STORIES OF CHANGE IN NUTRITION:

THE CASE OF ZAMBIA

Jody Harris, Scott Drimie, Terry Roopnaraine,

Namukolo Covic, Derek Headey

SIG meeting, Washington DC

November 2015

Nutrition policy processes- literature review

• Some have called for nutrition research to engage with political economy (Pinstrup-

Anderson 1993; Berg 1987; Gillespie 2003), but call was largely ignored at the time

• Recent (~5-10 years) more widespread understanding in the literature that action is

aided or constrained by the ‘enabling environment’, defined as political and policy

processes (Gillespie, Haddad et al. 2013)

• Several key case studies assessing elements of these issues for nutrition (Benson 2008;

Natalicchio 2009; Menon/Hoey/Pelletier 2011; Garrett 2012)

• Literature tends to use policy frameworks to structure research (particularly Shiffman 2007

agenda setting; Heaver 2005 commitment), but few links to political or social science theory.

• Nutrition is slightly behind similar health systems research in its sophistication (eg. Walt

and Gilson 1994; Gilson et al 2008)

• Call for more, and more nuanced, nutrition policy research, including attention to power

structures (Nisbett et al. 2014)

Stories of Change initiative

Goal: To improve the formulation and implementation of nutrition-relevant policy

and action by producing a set of documented experiences of how undernutrition

has been addressed, in different contexts.

Change Challenge

Commitment

Coordination

Community

International level:• How has understanding of nutrition evolved internationally? †

• How has this informed and affected national policy and programs? †

National level:• How has nutrition arrived on the national policy agenda?• What characterises the broader enabling environment for nutrition?• What has driven change in stunting prevalence in Zambia? *

Local level• How is action for nutrition understood and implemented at local level?• How do national and international processes affect this?

Community level:• How have communities and individuals experienced changes in

nutrition services? *• How is nutrition perceived to have changed in rural communities? *

SUN level:• How is the SUN movement playing out in this context?• How does this apply to other SUN countries? *• What can we learn from patterns across different countries? *

*Stories of Change study only† PhD study only

Interviews with long-standing international nutrition expertsHistorical literature review

Interviews with international nutrition actors with explicit links to Zambian nutrition policy and practice

Quantitative assessment of drivers of undernutrition change

Interviews with Zambian national nutrition policy actorsReview of Zambian policies and program documents in

various nutrition-relevant sectorsSocial network mapping of national actors and interactions

Interviews with local nutrition implementation actorsSocial network mapping of local actors and interactions.

Focus group interviews with community members Interviews with community leaders

Data collection timeline

Policy document gathering Legend:

Netmap interviews International

Theory of change for coordination work National

Key informant interivews District

Policy document gathering Community

Key informant interviews

Key informant interviews

Netmap interviews

Key informant interviews

Netmap interviews

Focus groups

2011 2012 2013 2014 2015 2016

Analysis

Analysis stage Example analyses Steps in analysis

First stage: Descriptive

TimelinesNarratives Actor analysesSummarizing

Creating timelines of key events Describing key narratives Mapping key actors Coding data to original frameworks/ open coding

Second stage: Thematic

Patterns in the data Mapping to themesLooking across respondent types

Recognizing repetitions, clusters, disagreements in the coded data

Clustering codes into broader themes Splitting responses by respondent attributes

Third stage: Theoretical

Testing theory of changeIncluding broader social theory

Looking at themes across levels (international

community) Assessing assumptions in the theory of change Identifying broader social theory of relevance

1950 1960 1970 19901980 20102000

PROTEIN DEFICIENCY

M/SPLAN

NUTRITION POLICY

COMMUNITY

MICRONUTRIENT RIGHTS vsINVESTMENT

EMERGENCE OF NUTRITION SCIENCE

FOOD SHORTAGE

M/SPLAN

NUTRITION ISOLATIONISM

SPECIFIC & SENSITIVE

PROTEIN ERA

M/SPLAN

NUTRITION ISOLATIONISM

MICRO-NUTRIENT

INCREASING PRIORITY

INCREASING MOMENTUM

1

2

3

1: Jonsson 2009: International nutrition. 2: Herforth 2014: World Bank. 3: Nisbett et al 2014/Gillespie et al 2003: Nutrition policy. 4: Webb 2009/Golden 2009: Emergency nutrition. 5: Crowther et al 2007/Knaak 2006: Infant feeding. 6: Kennedy et al 2011/Kennedy 2008: Research priorities and policy. 7: Levinson and McLachlan 1999: International nutrition

