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OPERATIONALIZING MULTISECTORAL NUTRITION

PROGRAMS TO ACCELERATE PROGRESS:
A NUTRITION GOVERNANCE PERSPECTIVE

DISCUSSION PAPER December 2021

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Ali Winoto Subandoro

Silvia Holschneider
Julie Ruel-Bergeron
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OPERATIONALIZING MULTISECTORAL NUTRITION
PROGRAMS TO ACCELERATE PROGRESS:

A Nutrition Governance Perspective

Ali Winoto Subandoro, Silvia Holschneider,

Julie Ruel-Bergeron

December 2021
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ii
 Health, Nutrition, and Population (HNP) Discussion Paper

Operationalizing Multisectoral Nutrition Programs to Accelerate Progress:

A Nutrition Governance Perspective

Ali Winoto Subandoro,a Silvia Holschneider,b Julie Ruel-Bergeronc

a
Global Financing Facility (GFF), Health, Nutrition and Population (HNP), World Bank,
Washington DC, USA
b
Independent Consultant, Washington, DC
c
Global Financing Facility (GFF), Health, Nutrition and Population (HNP), World Bank,
Washington DC, USA

Abstract:

Malnutrition continues to be one of the world's most critical health and human
development challenges, threatening countries' Universal Health Coverage (UHC) goals
and the achievement of the Sustainable Development Goals (SDGs). Given the
complex, multifactorial, and interlinked determinants of nutritional status and well-being,
multisectoral nutrition programming has been widely promoted as the most effective way
to address the direct and indirect determinants of malnutrition and to improve nutrition
outcomes. Robust governance systems are essential for implementing multisectoral
nutrition interventions and creating cost-effective and sustainable programs.

The objectives of this report are to (i) document and synthesize implementation
experiences, challenges, and opportunities from seven countries supported by the World
Bank and Global Financing Facility (GFF) in operationalizing large-scale multisectoral
nutrition projects that emphasize and strengthen governance (Cambodia, the
Democratic Republic of Congo, Guatemala, Indonesia, Malawi, Nigeria, and Rwanda);
and (ii) facilitate cross-country learning. Given that the seven countries used as
examples in this report are still implementing their multisectoral programs, the report
focuses on documenting progress and lessons learned on implementation modalities
and innovations, rather than highlighting impact at this stage.

The report uses a multisectoral governance framework, adapted from Gillespie, Van Den
Bold, and Hodge (2019), to synthesize the implementation experiences across the World
Bank/GFF–financed multisectoral nutrition projects. The report provides eight lessons
learned, organized under three broad categories: (1) Advocacy, leadership, and
institutional support for multisectoral nutrition; (2) Management capacity and financing;
and (3) Results measurement, monitoring, and accountability.

iii
The report also discusses key issues that governments, donors, and program planners
may want to consider when moving forward with implementing such programs.

Keywords: Nutrition, multisectoral, governance, leadership, financing

Disclaimer: The findings, interpretations, and conclusions expressed in the paper are
entirely those of the authors, and do not represent the views of the World Bank, its
Executive Directors, or the countries they represent.

Correspondence Details: Ali Winoto Subandoro, Global Financing Facility (GFF) and
World Bank, 1818 H St., NW, Washington, DC 20433, USA; 202-473-0159;
[email protected]; www.globalfinancingfacility.org.

iv
 Acronyms

CARD Council for Agriculture and Rural Development (Cambodia)

CCT Conditional Cash Transfer

CHW Community Health Worker

COA Chart of Accounts (Indonesia)

COCOSAN Community Council for Food Security and Nutrition

(Guatemala)

CODESAN Departmental Council for Food Security and Nutrition

(Guatemala)

COMUSAN Municipal Council for Food Security and Nutrition (Guatemala)

CONASAN National Council for Food Security and Nutrition (Guatemala)

CNMN National Multisectoral Nutrition Committee (DRC)

CPWC Commune Program for Women and Children

CSO Civil Society Organization

DBM Double Burden of Malnutrition

DCAP District Convergence Action Plan

DLI Disbursement-Linked Indicator

DPEM District Plan to Eliminate Malnutrition (Rwanda)

DPO Development Policy Operation

DRC Democratic Republic of Congo

ECD Early Childhood Development

ECED Early Childhood Education and Development

GFF Global Financing Facility

HCP Human Capital Project

HEF Health Equity Fund (Cambodia)

IC Investment Case

v
IECD Integrated Early Childhood Development

IFMIS Integrated Financial Management Information System

INEY Investing in Nutrition and Early Years (Indonesia)

MCHN Maternal Child Health and Nutrition

M&E Monitoring and Evaluation

MFBNP Federal Ministry of Budget and National Planning (Nigeria)

MIYCN Maternal, Infant, and Young Child Nutrition

MNHP Multisectoral Nutrition and Health Project (DRC)

MoF Ministry of Finance

MoH Ministry of Health

MoHA Ministry of Home Affairs

MSP Multisectoral Platform

MoV Ministry of Village

M&E Monitoring and Evaluation

NCDDS National Committee for Subnational Democratic Development

Secretariat

NECDP National Early Childhood Development Program (Rwanda)

NPER Nutrition Public Expenditure Review

PBF Performance-Based Financing

PFM Public Financial Management

PforR Performance for Results

RBF Results-Based Financing

RMNCAH-N Reproductive, Maternal, Newborn, Child, Adolescent Health

and Nutrition

SBCC Social Behavior Change Communication

SDG Sustainable Development Goal

vi
SIINSAN Food and Nutrition Security National Information System
(Guatemala)

SSGBI Survey Status Gizi Balita Indonesia

StraNas National Strategy to Accelerate Stunting Prevention

(Indonesia)

SUN Scaling Up Nutrition

UHC Universal Health Coverage

UNICEF United Nations Children’s Fund

WASH Water, Sanitation, and Hygiene

WHO World Health Organization

vii
 Table of Contents
EXECUTIVE SUMMARY .............................................................................................. XI

PART I – INTRODUCTION .............................................................................................1

PURPOSE AND OBJECTIVES OF THE REPORT .................................................................... 2

PART II – WHY IS A MULTISECTORAL APPROACH TO NUTRITION IMPORTANT? . 3

TYPES OF MULTISECTORAL APPROACHES........................................................................ 4

CHALLENGES IN OPERATIONALIZING THE MULTISECTORAL APPROACH ............................... 4

PART III – NUTRITION GOVERNANCE FRAMEWORK ................................................ 6

PART IV – LESSONS LEARNED FROM EARLY IMPLEMENTATION EXPERIENCES 8

ADVOCACY, LEADERSHIP, AND INSTITUTIONAL SUPPORT FOR MULTISECTORAL NUTRITION 10

Evidence-based advocacy for positioning nutrition improvement within a broader

development agenda .............................................................................................. 10

Background ........................................................................................................ 10

Examples from countries .................................................................................... 11

High-level leadership, vision, and strategy for a “whole-of-government” approach . 13

Background ........................................................................................................ 13

Examples from countries .................................................................................... 13

Institutional and implementation arrangements for operationalizing the multisectoral

strategy ..................................................................................................................15

Background ........................................................................................................ 15

Examples from countries .................................................................................... 17

MANAGEMENT CAPACITY AND FINANCING ...................................................................... 19

Management capacity and accountability systems at the subnational level ............ 19

Background ........................................................................................................ 19

Examples from countries .................................................................................... 20

Integrating a multisectoral nutrition program into regular planning and budgeting

processes to ensure sustainable financing ............................................................. 22

viii
 Background ........................................................................................................ 22

Examples from countries .................................................................................... 23

Leveraging results-based financing to drive results ................................................ 25

Background ........................................................................................................ 25

Examples from countries .................................................................................... 26

RESULTS MEASUREMENT, MONITORING, AND ACCOUNTABILITY ....................................... 30

Strengthening performance monitoring systems and promoting the use of data to

improve program implementation ........................................................................... 30

Background ........................................................................................................ 30

Examples from countries .................................................................................... 31

Citizen engagement, community mobilization, and social accountability ................ 32

Background ........................................................................................................ 32

Examples from countries .................................................................................... 33

PART V – LOOKING AHEAD ....................................................................................... 35

REFERENCES..............................................................................................................38

ANNEX 1. PROGRAM FEATURES BY COUNTRY ...................................................... 42

ix
 ACKNOWLEDGMENTS
The authors are grateful to the World Bank for publishing this report as an HNP
Discussion Paper.

