Health Division, NTB

Plan Plan International, Health

PMK Coordinating Ministry of Human Development and Culture

PNPM Generasi Program Nasional Pemberdayaan Masyarakat (Indonesian Poverty Reduction Program)

PTSC_Kla PT SC Enterprises, Breastfeeding Counselors

RA Republic Act

RAN-PG Rencana Aksi Nasional Pangan dan Gizi (Indonesia’s National Food and Nutrition Plan)

REACH Renewed Efforts Against Child Hunger and Undernutrition

Reg5_MYC Region 5 MYCNSIA Coordinator

Reg6_MYC Region 6 MYCNSIA Coordinator

RPJMN Rencana Pembangunan Jangka Menengah Nasional (Indonesia’s Medium Term Development Plan)

RUTF Ready to Use Therapeutic Food

SAM Severe Acute Malnutrition

Save Save the Children

Selasi Sentra Laktasi Indonesia –Breastfeeding Center

SUN Scaling-Up Nutrition

TUCP Trade Union Congress of the Philippines

UN United Nations

UNICEF United Nations International Children’s Emergency Fund

UNICEF_C4D UNICEF, Communication for Development

UNICEF_CFLG UNICEF, Child Friendly Local Governance

UNICEF_Edu UNICEF, Education

UNICEF_Nut UNICEF, Nutrition

UNICEF_SPEA UNICEF, Social Policy and Economic Analysis

UNICEF_WASH UNICEF, Water and Sanitation

USAID US Agency for International Development

USI Universal Salt Iodization

WASH Water and Sanitation

WB World Bank

WFP World Food Programme

WHO World Health Organization

WVI World Vision International

Zam_CHO Zamboanga City Health Offi ce

Zam_ECOP Zamboanga Employers Confederation of the Philippines

Zam_Legis Zamboagna Legislative Council

Zam_MYC MYCNSIA Regional Coordinator for Zamboanga (Region 9)

Zam_ZCCI Zamboanga Chamber of Commerce and Industry

Recommended citation: Ruducha, J. (2016). Nutrition Upstream. Improving Policies, Programmes, and Partnerships for Maternal and Child Nutrition in Asia. UNICEF Regional Offi ce for South Asia. Kathmandu, Nepal.

This research was developed, conducted and authored by Jenny Ruducha, of Braintree Global Health and Boston University School of Public Health, Center for Global Health and Development. The research team included Carlyn Mann, who analyzed quantitative network data and built visual plots, and Amiya Bhatia and Renuka Pandya, who abstracted and analyzed qualitative data based on taped interviews.

This research would not have been possible without the support of the Maternal and Young Child Nutrition Security Initiative in Asia (MYCNSIA, 2011-2015) and UNICEF Nutrition teams in Bangladesh, Indonesia, Nepal and the Philippines with funding provided by the European Union. Country specifi c UNICEF teams included: Nepal - Stanley Chitekwe, Anirudra Sharma, Pradiumna Dahal and Sanjay Rijal; Bangladesh - Anuradha Narayan, Andrew Musyoki Sammy, Farhana Sharmin, Mohsin Ali and Ireen Akhter Chowdhury; Indonesia - Harriet Torlesse, Ninik Sri Sukotjo and Isti Rahayuni (interpreter); and the Philippines - Willibald Zeck, Aashima Garg, Maria Evelyn Carpio, Paul Zambrano and Melvin Marzan. The intellectual lead to document upstream organizational processes for maternal and child nutrition was provided by Victor M. Aguayo and Kajali Paintal from UNICEFRegional Offi ce for South Asia.

Lastly, the research team would like to thank the 138 study participants from different government departments, United Nations agencies, donors, national and international NGOs, academia and associations. They kindly offered their time to answer survey questions and share their insights to help us understand how upstream engagement is shaping national policies, programmes and partnerships for maternal and child nutrition in Asia.

Dr. Jenny Ruducha

UNICEF Regional Offi ce South AsiaLekhnath Marg, Kathmandu 44600, Nepal

Copyright © UNICEF South AsiaPrinted in September 2016Technical lead Victor M. AguayoGraphic design Giovanna BurinatoPhotographs Dimatatac pp. 79, 86; Esteve p. 36; Estey pp. 40, 46; Ferguson pp. 38, 45, 52, 76; Lemoyne p. 75; Noorani pp. 18, 22, 29, 35; Nybo pp. 3, 4, 5, 10, 16, 23, 30; Pirozzi cover photo, pp. 6, 8, 12, 54, 57, 64, 67, 69, 71, 73.


Nu

trit

ion

Up

stre

am: I

mp

rovi

ng

Pol

icie

s, P

rogr

amm

es, a

nd

Par

tner

ship

s fo

r M

ater

nal

an

d C

hil

d N

utr

itio

n in

Asi

a

nutrition upstream: improving policies, programmes… · nutrition upstream improving policies,...

Documents