1. Making Nutrition a Development Priority in Africa: What does it take? Marcela Natalicchio Menno Mulder-Sibanda HNP Africa-The World Bank

2. Why did we conduct a PE study in nutrition in Africa? Three Facts/One Puzzle ◦ -Malnutrition remains a critical public health issue ◦ - There is scientific evidence of workable solutions to malnutrition problems. ◦ - Yet, in many countries (in particular in Sub-Saharan Africa), it remains a low government priority. One Hypothesis: ◦ There are institutional, political obstacles to government commitment (in addition to known capacity constraints)

3. Comparative study (regional) Objective - Establish: Why is nutrition not becoming a higher priority? What factors/actions promote a better positioning of nutrition? Methodology - Conduct and compare eight case studies in Africa, with different levels of government commitment (priority) towards combat against malnutrition -Cases with highest level of commitment: Senegal, Madagascar and The Gambia -Cases with lower levels of commitment: Benin, Burkina Faso, Ghana, Tanzania and Ethiopia -Analysis of historical trajectories of government investment in nutrition policies -----------------------x------------------x--------------------------> 1960s change 1 change 2 present

4. Case studies: is malnutrition a problem? Malnutrition levels (children U-5) CountryYearSourceStunting Benin2006DHS44.7 B. Faso2003MICS344.5 Ethiopia2005DHS50.7 Gambia2006MICS327.6 Ghana2008DHS28.1 Madagascar2004DHS52.8 Senegal2005DHS20.1 Tanzania2004DHS44.4

5. Government response/Different trajectories -Nutrition issues have been on government agendas since Independence. In most cases, even during the colonial period. So, nutrition has had some government action. -In fact, nutrition activities have experienced a gradual increase in the following decades due to increased availability of HR, funds from DP, better understanding of causes/solutions. BUT, not enough attention to attract necessary resources to address alarming levels of malnutrition---> low priority cycle Senegal, Madagascar, The Gambia (2000s): stakeholders got together to draft national policies and plans, creation of national coordination agencies (PM/president), increased budget resources, implementation of ambitious national programs with good results.

6. Comparative Study (regional) Trajectories analysis - Definition of the “outcome”: government has committed to long-term nutrition policies to reduce malnutrition. Observed through government actions/decisions. Components: 1) Discourse/policies; 2) Budget; 3) Implementation. - Look at obstacles across time (influence of historical legacies, path dependency; are they similar?) - Observe changes: 1. partial positive change (missed opportunity); 2. full positive change; 3. reversal. -Factors associated with changes: agenda setting; adoption; implementation; sustainability.

7. Identification of changes Observations about changes -All case studies showed positive processes of change at some point in time, but they were truncated. They made changes in policies, sometimes creation of new institutions, but implementation did not proceed. Change was not sustained. Ex: Benin, Burkina Faso and Ghana (in response to ICN 1992) Good comparison with more sustained changes -Issues of sustainability appear very important: lessons from The Gambia, Tanzania in particular. So, focus was not exclusively on recent positive changes. It provided more experiences for comparison; and pointed to aspects that appear important to make them sustainable.

8. Obstacles: low priority cycle Low Demand for nutrition services Poor institutional placem ent/ Multiple narratives Fragmented support DP Poor results/no accountabil ity

9. Low demand for nutrition services Factors that affect low demand Low demand for nutrition services Low pressure on politicians 1.Nature of problem 2. Lack of power beneficiaries 3. Info problems 4. Inadequate training 5.Lack power nutritionists 6.Low priority donors

10. Poor institutional placement/multiplicity of narratives Low demand gets reflected in poor institutional placement Lld Low capacity/little power Fragmentation/lack of coord/rivalries Nutrition is the business of donor-led and supported small units Nutrition Units -small, understaffed, underfunded -low ranking (no access to decision- making/budget) Multiple narratives -Each unit different narrative -Influence of international discourses

11. Limited results/little visibility/little accountability Typical scenario -Many small projects funded by DP (development partners) -Little coordination and overlap -Little monitoring/evaluation -Little dissemination of some good results Little interest for political entrepreneurs to use in “portfolio of accomplishments” Little accountability for poor results (no clear responsible)

12. What breaks the cycle? Possible triggers: How to make it a priority? Changing the demand-side -Emergency situations? Natural disasters? They are windows of opportunity, but experience shows they can be short term. Danger of “food bias” -Attaching it to demand for food. Food distribution is more politically attractive. Risk of fund diversion from other key nutrition interventions. -Massive awareness campaigns. Not seen in cases -Starting a program that will create interest in beneficiaries—does not create enough pressure on politicians -Signing of international treaties/Assuming international commitments(International Nutrition Conference 1992, MDGs). It can initiate some action…but not enough in themselves.