The work benefitted tremendously from multiple rounds of discussions and feedback,
including from Blessings Nyanjagha Botha (Senior Agriculture Economist, World Bank),
Eleonora Cavagnero (Senior Economist, World Bank), Ritgak Dimka (Senior Health
Specialist, World Bank), Leslie Elder (Senior Nutrition Specialist, Global Financing
Facility), Elvina Karjadi (Senior Health Specialist, World Bank), Supriya Madhavan
(Senior Health Specialist, World Bank), Anne Marie Provo (Nutrition Specialist, World
Bank), Lisa Shireen Saldanha (Nutrition Specialist, World Bank), Chiho Suzuki (Senior
Health Specialist, and Collins Zamawe (Consultant, World Bank).

We also wish to thank the reviewers of this paper who provided invaluable feedback: Yi-
Kyoung Lee (Senior Health Specialist, World Bank), Anne Marie Provo (Nutrition
Specialist, World Bank), and Laura Rawlings (Lead Economist, World Bank).

x
 EXECUTIVE SUMMARY
Malnutrition continues to be one of the world's most critical health and human
development challenges, threatening countries' Universal Health Coverage (UHC) goals
and the achievement of the Sustainable Development Goals (SDGs) (WHO 2019). The
COVID-19 pandemic has further threatened the health, social, and economic gains
made for women and children, with the potential of erasing decades of progress in
nutrition. Given the complex, multifactorial, and interlinked determinants of nutritional
status and well-being, multisectoral nutrition programming that converges on vulnerable
populations has been widely promoted as the most effective way to address the direct
and indirect determinants of malnutrition and improve nutrition outcomes. Robust
governance systems are essential for implementing multisectoral nutrition interventions
and creating cost-effective and sustainable programs.

The purpose of this report is to delineate valuable lessons learned on early

implementation experiences from seven countries supported by the World Bank and the
Global Financing Facility (GFF) in operationalizing large-scale multisectoral nutrition
programs that emphasize and strengthen governance. The countries are Cambodia, the
Democratic Republic of Congo (DRC), Guatemala, Indonesia, Malawi, Nigeria, and
Rwanda. In all these countries, despite significant improvements in economic growth,
poverty, and maternal and child health outcomes over the past decades, undernutrition
remains a significant public health and development concern for women of reproductive
age and for children under five. The countries’ high rates of malnutrition point to
systemic challenges, highlighting that “business not as usual” is required to accelerate
progress.

The objectives of this report are to (i) document and synthesize implementation
experiences, challenges, and opportunities in selected countries as seen through a
nutrition governance lens; and (ii) facilitate cross-country learning. Given that the seven
countries used as examples in this report are still implementing their multisectoral
programs, the report focuses on implementation modalities and innovations rather than
outcomes at this stage.

The report uses a multisectoral governance framework, adapted from Gillespie, Van Den
Bold, and Hodge (2019), to synthesize the implementation experiences across the seven
World Bank/GFF–financed multisectoral nutrition projects. This report provides lessons
learned, organized under three broad categories. These are summarized below:
1. Advocacy, leadership, and institutional support for multisectoral nutrition
• Evidence-based advocacy for positioning nutrition improvement within a broader
development agenda. Advocacy is critical to securing and sustaining political will
and public support for a multisectoral nutrition agenda. Advocacy can be more
successful if supported by quantitative evidence that illustrates the effectiveness
of a multisectoral approach at both national and subnational levels. Knowledge-
sharing activities such as South-South knowledge exchanges are another
valuable method to advocate for and to learn from successful multisectoral
nutrition programming. Defining the composition of delegates for these types of
exchanges is critical for obtaining buy-in.

xi
 • High-level leadership, vision, and strategy for a "whole-of-government" approach.
Political commitment and high-level leadership are essential for implementing
multisectoral nutrition policies and programs through a whole-of-government
approach. The high-level vision needs to be translated into a national
multisectoral nutrition strategy and operational plan that provides the foundation
for implementing multisectoral actions at national and subnational levels. For the
countries included in this report, committed leadership at the highest levels of
government led to developing their national nutrition strategies—some of which
were designed as “Investment Cases”—a government-led participatory process
supported by the GFF to prioritize the key reforms and strategic shifts needed to
accelerate progress toward clearly defined nutrition outcomes.
• Institutional and implementation arrangements for operationalizing the
multisectoral strategy. Coordination mechanisms are essential at national and
subnational levels for vertical and horizontal coordination and collaboration and
to maximize the impact of multisectoral nutrition programs. In several countries
highlighted in this report, the national multisectoral nutrition programs are being
managed by a high-level coordination secretariat at the center of government,
typically sitting within the Prime Minister, President, or Vice President's Office
and coordinating nutrition actions across sectoral ministries. Ideally, multisectoral
platforms should be replicated and aligned from the national to the district and
subdistrict levels to effectively reach communities and vulnerable households.
2. Management capacity and financing
• Management capacity and accountability systems at the subnational level. For
many countries, there are gaps in translating national Multisectoral Nutrition
Plans to the district level. Given that more countries are decentralizing service
delivery to the local level, national governments must establish a coordinated
approach to improve subnational capacity to manage their multisectoral
programs from the district to the community level. Some national programs
include results conferences and performance contracts to ensure commitment
and build management capacity and accountability at the subnational levels.
Technical assistance, knowledge platforms, and financing are also being
provided in some countries to strengthen the subnational capacity to work
multisectorally.
• Integrating multisectoral nutrition programming into regular planning and
budgeting processes to ensure sustainable financing. To ensure that priority
interventions identified in the Multisectoral Nutrition Plan (MNP) are adequately
financed, the MNP needs to be linked to government planning and budgeting
processes. To monitor the implementation of MNP priorities and ensure that the
funds are allocated efficiently, tracking multisectoral nutrition spending is crucial,
as countries cannot manage or improve what they do not measure even if
coordination efforts are in place. In recent years, there have been efforts to better
capture nutrition spending across sectors. Institutionalizing budget tracking and
budget evaluation requires strengthening the public financial management
system.
• Leveraging results-based financing to drive results. Results-based financing
(RBF) has emerged as a promising approach to incentivize multisectoral

xii
 coordination and accountability for improved nutrition and stunting reduction.
Several countries highlighted in this report use innovative RBF mechanisms at
the central and subnational levels to incentivize governments to manage and
implement multisectoral nutrition interventions.
3. Results measurement, monitoring, and accountability
• Strengthening performance monitoring systems and promoting the use of data to
improve program implementation. Improving the availability of quality and timely
nutrition data and performance monitoring systems is key to enhancing program
implementation, informing decision making, enabling course correction, and
enhancing the accountability of multisectoral programs. The governments of
several countries highlighted in this report invest in interactive, interoperable, and
agile monitoring systems that routinely collect quality outcomes, output and input
indicators, and track the convergence of priority nutrition services. Furthermore,
the monitoring data are being used for program implementation and course
correction.
• Citizen engagement, community mobilization, and social accountability.
Community-based engagement models should be part of the national
multisectoral strategy and its coordination platforms. Communities need to be
integrated into a larger Social Behavior Change Communication (SBCC) effort
that works at all levels of government and uses multiple delivery channels.
Numerous World Bank/GFF–cofinanced projects actively engage communities in
their multisectoral nutrition interventions and are encouraging local participation
in setting nutritional goals, demanding accountability through community data
and scorecards. Projects are also implementing SBCC to positively influence
knowledge, attitudes, and norms to improve nutrition behaviors and outcomes.