Paradigms in nutrition 1950-present

PROTEIN AND STARVATION

MICRONUTRIENT

RUF / CMAM

4 TARGETED FEEDING

IYCF / BREASTFEEDING PROMOTION

LACTATIONAL PERFORMANCE; WEANING;FORMULA MILK AND MATERNAL FOOD PROVISION

5

DEFICIENCIES AND UNDERNUTRITION;DIETARY REOCMMENDATIONS

OVERWEIGHT AND NCDs; DUALBURDEN; FOOD SYSTEMS

6

7 MEDICAL PATHOLOGY; MILK POWDER;

HOME ECONOMICS

REHAB CENTRES;FOOD TECHNOLOGY

M/S PLANNING;FOOD DISTRIBUTION

INTEGRATED PROJECTS; BREASTFEEDING; SCHOOL FEEDING; FOOD COUPONS

Policy and

event timeline

1964-

1967

1968-

1971

1972-

1975

1976-

1979

1980-

1983

1984-

1987

1988-

1991

1992-

1995

1996-

1999

2000-

2003

2004-

2007

2008-

2011

2012-

2015

1964 Independence Legend:

1967 National Food and Nutrition Act, estabilshes NFNC in 1967 Policy or legislation

1972 Food and drugs act National event

1972 Food reserve act International event

1975 NFNA amended

1972 Goitre study Sources:

1978 Salt iodation legislation [not enforced] - "History" and "policy windows"

1978 Margarine fortification legislation (Vitamin A) themes of national interveiws

ANC supplementation for pregnant women - Harris and Drimie, policy review 2012

1985 Vitamin A study - Mucha, Zambia nutrition landscape 2014

1987 NFNC review (damning) - Haggblade et al, micronutrient policy review 2015

1990 Vitamin A supplementation begins - www.zambialaws.com

1991 Beginning of economic reforms

1991/2 drought

1992 Program Against Malnutrition formed

1992 international conference on nutrition

1992 Zambia plan of action on nutrition 1994-2004 [never enacted]

1992 Zambia started work on national nutrition policy

1994 Salt iodation mandatory

HIV epidemic links to nutrition

1998 Sugar fortification mandatory (Vitamin A)

2003 PROFILES tool used for advocacy and awareness-raising

2003 PRSP- mentioned nutrition for poverty reduction

2003 Biofortified sweet potato released

2005-2011 National micronutrient policy

2005-2010 NFNC strategic plan

2006 National food and nutrition policy

2006 Maize fortification plan [vetoed by government]

2008 Lancet series provided key evidence

2009 National nutrition symposium

2009 Financial scandal; donor reductions

2011 National nutrition forum

2010 Zambia signed on as an early riser SUN country

2011 National election and re-ordering of the health sector

2011-15 NFNSP

2012 Biofortified maize released

2012 SUN Fund established

2013-2015 1000 MCDP

2013 Nutrition for Growth event, London

2014 Multi-sectoral district plans [7 districts]

2015 5 key line ministries have nutrition budget lines added

2015 Review of 1975 NFNC Act

2015 CAADP results framework includes nutrition

1964-

1967

1968-

1971

1972-

1975

1976-

1979

1980-

1983

1984-

1987

1988-

1991

1992-

1995

1996-

1999

2000-

2003

2004-

2007

2008-

2011

2012-

2015

1964 Independence Legend:

1967 National Food and Nutrition Act, estabilshes NFNC in 1967 Policy or legislation

1972 Food and drugs act National event

1972 Food reserve act International event

1975 NFNA amended

1972 Goitre study Sources:

1978 Salt iodation legislation [not enforced] - "History" and "policy windows"

1978 Margarine fortification legislation (Vitamin A) themes of national interveiws

ANC supplementation for pregnant women - Harris and Drimie, policy review 2012

1985 Vitamin A study - Mucha, Zambia nutrition landscape 2014

1987 NFNC review (damning) - Haggblade et al, micronutrient policy review 2015

1990 Vitamin A supplementation begins - www.zambialaws.com

1991 Beginning of economic reforms

1991/2 drought

1992 Program Against Malnutrition formed

1992 international conference on nutrition

