Five, 10-minute abstract-driven presentations.  

Speakers and Presentations:

• Chair: Mahendra Dev, Indira Gandhi Institute of Development Research (IGIDR)

• Charulatha Banerjee, Emergency Nutrition Network (ENN), UK
  Exploring multi-sector programming for nutrition at district level in Senegal, Nepal and Kenya
  Slides/ Recording

• Amos Laar, University of Ghana
  Implementation of healthy food environment policies in Ghana: Gaps and priorities to prevent nutrition-related non-communicable diseases
  Slides/ Recording

• Helen Walls, London School of Hygiene and Tropical Medicine, UK
  Does Malawi’s Farm Input Subsidy Programme (FISP) improve dietary diversity?
  Slides/ Recording

• Mirriam Matita, University of Malawi
  Has the provision of legume seeds subsidies affected dietary diversity? Evidence from Malawi’s Farm Input Subsidy Programme (FISP)
  Slides/ Recording

• Jody Harris, Institute of Development Studies (IDS), UK
  Coalitions of the willing? Advocacy coalitions and the transfer of nutrition policy to Zambia
  Slides/ Recording

• Q&A
  Recording

Abstracts:

Exploring multi-sector programming for nutrition at district level in Senegal, Nepal and Kenya

Charulatha Banerjee, Emergency Nutrition Network (ENN)

Introduction:  Multi Sector Nutrition Programming (MSNP) is now integral to many national plans. There is a shift towards devolved governance in many countries; there has been little examination of its impact on multi-sector nutrition programming. In 2017, ENN documented in 3 ‘high achieving’ SUN countries, Senegal, Kenya, and Nepal, the rollout of multisector programmes at the subnational level. Documentation has often centred around national policies, strategies, and frameworks, and guidance available is still generic and “top down.” This series of case studies aims to help fill this gap by providing important lessons learned to help shape future approaches and practice.

Methods:  The study was done between July and September 2017 in two districts in each of the three focus countries chosen (Kenya, Nepal, Senegal). These districts represent diverse regions within the countries selected and have diverse patterns of malnutrition. One multi-sector programme with nutrition-sensitive and nutrition-specific components was selected for focus in each district. At the first stage, mapping was conducted at country and sub-national level of key stakeholders in nutrition and related sectors, including mapping major government and partner programmes relating to nutrition. Stakeholder interviews started with consultations at the national level and continued with follow-up at district/county level. Counties/districts were then selected based on this mapping work. In all three countries, regions were selected to demonstrate diversity within the national context and how national-level plans/programmes were playing out in regions with distinct needs and different patterns of malnutrition and governance. District-level meetings were held with key stakeholders involved in programme implementation at the district/county level and in some exemplar villages or commune units. Semi-structured interviews were done based on a common list of questions that were adapted to the context. Questions covered several key themes, including governance, coordination, programme detail, coherence, roles, etc.

Findings:  At the front line, 3 critical elements were identified, some more successful in one than the other country:  

• Importance of broad, simple messaging and advocacy (Nepal)
• Use of different sectors or delivery points that connect to vulnerable communities and households with frontline workers seeing opportunities to co- target and share (Kenya)
• Targeting of nutritionally-vulnerable households which was achieved differently in each of the programmes looked at.

A significant challenge in the implementation of MSNP across multiple administrative levels is coordination: it has evolved in a way that is “loose,” “unstructured,” and “opportunistic.” Barriers were analysed in detail in the study. There is a lack of robust data on households’ receipt of comprehensive sector support. None of the programmes examined collected data on the additional cost of implementing multi-sector nutrition sector programming and have not yet developed robust monitoring systems able to demonstrate their nutrition impact. There are diverse understandings of what nutrition sensitivity means. Many stakeholders are not acknowledging the need to adapt approaches in their sector. The study identified, amongst others, 2 areas of future work: (a) assessing the impact of devolution on MSNP and (b) cost effectiveness to understand what funds are needed for programming at scale.

Conclusions:  Despite the substantial progress towards reducing undernutrition in the 3 countries that ENN looked at in this work, multi-sector nutrition programming at scale is still limited, although it is emergent. One clear, overarching message is that multi-sector nutrition programming impact is poorly evidenced; only a critical mass of evidence is likely to generate the resources and decentralised political will that will allow MSNP scale-up. ENN is following this series of case studies with a second round of case studies in Niger, Ethiopia, and Bangladesh. Findings will be available and included in the final presentation in June 2019.