The report concludes with a “Looking Ahead” section that focuses on the continued need
for investment in data quality and data systems. High-quality data are the foundation for
better understanding of (i) the impact of multisectoral governance approaches on
delivery and quality of nutrition-specific and nutrition-sensitive services; (ii) financing
sustainability and financing efficiency; and (iii) the impact of interventions on nutrition
outcomes. Investments to improve monitoring and evaluation (M&E) include the
following:
• Strengthening routine data systems that enable continuous feedback on the
population's nutritional status, service coverage/utilization, and quality of care.
• Improvement of national Integrated Financial Management Information Systems
(IFMIS) to enable tagging and trackingof nutrition spending across sectors and levels
of government (national and subnational).
• Investments in technologies that improve the collection and availability of high-quality
nutrition data, including those that enhance the interoperability and/or consolidation
of different sectoral and regional data systems (e.g., through digital dashboards and
platforms such as mobile phones).
• Implementation research to measure programmatic and implementation processes
including the following:
o The impact of the governance interventions on process outcomes such as
improved knowledge, skills, and coordination among management to

xiii
 operationalize multisectoral programs and improved nutrition-related
services.
o Sectoral capacity to implement multisectoral interventions at national and
subnational levels and factors or implementation arrangements that enhance
different sectors’ abilities to maintain minimum quality standards.
o Diagnostic analysis to identify suitable entry points to enhance convergence,
including integrated planning and budgeting, targeting, delivery platform,
monitoring systems, community mobilization, and peer learning.
o Budget evaluations review to improve the methodology for robust budget
evaluations to generate recommendations on efficient resource allocations for
nutrition, including a clear theory of change as a basis for assessing spending
against performance.
o Citizen engagement and social accountability to strengthen community-level
decision-making and accountability processes to strengthen the demand for
quality services and enhance program course corrections.
• Impact evaluations on the following:
o Impacts of efforts to enhance the quality of nutrition services: Analyze the
effect of efforts and mechanisms to improve the quality of multisectoral
nutrition interventions. Outcomes include improved health, competent health
care providers, positive user experiences, equity of care, and economic
benefits.
o Mix of nutrition interventions for convergence: Conduct impact evaluations to
understand better which combination of nutrition-sensitive and nutrition-
specific interventions can impact nutrition and its immediate determinants in
different contexts.

Lastly, the report recommends improving the use of data to achieve the following:
• Strengthen the alignment of multisectoral programming priorities with country
planning and budgeting processes to improve oversight of nutrition budgets across
sectors, secure financing from domestic resources, and course-correct program
implementation.
• Enhance the capacity at all levels to understand, analyze, and use data for decision
making.
• Improve documentation and dissemination of data from routine M&E systems,
including through improved multisector nutrition planning and programming practices
to enhance knowledge exchange and peer-to-peer learning.

xiv
 PART I – INTRODUCTION
Malnutrition continues to be one of the world's most critical health and human
development challenges, threatening countries’ Universal Health Coverage (UHC) goals
and the achievement of the Sustainable Development Goals (SDGs) (WHO 2019). Globally,
undernutrition is an underlying cause of nearly half (45 percent) of all deaths among children
under five years of age (Black et al. 2013). Childhood stunting (low height-for-age and an
indicator of chronic undernutrition) is a marker for long-term malnutrition and ill health and has
lifelong consequences including negative impacts on health, cognitive and socio-emotional
skills, and educational attainment and income, and makes children less likely to escape poverty
as adults (Shekar et al. 2016; WHO 2014). In many regions, the overlapping burdens of
undernutrition and overnutrition—or the double burden of malnutrition (DBM)—are becoming the
new normal (Shrimpton, Mbuya, and Provo 2016; Black et al. 2013). In addition, the COVID-19
pandemic has further threatened the health, social, and economic gains made for women and
children, with the potential of erasing decades of progress in nutrition.

Given the complex, multifactorial, and interlinked determinants of nutritional status and
well-being, multisectoral nutrition programming has been widely promoted as the most
effective way to address the direct and indirect determinants of malnutrition and to
improve nutrition outcomes. To be effective, however, the implementation of multisectoral
nutrition action must systematically, explicitly, and comprehensively engage and coordinate with
multiple ministries or agencies. Many governments have coordinated across sectors and
stakeholders to better address malnutrition (MQSUN+ 2020; Brown et al. 2020; Lamstein et al.
2016; Shrimpton, Mbuya, and Provo 2016; World Bank 2013; Reinhardt and Fanzo 2014). Key
initiatives supporting this approach have been endorsed by numerous donors 1 and
stakeholders, including the Scaling up Nutrition (SUN) Movement, with high-level commitments
from 62 countries; the SUN learning exchanges between its member countries; and the
Maximizing the Quality of Scaling Up Nutrition (MQSUN+) Project that provides flexible technical
assistance for nutrition policy and programming.

Robust governance systems are essential for implementing multisectoral nutrition

interventions and creating cost-effective and sustainable programs (Acosta and Fanzo
2012). According to the World Health Organization (WHO), leadership and governance are
among the most complex and critical of the six health system building blocks. Enhanced
governance systems are key to achieving and sustaining improvement across the other five
building blocks: service delivery; health workforce; financing; health information systems; and
medical products, vaccines, and technologies. To date, only a few studies have focused on the
role of governance in scaling up and sustaining multisectoral nutrition interventions at both
national and subnational levels (MQSUN+ 2020; SNV et al. 2017; Pelletier et al. 2018; Acosta
and Fanzo 2012; Kennedy et al. 2015). Given the increased global interest in operationalizing
multisectoral nutrition interventions, there is an urgent need to provide practical knowledge on
designing, strengthening, implementing, and monitoring and evaluating effective systems
interventions, highlighting the role of policy implementation and governance (Pelletier et al.
2018).

1
USAID Food and Technical Assistance III Project (FANTA); USAID, the Strengthening Partnerships, Results, and
Innovations in Nutrition Globally (SPRING) Project; USAID, Feed the Future; UK Department for International Development’s
Transform Nutrition, Global Alliance for Improved Nutrition.
 PURPOSE AND OBJECTIVES OF THE REPORT

The purpose of this report is to complement existing findings and key learnings by
highlighting important lessons learned from selected countries in operationalizing large-
scale multisectoral nutrition approaches that emphasize and strengthen governance.
“Governance for nutrition” was recently defined by Gillespie, Van Den Bold, and Hodge (2019)
as “the process by which impact on nutrition by nonnutrition policies (e.g., in agriculture,
education, employment, health, environment, and trade) is leveraged or mitigated.” Improving
governance is central to promoting sustainable financing practices, maximizing public service
delivery's impact, building confidence in institutions, and building better data and analytics in
client countries, which can be used for evidence-based decision making.

The paper delineates valuable lessons on early implementation experiences through a

systems approach across sectors from seven countries supported by the World Bank
and Global Financing Facility (GFF) in operationalizing large-scale multisectoral nutrition
programs that emphasize and strengthen governance. The projects are in Cambodia, the
Democratic Republic of Congo (DRC), Guatemala, Indonesia, Malawi, Nigeria, and Rwanda.
Their multisectoral government-led nutrition programs are unique because they present new
ways of approaching and solving problems by focusing on critical underlying service delivery
and by financing bottlenecks that often lie outside the health sector. Essential features of these
large-scale nutrition programs include incentives to enhance the enabling environments through
government reforms in critical areas, including public financial management (PFM), creating
performance-based financing (PBF) schemes linked to scorecards to hold heath facilities or
communities accountable for results, and upgraded data systems. This requires doing “business
not as usual” through innovative tools and policy instruments.