1992 Zambia plan of action on nutrition 1994-2004 [never enacted]

1992 Zambia started work on national nutrition policy

1994 Salt iodation mandatory

HIV epidemic links to nutrition

1998 Sugar fortification mandatory (Vitamin A)

2003 PROFILES tool used for advocacy and awareness-raising

2003 PRSP- mentioned nutrition for poverty reduction

2003 Biofortified sweet potato released

2005-2011 National micronutrient policy

2005-2010 NFNC strategic plan

2006 National food and nutrition policy

2006 Maize fortification plan [vetoed by government]

2008 Lancet series provided key evidence

2009 National nutrition symposium

2009 Financial scandal; donor reductions

2011 National nutrition forum

2010 Zambia signed on as an early riser SUN country

2011 National election and re-ordering of the health sector

2011-15 NFNSP

2012 Biofortified maize released

2012 SUN Fund established

2013-2015 1000 MCDP

2013 Nutrition for Growth event, London

2014 Multi-sectoral district plans [7 districts]

2015 5 key line ministries have nutrition budget lines added

2015 Review of 1975 NFNC Act

2015 CAADP results framework includes nutrition

Policy coherence- horizontal and verticalMDGs

Bu

dge

ts a

nd

res

ou

rcin

g

Zambia Poverty Reduction Strategy Paper

Zambia Vision 2030

Zambia Sixth National Development Plan

SUN agreement CAADP agreement

National Food and

Nutrition Policy 2006

National Agriculture

Policy 2004-15 National Health Policy

National Education

Policy

National Food and

Nutrition Strategic Plan

2011-15

National Agriculture

Investment Plan 2014

National Health

Strategic Plan 2006-10

National School Health

and Nutrition Policy

2006

1000 Most Critical

Days Program 2013-15

MAL Strategic Plan

2013-16 (“Budget

Strategy”)

IMAM Policy?

IYCF Policy?

Micronutrient Policy?

Social Protection

Policy?WASH Policy?

Multisectoral District

Plan (Mumbwa)

Agriculture Sector

Implementation Plan

School Health and

Nutrition Program

Guidelines 2008

Ministry Workplans

(Mumbwa)

Agriculture Ministry

Workplan (Mumbwa)

MCDMCH-DOH

Workplan (Mumbwa)

Education Ministry

Workplan (Mumbwa)

MCDMCH-DCW/DSP

Workplan (Mumbwa)

Local Gov Ministry

Workplan (Mumbwa)

Statutory Instrument No. 90 (2001): Fortification

National Code of Marketing of Breast Milk Substitutes 2006 Regulations

Employment Act CAP 268; Statutory Instruments No. 56 and 57

Social, political, institutional, economicPolitical: Permanent secretaries nutrition group, parliamentary nutrition caucusDonors: SUN Fund, DFID, Irish Aid, SIDA, USAID, EUAcademic: UNZA, IAPRI, NRDCMedia: Post, Daily Mail

Source: Adapted from UNICEF 1990

Immediate causes

Underlying causes

Basic causes

Food securityMAL, MCDMCH, WFP, FAO, PAM, Java foods

Care environmentUNICEF, MOG, CWZ

Health and WASH servicesMOH, MLGH, WHO, UTH

Health statusMOH, UNICEF

DietMCDMCH, Java foods, WFP

NutritionNFNC, NAZ, CSOSUN, CARE, CWZ, PATH, REACH, ECF

Stakeholder mapping at national level:Zambian nutrition actors

District-level coordination- NetMap

2011 2015

International level:• There have been clear paradigms in international nutrition• Including intersectoral coordination / nutrition sensitivity• These have to some extent gained traction in national policy

National level:• Written policy is to some extent coherent (vertical/horizontal)• International nutrition funding encourages coordination• Coordination discourse limited to a nutrition policy elite

Local level• Multi-sectoral plans are funded directly with international funds• In one pilot district, significant progress has been made• Difficult to replicate and scale up