13. What breaks the cycle? Possible triggers: how to make it a priority? Changing the supply-side - Creating a coordinating mechanism/body. In many cases, it does not work. Several shortcomings: not enough authority, no appropriate budget, no clear mandate/leadership role, not good incentives for cooperation. -”Champions” : advocacy and leadership. Important but limited (high turn- over; relatively limited influence) -Implementing a successful national program with good results -Creating greater capacity to implement effective programs

14. What breaks the cycle? Comparing cases (what makes a difference?) -Making nutrition a priority is “an explicit attempt to break the elements of the low priority cycle by a coalition for reform” -Several actions need to be taken simultaneously or in sequence (in least successful cases, some actions are missing, so priority is established but with no implementation, or unsustainable) -Coalition for reform seeks to tackle problems of low priority cycle: a) increase demand; b) reduce fragmentation of discourse, institutions and actors; c) improve accountability; d) get DP to work in favor of long term policies

15. What breaks the cycle? Agenda setting and adoption (1) Creation of a broad based coalition for reform (leadership and vision) (2) Developing a common narrative (and platform for cooperation) (3) Influencing powerful actors (who needs to be on board) (4) Contextual variables (affect chances of reform)

16. Breaking the cycle Agenda Setting and Adoption Advocacy Stakeholders’ Workshops - Finance Ministry -Consolidate coalition -President/PM office -Common narrative -DP (National Policy) -parliamentarians -Discussion on best -local authorities institutional placement Vision/Leadership Gain support of powerful actors Coalition for reform Favorable Policy Context + ‘Window of Opportunity’

17. Breaking the cycle Favorable policy context -PRSP (pro-poor orientation; participation)—inscription necessary but not sufficient -MDGs (MDG1, 4 and 5)—not all government have shown same level of commitment -Orientation of DP towards longer-term policies (from projects to programs) MDGs (results) and Paris Declaration (results, coordination, support for government leadership) Window of Opportunity -Coalitions have used “windows of opportunity” to put nutrition on the agenda. Senegal, Madagascar and The Gambia have used re- negotiation (negotiation) of WB loan to do so.

18. Breaking the cycle Implementation and sustainability (1) Changing institutional arrangements (2) Ensuring results (issues of capacity) (3) Using strategic communications (1) Better access to decision-making, resources, capacity to coordinate, and mobilize needed resources (HR, funding): ex. Coordinating agencies attached to PM/president office, with clear responsibility and resources to implement effective nationwide nutrition policies (CLM, ONN, NANA)

19. Breaking the cycle Implementation and sustainability (2) Ensuring results: they can be claimed by politicians as part of their achievements (Capacity and commitment meet here) (3) Strategic communication: always room for issue competition (many needs/budget constraints). Strategic communication is essential to keep powerful actors interested in nutrition.

20. Implications for WB Implications for WB operations? Main lesson: “avoid actions that feed into the “low priority cycle” AND “take steps to reform” - Based on workshop participation and results of study, Benin is on its way to “breaking the cycle” -Supportive TTL with vision of where change needs to happen -Avoid narrow focus on “nutrition departments” and narrow/small interventions (feeds into “low priority cycle”) -Initiate dialogue with key DP -Use different bank instruments at same time (investment + TA)

21. Implications for WB Operations Implications for WB operations? -Single it out for policy dialogue -Identify champions “across the board” (different levels of government) -Manage “changes in the environment” in your favor and adapt (develop possible scenarios) -Be opportunistic in getting initial funds to get action going (risk: staying small) -Get results and communicate them! -Soft elements: getting out of the “comfort zone” : courage, creativity, entrepreneurship, and tenacity.

22. Thank You!