The objectives of this report are to (i) document and synthesize implementation
experiences, challenges, and opportunities in selected countries as seen through a
nutrition governance lens; and (ii) facilitate cross-country learning. Given that the seven
countries used as examples in this report are still implementing their multisectoral programs, the
report focuses on documenting progress and lessons learned on implementation modalities and
innovations rather than highlighting impact at this stage.

The report draws on a desk review of the current literature on multisectoral nutrition
interventions and the role of governance in carrying out these interventions. In addition, a
detailed review was conducted of World Bank project documents from the seven case countries
in this report, and interviews were held with World Bank project leaders and technical specialists
working on these projects. The seven countries receive financing, technical assistance (TA),
and analytical support from the World Bank and the GFF to roll out and implement their large-
scale, government-led multisectoral nutrition programs. The World Bank/GFF TA and analytics
are extensive and cover knowledge-sharing, diagnostics to inform evidence-based advocacy,
project design and formulation, and support for implementation and monitoring and evaluation
(M&E)—all of which are critical for scaling up each country’s program.

The report is structured as follows: Part II summarizes the rationale for a multisectoral
approach to nutrition and outlines key challenges in operationalizing a multisectoral approach.
Part III presents a multisectoral nutrition governance framework. Part IV offers lessons learned
from early implementation experiences and recommendations on how to improve multisector
policy and programming. Finally, Part V discusses key M&E issues that governments, donors,
and program planners may want to consider when moving forward with implementing such

2
programs. The report's target audience is internal and external, including policy makers in
countries, the broader development community, and the World Bank and GFF staff.

PART II – WHY IS A MULTISECTORAL APPROACH TO NUTRITION

IMPORTANT?
A multisectoral approach to nutrition is not a new concept. However, in the last decade,
there has been a renewed interest in using such an approach to address malnutrition and
its underlying causes across the life course. Multisectoral nutrition programming became of
interest as early as the 1970s, with the realization that no one sector can improve nutrition
alone. This resulted in numerous countries creating multisectoral nutrition planning units so that
other sectors could reorient a portion of their activities to better address the causes of
malnutrition. At the time, these attempts were too ambitious and did not work because of many
sectors' unwillingness to participate (Levinson, Balarajan, and Marini 2013). In 1990, the United
Nations Children's Fund (UNICEF) created a conceptional framework that demonstrates child
undernutrition's multisectoral nature, which in turn necessitates interventions to address the
immediate causes of malnutrition—inadequate dietary intake and infectious diseases— through
nutrition-specific interventions, as well as the underlying causes that are rooted in many other
sectors—water and sanitation, social protection, early childhood development (ECD), schooling,
and agriculture, through "nutrition-sensitive" interventions (Ruel and Alderman 2013).

A focus on both the direct and underlying causes of malnutrition is needed to make a
significant long-term impact (Levinson, Balarajan, and Marini 2013; Brown et al. 2020; Black
et al. 2013). During the last decade, there has been a renewed interest in a multisectoral
approach to malnutrition. It has been promoted as the most effective way to strengthen
nutritional outcomes by (a) accelerating action on determinants of malnutrition; (b) integrating
nutrition considerations into programs in other sectors that may be substantially larger in scale;
and (c) increasing "policy coherence" or "government-wide attention to policies or strategies and
trade-offs, which may have a positive or unintended negative consequence on nutrition" (World
Bank 2013; Gillespie, Van Den Bold, and Hodge 2019; MQSUN+ 2020; SNV et al. 2017; Brown
et al. 2020).

Furthermore, analyses from countries that have achieved dramatic acceleration in the
reduction of child stunting in recent decades point to the importance of intervening
beyond the health sector and to the critical role of governance for enabling such
improvements. For example, in five countries studied by Bhutta et al. 2020 (Ethiopia, the
Kyrgyz Republic, Nepal, Peru, and Senegal), investments in nonhealth sectors were estimated
to contribute to anywhere between 36 and 70 percent of stunting reduction (median 47 percent),
while interventions in the health sector contributed to an estimated 20–64 percent (median 37
percent) (Bhutta et al. 2020). The presence of strong governance and supportive sectoral
strategies are more difficult to quantify in their contribution to stunting reduction but are
nevertheless seen as essential for enabling and accelerating equitable and large-scale
improvements in nutrition (Bhutta et al. 2020).

3
 TYPES OF MULTISECTORAL APPROACHES

Over the years, multisectoral nutrition interventions have been implemented in different
ways, and there are various interpretations of how such interventions can be
operationalized in practice. On one side of the spectrum are programs where sectors outside
of health have added activities to be more nutritionally focused, nutrition-sensitive, or at a
minimum, to minimize potential harm. On the other, some programs comprehensively involve
multiple ministries or agencies to address malnutrition (Lamstein et al. 2016).

One approach that has emerged as a promising model for operationalizing multisectoral
nutrition programs is convergence, whereby coordinated multisectoral nutrition-specific
and nutrition-sensitive interventions are jointly targeted in selected geographical areas
and at the most vulnerable low-income populations. This approach has been successfully
applied in several countries, including Bangladesh, Brazil, Indonesia, and Peru. Emerging
evidence indicates the convergence approach has considerable potential to accelerate
improvements in child health and development outcomes (Levinson, Balarajan, and Marini
2013; World Bank and the Republic of Indonesia, MoH 2017). For example, in part due to a
significant multisectoral nutrition effort, child stunting rates in Peru fell by almost half in less than
a decade (2008–2016). Key factors behind Peru's success include political will and commitment
at the highest level (President's Office); broad social participation; a coordinated multisectoral
program that included health, nutrition, early childhood education and development (ECED),
water, sanitation, and hygiene (WASH), and social protection interventions; geographic
targeting to vulnerable low-income populations; performance-based budgeting; and alignment of
incentives for households, health facilities, and local government. Another critical feature of
Peru's success was convincing policy makers, public officials, and parents of the importance of
early childhood interventions to encourage them to tackle the malnutrition problem. Finally, a
credible data information system, clear and achievable targets, and a monitoring and evaluation
system also contributed to the program's success.

CHALLENGES IN OPERATIONALIZING THE MULTISECTORAL APPROACH

While the multisectoral approach is conceptually appealing, it is challenging to

operationalize in practice. Reviews of multisectoral nutrition interventions over the last decade
highlight numerous challenges and bottlenecks to operationalizing such an approach
(Shrimpton, Mbuya, and Provo 2016; Brown et al. 2020; Menon et al. 2019; Lamstein et al.
2016; Acosta and Fanzo 2012).

1. Leadership, coordination, and collaboration. Implementing multisectoral approaches

requires sustained and robust leadership and champions at national and subnational
levels (Shrimpton, Mbuya, and Provo 2016; Acosta and Fanzo 2012). However, a recent
strategic review of the SUN Movement found that multisectoral nutrition responses can
be affected by high turnovers of political appointees (SUN Movement 2020). In addition,
leadership, coordination, and collaboration challenges can stem from a lack of
awareness among national and subnational stakeholders of the importance of nutrition
on development, collaboration benefits, or fragmented institutional arrangements. They
can also be related to difficulties in achieving broad stakeholder engagement across a
diverse set of stakeholders who may not always speak the same technical language or
have the same goals in mind (Acosta and Fanzo 2012). As illustrated by the review of
SUN, while ideally, programs should be “country-driven and country-led,” the agenda of

4
 multilateral entities and donors often have considerable influence (SUN Movement
2020).

2. National multisectoral policy framework. A national multisectoral nutrition policy and

strategy/plan is vital for promoting policy coherence for nutrition across sectors.
According to the 2019 SUN annual progress report, across the 61 SUN Movement
countries, 42 countries had a multiyear national nutrition plan, bringing together sectors
and stakeholders in a “whole-of-government” approach to address malnutrition (SUN
2019). It is unclear how many of these are being implemented at scale. Research
demonstrates that some country plans simply bring together sector-specific activities
under a single strategy to scale up implementation rather than introduce new activities.
This can undermine the value-added of multisector collaboration (MQSUN+ 2020). Also,
many national Multisectoral Nutrition Plans have not been costed or integrated into
existing planning and budgeting processes at the national or subnational level.