Implementation of healthy food environment policies in Ghana: Gaps and priorities to prevent nutrition-related non-communicable diseases

Amos Laar, University of Ghana

Introduction:  Obesity and other nutrition-related non-communicable diseases(NR-NCDs) are a major global public health problem. Increasingly, populations are exposed to unhealthy food environments (FE) which increase their risk of NR-NCDs. FE are defined as the “collective physical, economic, policy and sociocultural surroundings, opportunities and conditions that influence people’s food and beverage choices and nutritional status.” Implementing recommended policies to improve FE is crucial to tackling these risk factors. We assessed the extent of implementation of FE policies in Ghana and derived priority actions for improving FE.

Methods:  The International Network for Food and Obesity/Non-communicable Diseases Research, Monitoring and Action Support(INFORMAS) Healthy Food-Environment Policy Index (Food-EPI) tool/process was adopted and implemented in four steps: i. Tool and process adaptation and contextualization; ii. Compilation of evidence and verification of document by the Ghanaian government; iii. Assessment of implementation of good practice policies; and iv. Identification and prioritization of actions. Following compilation and validation of evidence, a panel of 19 local public health experts rated the extent of government action against international best practice, and against the local policy development trajectory (‘initiation,' ‘in development,’ ‘implementation,’ or ‘evaluation’). Further, concrete actions for the government to improve the FE were proposed and prioritized. Taking into account implementation gaps, a total of 13 policy actions and 14 infrastructure support actions were identified by the expert panel. Further, the panel prioritised the actions, taking into account perceptions of the relative importance (i.e. perceived need, likely impact, and equity) and achievability (i.e. feasibility, level of acceptability to a wide range of key stakeholders, affordability, and cost-effectiveness) of each action.

Findings:  There were major implementation gaps. Three-quarters of all areas of good practice indicators were assessed as ‘low’ or with ‘very little’ implementation. However, the Government of Ghana was assessed to be performing very well (‘high’) at the level of international best practice in restricting the marketing of breastmilk substitutes. The government was judged to be performing relatively well (‘medium’) in policy action to establish nutrient declarations, in particular through setting standards for maximum fat content in beef, pork, mutton, and poultry. Similarly, the government was judged to be performing relatively well (‘medium’) in six infrastructure support areas (e.g.access to government information, monitoring progress on reducing health inequalities, platforms for interaction). Actions identified and prioritized as “most important and feasible” to improve the Ghanaian FE included the introduction of legislation to regulate the promotion/sponsorship/advertisement and sale of unhealthy food and drinks in school environments and in the media. Adopting a mandatory food labelling scheme and implementing subsidies to increase the affordability of healthy foods were also ranked as important, but concerns about feasibility were raised. Improving the funding environment for nutrition was prioritized as the most important and feasible form of action to improve infrastructural support towards preventing obesity and NR-NCDs.

Conclusions:  The first such NCD policy appraisal in West Africa, this study identified important gaps in implementation of key policies to promote healthy FE, compared with international best practices. These findings support current calls to improve the FE, but also asserts the feasibility of deploying the Food-EPI methodology in Africa. The findings have policy and practice utility, as well as value for public health advocacy. Serving as baseline benchmarks for the Ghanaian government, surveillance of current and future policies is possible using the accountability criteria embedded in the process. Civil societies could hold governments to account based on the data generated.

Does Malawi’s Farm Input Subsidy Programme (FISP) improve dietary diversity?

Helen Walls, London School of Hygiene and Tropical Medicine, UK

Introduction:  Agricultural input subsidies (AISs) are often considered an important means of improving agricultural productivity and food security in low- and middle-income countries. However, AIS nutritional impact is unclear, not least because the staple crops often targeted tend to be calorie-dense but nutrient-poor. AISs targeting maize, for example, may increase production/consumption of maize and reduce intake of nutrient-rich foods. Alternatively, if maize prices fall, this may enable consumers to purchase other goods including other food items. Using mixed methods, this paper examines the impact of Malawi’s AIS programme, the Farm Input Subsidy Program (FISP), targeting mostly maize, on overall food choice.