3. Subnational implementation. There are often gaps in understanding national

Multisectoral Nutrition Plans at the subnational level. Ideally, national plans should be
translated into district- or community-level action plans and have institutional
coordination mechanisms, which is not always the case and affects the various sectors'
ability to work together (Brown et al. 2020; SNV et al. 2017; MQSUN+ 2020). In addition,
the subnational level cannot often manage multisectoral programs.

4. Sustainability of supporting systems. Sustaining the operationalization of the

multisectoral program can be potentially challenging. Often donors or movements such
as SUN provide the capacity, funds, and/or incentives to establish the structures for
multisector and multistakeholder national nutrition responses. However, if these
programs are to be sustainable, they must continue to be funded and supported by the
government in the country (SUN Movement 2020). In addition, sustainability can also be
influenced by changes in leadership within countries, organizational structure, or the
reallocation of financial priorities.

5. Financing. Several bottlenecks to financing multisectoral nutrition services exist.

Globally, there are insufficient resources for nutrition, and there is a need for increased
government spending to fill the gap (Shekar et al. 2016). Moreover, the financing
landscape for nutrition is complex and fragmented, with funding coming from different
channels coordinated by multiple agencies and ministries. Financing requires a
commitment from the minister of finance, as well as from key technical sectors. Yet, at
the devolved administrative level, budgeting and decision-making capacities can be very
limited (Brown et al. 2020). Also, there is a shortage of nutrition financing data and
financial tracking systems for nutrition, resulting in low accountability for delivering
nutrition services (Brown et al. 2020; Lamstein et al. 2016). A lack of clear financial
incentives to work across sectors remains a barrier to multisectoral collaboration,
particularly among nutrition-sensitive sectors (MQSUN+ 2020).

6. A mix of high-impact interventions. National multisectoral policy frameworks can be

hampered by the general lack of clarity about which combination of sectors and mix of
interventions can achieve the most significant impact and about which groups to target
(Brown et al. 2020). While most Multisectoral Nutrition Plans target pregnant women and
children under two years (the "first 1,000 days"), other important groups, for example,
adolescents, are not always included in plans and programming (Brown et al. 2020).

5
 Also, many countries and regions do not yet have the knowledge and evidence needed
to effectively target the increasing problem of overweight/obesity and the double burden
of malnutrition (Brown et al. 2020; Shrimpton, Mbuya, and Provo 2016). Furthermore,
and given the implementation of nutrition actions across sectors, clear, concise, and
nationally standardized and implemented messaging on nutrition that all sectors and
actors deliver is fundamental. Very few countries, however, benefit from such policies.

7. Organizational capacities and human resources. Challenges can include a lack of

technical knowledge and skills to operationalize large-scale nutrition programs at the
administrative level as well as of the human resources and capacity required to carry out
these programs (Brown et al. 2020; Baker et al. 2018). Among health workers,
engagement levels across sectors are often related to the availability of nutrition staff or
focal points (MQSUN+ 2020). Also, frontline health workers’ competencies in nutrition
can be limited, and their responsibilities are often not fully explained in their job
descriptions (Shrimpton, Mbuya, and Provo 2016).

8. Monitoring, evaluation, and accountability. Many country Multisectoral Nutrition Plans

lack a robust monitoring and evaluation framework and performance metrics (Brown et
al. 2020). Data for multisectoral performance monitoring are not always available, and
there is a lack of indicators that measure results from such programs (Shrimpton,
Mbuya, and Provo 2016; Brown et al. 2020). Metrics measuring key approaches such as
governance, coordination/collaboration, training, and application of information from
training are usually not measured (Brown et al. 2020). A robust data system is needed to
drive accountability from various stakeholders (Brown et al. 2020; Menon et al. 2019).

PART III – NUTRITION GOVERNANCE FRAMEWORK

Figure 1 shows the framework we use to synthesize the implementation experiences
across the World Bank/GFF–financed multisectoral nutrition projects. The framework is
based on a 2018 systematic review by Gillespie, Van Den Bold, and Hodge (2019) of nutrition
and the governance of agri-food systems in South Asia. The framework depicts several
dimensions deemed necessary, and often interrelated, to ensure strong multisectoral nutrition
governance. These dimensions include political commitment and power authority, leadership,
accountability, policy coherence, data for knowledge and advocacy, and capacity (Gillespie, Van
Den Bold, and Hodge 2019). Predictable and sustainable financing is a dimension that receives
much attention in this document and has thus been added to the existing framework. Lastly, the
importance of intersectoral cooperation across government sector stakeholders and vertical
coordination among different government levels highlighted in Acosta and Fanzo’s (2012)
governance framework is incorporated under Gillespie and colleagues’ policy coherence
dimension.

To simplify the framework, we subdivided the dimensions into three categories: (1)
Advocacy, leadership, and institutional support for multisectoral nutrition; (2) Management
capacity and financing; and (3) Results measurement, monitoring, and accountability.

6
Figure 1: Multisectoral Nutrition Governance Framework

Source: Adapted from Gillespie, Van Den Bold, and Hodge 2019.

Advocacy, leadership, and institutional support for multisectoral nutrition

• Political commitment and power authority. As stated by Gillespie, Van Den Bold, and
Hodge (2019), this dimension includes not only the political will to engage in
multisectoral governance but also the commitment by high-level leadership to make
changes in “institutional procedures, incentives, decisions and actions
(system/institutional commitment) that lead to new actions and possibly to new
budgetary or financial commitments.”
• Leadership. Leadership and commitment for a multisectoral approach to nutrition from
the highest government levels to communities are essential for implementing policies
and programs.
• Policy coherence. This dimension includes not only the need for a multisectoral
nutrition strategy but also intersectoral policy coherence and coordination across various
sectors (i.e., “horizontal” coordination) and legal frameworks to facilitate coordination
“vertically” among different levels of government (Gillespie, Van Den Bold, and Hodge
2019).

7
Management capacity and financing
• Accountability/Transparency. Accountability relates to clear and transparent roles and
responsibilities for actions across multiple stakeholders from national to community
levels through coordination platforms (Gillespie, Van Den Bold, and Hodge 2019),
operating both horizontally and vertically. Accountability can be measured by results-
based approaches that use incentives to promote improved performance accountability
across different levels of implementation or nutrition action (e.g., health facilities, district-
level, ministry-level, etc.). A combination of results-based approaches and their
alignment across service providers, households, local governments, and communities in
the same geographical area is ideal for incentivizing actions at multiple levels to support
nutrition improvements.
• Capacity. The capacity of stakeholders to manage their multisectoral programs from the
national to subnational and community levels is critical and requires strong program
planning and management skills, including program planning, budgeting, coordination,
supervision, and monitoring. Capacity includes institutional coordination mechanisms or
“platforms” from the national to subnational levels to enable coordination and
collaboration horizontally and vertically. Also necessary is stakeholders’ technical
capacity to implement quality multisectoral interventions.
• Predictable and sustainable financing. The availability of predictable, adequate, and
timely financing to support multisectoral nutrition initiatives is essential. This dimension
can impact multisectoral cooperation and facilitate or obstruct the implementation of
nutrition policies across government levels. It includes a robust nutrition-responsive
public financial management system to identify funding and spending gaps and
effectively manage spending across multiple agencies from multiple funding sources.

Results measurement, monitoring, and accountability

• Data for knowledge and advocacy. Timely and reliable data on trends of malnutrition
indicators are essential to raise “knowledge” and enable governments to monitor
nutrition-related impact and cost of nutrition interventions and gaps in interventions, set
targets, and measure progress (Gillespie, Van Den Bold, and Hodge 2019; Acosta and
Fanzo 2012). Data are also an important advocacy tool. Data have been used to make a
case for government leaders to invest in a multisectoral nutrition approach. Data can
also be used for community engagement and accountability (e.g., through community
scorecards) on a community level.

PART IV – LESSONS LEARNED FROM EARLY IMPLEMENTATION

EXPERIENCES
The eight lessons learned from early World Bank and GFF implementation experiences
presented in this report are grouped according to the three general categories of the
governance framework. The categories are, as follows:
1. Advocacy, leadership, and institutional support for multisectoral nutrition

8
 • Evidence-based advocacy for positioning nutrition improvement within a broader
development agenda
• High-level leadership, vision, and strategy for a whole-of-government approach
• Institutional and implementation arrangements for operationalizing the
multisectoral strategy
2. Management capacity and financing
• Management capacity and accountability systems at the subnational level
• Integrating multisectoral nutrition program into regular planning and budgeting
process
• Leveraging results-based financing to drive results
3. Results measurement, monitoring, and accountability
• Strengthening performance monitoring systems and promoting the use of data to
improve program implementation
• Citizen engagement, community mobilization, and social accountability

To the extent possible, lessons are meant to respond to some of the challenges
identified in Part II and to clarify how the dimensions in the report’s framework were
implemented in “real-life” settings. Furthermore, these lessons are drawn from early
implementation experiences in selected countries that include Cambodia, DRC, Guatemala,
Indonesia, Malawi, Nigeria, and Rwanda. Annex 1 provides a broad overview of the program
features by each country, which are further explained in each part of the report.

In all these countries, as seen in Figure 2 below, despite improvements in economic

growth, poverty, and maternal and child health outcomes over the past decades,
undernutrition remains a significant public health and development concern for women
of reproductive age and children under five. Across all seven countries, stunting rates
among children less than five years old are high. Anemia prevalence among women of
reproductive age remains at medium to high levels among six of the seven countries. Wasting
rates are also medium to high in five of the seven countries. Four countries are experiencing a
rapidly rising double burden of malnutrition, with more than 5 percent of children under five
presenting with overweight and obesity. These high rates of malnutrition point to systemic
challenges, requiring a new approach to accelerate progress.

9
Figure 2: Dashboard of Key Nutrition Indicators in Selected Countries

Guatemala
Cambodia

Indonesia

Rwanda
Nigeria
Malawi
DRC
Women and Children's Nutrition Indicators

Anemia prevalence WRA (%)a 47 41 14 49* 33 50 22

LBW (%)b 12 11 15 6** 12 — 8

Stunting (% of children <5 years)c 32 43 47 28** 37 37 37

Wasting (% of children <5 years)d 10 8 1 7** 3 7 2

Overweight (% of children <5

2 4 5 8** 5 2 6
years)e

LOW MEDIUM HIGH

Source: Key nutrition indicators are based on Countdown to 2030 Country Profiles 2020. https://profiles.countdown2030.org/#/.

Notes: DRC = Democratic Republic of Congo; WRA = Women in reproductive age; LBW = Low birth weight; — = Not available.
a. Green (low) <20%; Yellow (med): 20.0–39.9%; Red (high): >=40%. Table 3, p.17:
https://www.who.int/nutrition/publications/en/ida_assessment_prevention_control.pdf.
b. Green (low) </=10%; Yellow (med): 11–19%; Red (high): >/=20%. GFF estimations. Also see UNICEF:
https://www.unicef.org/media/53711/file/UNICEF-WHO%20Low%20birthweight%20estimates%202019%20.pdf.
c. Green (low): 2.5<10%; Yellow (med): 10-<20%; Red (high): 20+%. WHO Severity Rating. See
https://www.who.int/nutrition/team/prevalence-thresholds-wasting-overweight-stunting-children-paper.pdf.
d. Green (low): 2.5-<5.0%; Yellow (med): 5-<10%; Red (high): 10+%. WHO Severity Rating. See
https://www.who.int/nutrition/team/prevalence-thresholds-wasting-overweight-stunting-children-paper.pdf.
e. Green (low): 2.5-<5.0%; Yellow (med):5-<10%; Red (high): 10+%. WHO Severity Rating. See
https://www.who.int/nutrition/team/prevalence-thresholds-wasting-overweight-stunting-children-paper.pdf.
*2018 RISKESDAS.
**2019 (SUSENAS-SSGBI).

ADVOCACY, LEADERSHIP, AND INSTITUTIONAL SUPPORT FOR MULTISECTORAL NUTRITION

Evidence-based advocacy for positioning nutrition improvement within a broader

development agenda

Background

Advocacy is critical to securing and sustaining political will and public support for a
multisectoral nutrition agenda. Advocacy efforts are most effective when they tie nutrition to

10
broader social and economic development such as poverty, inequalities, and human capital
development, thereby shifting the perspective that improving nutrition outcomes is solely the
health sector's responsibility. By doing so, commitment among numerous government
stakeholders is more likely to be obtained, including by the Ministry of Finance. Multiple
countries have shown that high-level political advocates for nutrition can drive the multisectoral
nutrition agenda forward at the national level, increase political discourse, and in some cases,
increase financing (Brown et al. 2020; MQSUN+ 2020). In addition, global and institutional
initiatives such as SUN and the Human Capital Project (HCP) which highlight the role of
nutrition in meeting SDGs and improved human capital outcomes, can be important levers to
strengthen advocacy around the importance of a multisectoral approach to address nutrition.

From national to subnational levels, advocacy is more successful if supported by

quantitative evidence that illustrates the effectiveness of a multisectoral approach.
Governments and other stakeholders need to clearly understand the causes and consequences
of malnutrition and how different sectors impact nutrition outcomes. Quantifying UNICEF’s
conceptual framework for undernutrition, for example, by using country-specific data, can assist
in obtaining political buy-in. It will help make a case for the roles and responsibilities of different
sectors outside of health to address the underlying determinants of malnutrition. Quantitative
evidence will also facilitate communication about malnutrition within and across sectors and
should be translated into clear and unified messaging across government, media, and partner
organizations (Brown et al. 2020; MQSUN+ 2020).

Knowledge-sharing activities are another valuable method to advocate for multisectoral

nutrition agendas. Experiences from countries that have successfully implemented
multisectoral nutrition programs and included details on “how” to operationalize the approach
can help motivate and convince politicians and government ministries about the value of such
programs (MQSUN+ 2020; Brown et al. 2020; Acosta and Fanzo 2012). In-person study tours,
or virtual knowledge-sharing through webinars that engage the right mix of decision makers
from enabling and technical ministries, can effectively stimulate the implementation of
multisectoral action. Ideally, knowledge-sharing activities should be supported by tailored
technical assistance to adapt the program to the country context.

Motivated and engaged advocates to raise awareness and understanding around

multisectoral approaches are critical at national, subnational, and community levels.
While government leadership at the highest levels of office can create visibility, momentum, and
oversight, active and sustained civil society advocacy is also a powerful way to raise local-level
awareness, build social commitment to multisector nutrition action, and create political
accountability (Brown et al. 2020; MQSUN+ 2020). Civil society organizations (CSOs) often
work across sectors, have a greater reach than government programs, and have a lot of
experience in implementing and understanding the causes of malnutrition (Lateef 2013). Within
SUN, the SUN Civil Society Network recently launched its five-year strategy (2021–2025), with
one of its key objectives being to “advocate for improved financial, policy, and legal action on
nutrition, and hold all stakeholders accountable” (SUN 2021).