Methods:  Qualitative data of stakeholder perceptions was collected through semi-structured key informant interviews (21, from organisations including Malawi’s Ministry of Health, Ministry of Agriculture, District Council representatives from Phalombe and Lilongwe Districts, local and international non-governmental organisations) and focus group discussions (8, split by gender). Quantitative data were collected through household and individual surveys, market surveys, and by conducting a discrete choice experiment. With the exception of the key informant interviews, primary data collection was undertaken in two districts of rural Malawi: Lilongwe District and Phalombe District. Data for household and individual surveys were collected from 400 households (200 in each district), at two time points: May 2017, representing a post-harvest season when maize prices are expected to be low, and February/March 2018, representing a lean season with expected high maize prices. Discrete-choice experiment data were collected with a sub-sample of participants at only the second time point. We analysed the qualitative data thematically, manually coding key themes emerging, based on the Framework Synthesis Method for analysis. With quantitative data, we undertook regression analyses using Stata® software to understand key relationships. Brought together, the different data types provide a nuanced understanding of policy impact and the context for this.

Findings:  Discrete choice experiment analyses suggest that if the FISP led to lower maize prices, dietary diversity would likely improve. We developed models capturing FISP participation and measures of dietary diversity, and found no evidence of impact, whether measured as a current (agricultural season covered in the study) or previous beneficiary in the program. This lack of benefit was largely reflected in the qualitative analyses.

Community participants were mostly negative about the FISP, perceiving minimal impact from it on their nutrition:

• “It is supposed to help poor people to access cheaper fertiliser and seeds but they do not access the help, rather it is the wealthier people who do.”
• “It’s hard to sell even one bag of maize to buy other foods like chips or meat.”

Village chiefs were the most positive stakeholder group about the FISP’s nutritional impact:

• “FISP contributes to better nutrition as people are given beans, soya and groundnuts.”
• “FISP affects people’s food choices as it increases their incomes, and they can then buy what they wish.”

District Council participant views and those of national-level participants were fairly mixed, with concerns often expressed:

• “FISP does not result in improved productivity because it does not target the productive farmers.”

Conclusions:  Hypothesised pathways of impact from AIS to food choice and dietary diversity suggest that Malawi’s FISP could be contributing to improved dietary diversity. Our discrete choice experiment with community members also suggests that if the FISP was leading to lower maize prices, dietary diversity would likely improve. However, the quantitative and qualitative analyses from our surveys, key informant interviews, and focus group discussions suggest no impact of the FISP on food choices and dietary diversity in any significant way. The interviews and focus group discussions raise several issues relating to policy implementation that may help explain this lack of impact.

Has the provision of legume seeds subsidies affected dietary diversity? Evidence from Malawi’s Farm Input Subsidy Programme (FISP)

Mirriam Matita, University of Malawi

Introduction:  Malawi provides subsidies on fertilizer and improved seeds under the Farm Input Subsidy Programme (FISP) to resource-constrained smallholder farmers. This is considered to have contributed to achieving national maize self-sufficiency. However, critics point to nutritional consequences of diets that continue to be dominated by maize, which lacks essential nutrients. Relatedly, nutrition indicators for Malawi are below global standards: 37% of under-five children are stunted, presenting developmental consequences. The FISP package has included provisions for legumes, as well as maize, in recent years. Accordingly, legume production has risen, but it is unknown whether such increases have resulted in increased dietary diversity (DD).

Methods:  This study uses Integrated Household Panel Surveys data, collected by Malawi’s National Statistical Office with support from the World Bank as part of the Living Standards Measurement Surveys. This is nationally-representative data collected from a sample of randomly selected households across the country. Data used here were from 2013 and 2016, to estimate Panel Poisson Regressions undertaken to investigate whether redemption of legume coupons is associated with dietary diversity. We removed outlier observations from the data and obtained a usable sample of 1,980 observations. To improve accuracy of estimates, bootstrap estimation with 50 replications was conducted. Robust standard errors accounting for any heterogeneity in the data were obtained. The model presented below was estimated:

γ_it = α_0+δ_t+β_i (〖FISP〗_i )+X_it+ε_it

where, i individual Household, t season of survey (2013 and 2016); γ_it outcome of interest (Dietary Diversity defined as count of food groups consumed); δ_t  is season when consumption module was administered; 〖FISP〗_i defined as a dummy variable whether household redeemed legume coupon; alternative definition as in receipt of any subsidized coupon is also used; X_it other control variables (socioeconomic factors, market participation, wealth, demographic factors). We also used descriptive analysis to determine emerging patterns of dietary diversity across seasons.