Examples from countries

In Indonesia and Rwanda, quantitative evidence that tied stunting to critical development
agenda outcomes became an “advocacy tool” to obtain political buy-in. In Indonesia, the
opportunity for elevating the nutrition agenda to the highest level (i.e., the president and vice
president) stemmed from a powerful finding from several robust analytical studies. A 2016

11
report by the World Bank showed that Indonesia's persistently high stunting rates are related to
inequality in the country, including children’s unequal access to basic health, nutrition, and water
and sanitation services. This helped raise awareness that addressing stunting would require
moving away from viewing nutrition as a health sector issue alone to one that spans multiple
sectors (World Bank 2016). Other important findings from longitudinal data analyses
demonstrated that stunted children in 1993 had lower productivity and earnings 20 years later—
providing robust evidence for the importance of the long-term benefit of investing in early years
(World Bank 2017a). In addition, a 2017 World Bank study (using the UNICEF Framework)
conducted jointly with Indonesia’s Ministry of Health highlighted that stunting rates continue to
be high because of a lack of simultaneous or “convergent” access to the full package of
interventions that impact stunting (World Bank and the Republic of Indonesia, MoH 2017). 2 In
Rwanda, a 2017 World Bank nutrition situation analysis found that less than 4 percent of
children under two in the country have access to the three critical determinants of malnutrition
(care practices, environmental health, and food adequacy), illustrating to the government that
important gaps in the convergence of interventions needed to be addressed to have a more
dramatic impact on stunting (World Bank 2017b).

In Guatemala, the impact evaluation of the national hunger-reduction program provided

quantitative evidence that none of the nine interventions targeted to the first 1,000 days
had individual effects on children’s nutritional status. However, the combination or
convergence of five or more (of the nine) complementary activities did yield improvements in
linear growth (IFPRI 2016). Findings from this evaluation were instrumental in pushing forward
the importance of a convergence approach, which was adopted first in the 2016–2020 National
Nutrition Strategy and in the subsequent and current nutrition strategy document, the “National
Crusade for Nutrition 2020–2024.” Other key recommendations surfacing from this work
included governance considerations, for example, the need to coordinate among the various
programs and sectors implementing nutrition activities and the capacity-building underpinning
their successful implementation.

Knowledge-sharing was another advocacy tool that helped propel the multisectoral
nutrition agenda in several GFF-cofinanced countries. In Indonesia, a delegation of GoI
officials traveled to Peru to learn from the country’s success in championing stunting reduction
and to better understand how the program works on the ground (Rokx, Subandoro, and
Gallagher 2018). Defining the composition of delegates for this trip was particularly important to
obtain their buy-in. High-level sectoral ministries participated, such as the Ministry of Finance,
the Ministry of National Development Planning (Bappenas), and the Ministry of Home Affairs
(Local Government). The study tour has motivated the government to adopt several practices
that had worked in Peru, to the Indonesian context, including using a multisectoral and a results-
based approach to tackling the stunting crisis in the country and building firm commitments and
leadership (Devi 2019). The World Bank provided intensive follow-up technical assistance to
adapt the lessons learned to the Indonesian context and immediately started working with the
government to develop the multisectoral nutrition program.

2
The study found an upward shift in the growth faltering curve in the first 24 months of age, depending on children’s access
to none, one, two, and three or four drivers of the UNICEF Conceptual Framework on Malnutrition.

12
Similarly, the Rwanda delegation also traveled to Peru to understand how Peru accelerated its
stunting reduction progress, including necessary institutional arrangements and accountability
systems. In Cambodia, a Cambodian delegation of officials from the Ministry of Health, Ministry
of Finance, and the National Committee for Sub-National Democratic Development Secretariat
(NCDDS) conducted a study tour in Indonesia, looking at the implementation of the National
Strategy to Accelerate Stunting Prevention (StraNas). The tour allowed the delegation to learn
about implementation at the subnational level and helped with relationship-building and a
stronger degree of comfort in collaborating and coordinating with the government counterparts
who participated.

High-level leadership, vision, and strategy for a “whole-of-government” approach

Background

Political commitment and high-level leadership are essential for implementing

multisectoral nutrition policies and programs through a whole-of-government approach.
A synthesis paper of government nutrition strategies in six countries found that executive
leadership from the president or prime minister was critical for incentivizing actions across
different sectors and government levels (Acosta and Fanzo 2012). In Peru, for example, strong
political commitment to stunting helped halve its rate of stunting from around 28 percent in 2008
to 13 percent in 2016. Stunting became a political priority and was seen as a serious challenge
to human development, even under numerous successive governments (Marini and Rokx
2017). A recent review of 14 case studies on multisectoral nutrition policy and programming
found that in several countries, high political visibility was essential to leverage buy-in to
improve nutrition outcomes (Pakistan, El Salvador, and Benin) (MQSUN+ 2020).

The high-level vision needs to be translated into a national strategy and operational plan
that provides the foundation for implementing multisectoral nutrition actions at national
and subnational levels. This involves the development and implementation of a government-
led, prioritized, and costed national strategy/plan that lays out the pathway to scaling up
universal access to a basic package of high-impact multisectoral interventions along with critical
health financing and system reforms to resolve underlying service delivery challenges. The
national plan/strategy identifies the key reforms and strategic shifts needed to accelerate
progress toward clearly defined outcomes, emphasizing implementation (the “how”) across
various government levels. It includes a well-founded intervention logic behind individual
initiatives and the program as a whole. The strategy/plan should contain essential elements: a
description of what a country wants to achieve—the intended results; a set of priority, costed
investments that will put the country on the trajectory to attain the desired results; a clearly
defined resource envelope to fund these priorities; and a description of how the desired results
will be monitored and evaluated. Ideally, cross-sectoral partners should be consulted in
developing the plan at both national and subnational levels (Kennedy et al. 2015). Recently, the
MQSUN+ has developed guidance and tools on multisectoral planning and developing a policy
framework for nutrition (MQSUN+ n.d.).

Examples from countries

Governments in Indonesia, Rwanda, Nigeria, Cambodia, and Guatemala have shown

political commitment at the highest level of leadership to addressing nutrition
multisectorally. In Indonesia, the strong political will and commitment to enhancing its human
capital, triggered by evidence-based advocacy and effective peer learning, resulted in the high-
13
profile launch of its nutrition program in 2017 and endorsement of the program by the President
and the Vice President’s Office. This represents significant progress in operationalizing the
government’s commitment when it joined Scaling Up Nutrition (SUN) in 2011. Similarly, in
Rwanda, the president has committed to assigning integrated early childhood development
(IECD) among the country’s priorities by forming a high-profile National Early Childhood
Development Program (NECDP). In Guatemala, when the new administration took office in
January 2020, the president demonstrated his commitment to more comprehensively and
directly tackling the country's nutrition challenges, which was supported by his unveiling of the
new national nutrition strategy, the “National Crusade for Nutrition 2020–2024” (see Box 1). In
Cambodia, the Council for Agriculture and Rural Development (CARD), chaired by the deputy
prime minister, is responsible for oversight and stewardship of the country’s multisectoral
approach to nutrition. In Nigeria, the National Council for Nutrition, approved in 2007 to be the
highest coordinating body for food and nutrition, is chaired by the vice president of the country
and is responsible for addressing nutrition multisectorally.

Committed leadership at the highest levels of government led to developing the national
nutrition strategies in the seven countries included in this report. Some of these strategies
were designed as “Investment Cases” (IC) 3 that identify a whole-of-government approach to key
reforms and strategic shifts needed to accelerate progress toward clearly defined outcomes.
The IC emphasizes implementation (the “how”) across various government levels. Each
investment case defines the theory of change, prioritized interventions, strategies, and a results
framework. Development of these investment cases involved intensive reviews of evidence
informing what priority interventions to include in the interventions package. Consultations were
also held with a broad set of stakeholders at national, district, and community levels to prioritize
interventions and develop a comprehensive M&E plan. The collaborative work promoted the
coordination and harmonization of stakeholders’ support for the government programs. The
Indonesia, Rwanda, and Guatemala national nutrition strategies all highlight the need for a
multisectoral approach to improving nutrition outcomes across different sectors. In Indonesia
and Rwanda, the investment cases include references to strengthened public financial
management systems, performance monitoring systems, and community engagement, which
are critical for implementation. They also clearly specify the roles and responsibilities of different
stakeholders, including the local government. Additional details about each strategy are listed in
Box 1.