Findings:  Redemption of legume coupons influences dietary diversity:  While receipt of any subsidy coupon was not associated with dietary diversity, redemption of the legume coupon was positively and significantly associated with DD. Households that redeemed legume coupons are expected to have one additional food group in their DD. Household wealth drives dietary diversity:  As in previous studies, we found a significant positive association between household wealth and DD, with durable assets being more prominent (17.9 percent increase in number of food groups consumed) than ownership of livestock (2.5 percent) in increasing DD. Poverty was associated with lower DD at household level. Market participation affords dietary diversity: Some types of market participation were associated with dietary diversity. Results show sale of maize was positively associated with DD, whilst the sale of legumes was not. Overall, however, crop sales value was associated with higher DD. Seasonal variation affects dietary diversity: Accounting for seasonality, we found households consumed fewer food groups during lean seasons, with precarious falls in consumption of food in the ‘meat,’ ‘eggs,’ ‘milk,’ and ‘legumes, nuts, & pulses’ food groups. Households interviewed in post-harvest and planting seasons experienced higher DD relative to those interviewed in lean period.

Conclusions:  Farming systems in Malawi dominated by maize production are supported with government input subsidies, which translates into consumption of calorie-dense foods associated with nutrient deficiencies. Since 2009, legumes are subsidized to diversify production and consumption of foods available. Panel Poisson Regression results from nationally-representative data point to relevance of input subsidies, especially redemption of legume coupons, in facilitating access to diversified diets. This suggests the importance of addressing varied availability of legume seeds in FISP markets and scaling up the legume component of FISP, which has been declining from 2.8 MT in 2014/15 farming year to 1000 MT in 2017/18.

Coalitions of the willing? Advocacy coalitions and the transfer of nutrition policy to Zambia

Jody Harris, Institute of Development Studies (IDS), UK

Introduction:  As well as understanding which policies are needed to advance synergies between agriculture, nutrition, and health, we also need to understand how those policies are created and negotiated if we want to turn our research into impact. The aim of this study was to explore how and why certain international nutrition ideas and approaches have found their way into national nutrition policy and practice in Zambia, and therefore to contribute, through investigation of the case of nutrition policy in one country, to an understanding of policy processes more generally.

Methods:  This paper takes the case of nutrition policy in Zambia, tracing its history and teasing out the actors, narratives, and politics underlying policy change over several decades. To approach this issue, data were collected at national and international levels in the form of key informant interviews (70 interviews with 61 different respondents over six years); policy documents (food security and nutrition policy dating back to Zambian independence in 1964); and social network maps (of organizations involved in nutrition-relevant policy and action, as well as their influence over the issue of nutrition policy, and links of accountability between organizations). As the data were explored and synthesised and initial themes developed, a broad reading of the public policy literature suggested several different political science theories that might shed theoretical light on the emerging empirical findings. This study eventually applied theories of policy transfer and advocacy coalitions as useful in understanding the policy process in both empirical and theoretical depth.

Findings:  Stunted growth in children and the need for multi-sectoral action are dominant ideas in the international nutrition community currently. These framings are increasingly evident in Zambian nutrition policy, largely displacing framings of hunger formerly dominant in food security policy. With its focus on multi-sectoral action, the recent nutrition policy narrative impinges directly on existing food security narratives as it attempts to alter agricultural policy away from maize reliance and towards the diverse diets needed for improved nutrition. These changes can be shown to result from the international community’s nutrition agenda, transferred to Zambia through advocacy and funding priorities. Dominant international narratives do not encounter a vacuum at national level; rather they interact with myriad interests, and beliefs in the national policy arena. With the introduction of the multisectoral narrative around 2008, the nutrition policy sub-system has become split between a largely international coalition promoting multisectoral action on child stunting, and a largely national coalition focused on food security to address hunger. This leads to a divergence in preferred policy responses, with the stunting coalition promoting multisectoral coordination and focus on women to address poor diets and health; and the food security coalition promoting agriculture-sector policy for increased calorie production.

Conclusions:  Stunting is an important issue in Zambia, but hunger is also the lived experience of many Zambians, so a strategy that focuses on both is needed if the legitimacy of either coalition is to be maintained and if all forms of malnutrition are to be improved. This study finds that it is possible to understand policy processes through the application of multiple political science theories, allowing the generalization of findings from this case to other contexts. These concepts can be investigated wherever the nutrition system reaches down from international to national level.