3
The IC was developed as part of the GFF process—the IC development involves a participatory approach to develop a
government-led, prioritized, and costed plan that outlines priority interventions, defines concrete results, and lays out the
pathway to scaling up universal access to a basic package of RMNCAH-N services along with critical financing and delivery
system reforms.

14
Box 1 Multisectoral Nutrition Strategies

• In Indonesia, the National Strategy to Accelerate Stunting Prevention (StraNas) (2018–2024) brings
solid evidence-based analytical support from the World Bank and global partners for a multisectoral
approach to preventing stunting. This evidence base is acknowledged and owned by key government
counterparts. To date, StraNas has committed 23 ministries to increase the impact of $14.6 billion of
government spending over six years or to increase the impact of $4 billion of government spending
each year by converging priority nutrition interventions across health, water, and sanitation; early
childhood education; social protection; and food security. Its implementation framework explicitly
recognizes the multiple delivery systems at multiple government levels that need to be mobilized and
connected to sustainably reduce the incidence of stunting. It identifies the intended results (stunting
reduction acceleration), priority investments (convergence of nutrition-specific and nutrition-sensitive
interventions on 1,000-day households), available resources (central, district, and village spending),
and monitoring and evaluation arrangements.
• For Rwanda, the National Early Childhood Development Program (NECDP) (2018–2024) National
Strategic Plan (NSP), approved in 2019, promotes a “convergence” approach toward integrated early
childhood development (IECD). It is designed to increase access to quality early childhood
development services and address existing gaps in implementation among various sectors, including
education; social protection; food security; and water, sanitation, and hygiene (WASH). It includes key
service delivery, governance, and financing reforms to enable effective implementation (NECDP
2018).
• In Guatemala, the National Crusade for Nutrition 2020–2024 is among the few national nutrition
strategies that takes a holistic approach toward nutrition improvement instead of focusing solely on
undernutrition or overnutrition. The strategy aims to improve nutrition for all citizens, emphasizing
specific population groups such as children (under five, preschool, and school-age), women of
reproductive age, and populations living in rural areas, of indigenous ethnicities, and living in extreme
poverty. The strategy includes activities in five key sectors (health; water, sanitation and hygiene;
social protection; social and behavior change; and agriculture), with five priority areas including
improvements in (1) chronic malnutrition and anemia; (2) maternal and child morbidity and mortality;
(3) food and nutrition security, including access to nutritious foods; (4) primary health care; and (5)
prevention of chronic and infectious disease.

Source: Authors

Institutional and implementation arrangements for operationalizing the multisectoral

strategy

Background

Multisectoral nutrition programs necessitate formal institutional coordination and

implementation arrangements. Ideally, a multisectoral nutrition strategy needs to outline
which coordinating body at the central level is responsible for overall coordination and oversight
of the program and how this body will be financed. It should also explain how the program will
be coordinated vertically (between the national and various subnational levels) and horizontally
(across sectors within national and subnational levels). In addition, the coordination section of
the strategy should provide specific objectives and indicators and a monitoring and evaluation
system to hold actors accountable for coordination.

15
Coordination “platforms” at national and subnational levels are essential for this vertical
and horizontal coordination and collaboration and to maximize the impact of
multisectoral nutrition programs (see Figure 3). These multisectoral platforms (MSPs)
optimally include different sectoral ministries at the national level and a broader range of
stakeholders encompassing donors and representatives of civil society, the private sector, UN
agencies, and academia. A coordination secretariat manages many multisectoral programs at
the center of government, supporting the political leadership managing the program,
coordinating cross-agency leadership meetings, and providing guidance and support to
implementing agencies.

Ideally, multisectoral platforms should be replicated and aligned from the national to the
district and subdistrict levels to reach communities and vulnerable households
effectively. At the subnational level, existing platforms can be used to build multisector nutrition
interventions (Acosta and Fanzo 2012; Brown et al. 2020; Kennedy et al. 2015). Establishing
effective subnational coordination platforms may entail involving line ministries to provide
incentives and hold local governments accountable for implementing multisectoral programs.

Figure 3: Good Nutrition Accountability Needs Vertical and Horizontal Coordination

across Government Entities

Source: Authors

Note: The above figure is illustrative; there may be many more sectors involved.

For multisectoral nutrition platforms to succeed, addressing institutional and capacity

aspects is paramount. It requires tackling challenges related to technical capacity,
organization, and coordination. Regarding technical capability, stakeholders at the national and
subnational levels may need to be made more aware of the causes and consequences of

16
malnutrition in different sectors. Successful platforms also may require recruiting qualified staff
and building technical capacity and expertise. Key features of the coordination secretariat at the
central level are providing technical assistance to implementation agencies to help “de-
bottleneck” significant program problems and share emerging good practices around agencies
at a technical and/or leadership level. Regarding organization, there needs to be a clear
delineation of roles and responsibilities in designing and implementing strategies and
interventions. This requires developing job descriptions that spell out platform members’
responsibilities, including supporting coordination efforts (Brown et al. 2020). Additional
information about management capacity at the subnational level is provided below.

Examples from countries

In several countries highlighted in this report, the national multisectoral nutrition

programs are being managed by a high-level coordination secretariat at the center of
government, typically sitting within the Prime Minister, President, or Vice President's
Office. The coordination tasks differ from country to country. Still, most units provide some or all
of the following functions: supporting the political leadership managing the program,
coordinating leadership meetings across various agencies, providing technical assistance to the
implementing agencies, and sharing good technical and leadership practices of agencies. In
Indonesia, the Vice President’s Office is leading the multisectoral coordination body, Tim
Percepatan Penurunan Stunting, along with the 23 line ministries to converge 28 priority
nutrition interventions to “1,000-day households” in more than 360 out of 514 districts, with the
goal of scaling up nationwide. In Rwanda, coordinating implementation of the National Early
Childhood Development Program (NECDP) is the responsibility of the Ministry of Gender and
Family Promotion, with oversight by the President’s Office, and is supported by the Social
Cluster Ministerial Committees. In Guatemala, the Secretariat for Food Security and Nutrition,
under the Office of the President, is responsible for coordinating, integrating, and monitoring
food security and nutrition interventions that are laid out in the National Strategy for Reducing
Malnutrition across several key ministries. In Nigeria, the multisectoral nutrition programs are
being coordinated by the Ministry of Finance, Budget, and National Planning. Policy decisions
are taken by the National Council on Nutrition and implemented by the implementing sectors
through the National Committee on Food and Nutrition. In Malawi, the Department for Nutrition,
HIV, and AIDS once sat at a supraministerial level but was reabsorbed into the Ministry of
Health. Despite the modification in its placement, it continues to be responsible for oversight,
strategic leadership, policy direction, coordination, resource mobilization, capacity-building,
quality control, and monitoring and evaluation of the national nutrition response. It is also
supported by three committees (Cabinet, Parliamentary, and Principal Secretaries), which play
an oversight role, ensuring that respective sectors are implementing nutrition interventions
according to each sector’s mandate, roles, and responsibilities, as agreed in the National
Multisector Nutrition Policy and Strategic Plan (NMNPSP) 2018–2022 (Government of Malawi
2018).

In addition to the national level, these countries’ multisectoral implementation

arrangements include linkages between the national and subnational levels. For Indonesia
and Rwanda, these platforms, or institutional arrangements, are described in their nutrition
strategies and have information on coordination strategies, monitoring, reporting, accountability
systems, and funding frameworks. In Rwanda, for example, the central level platform's role is to
conceptualize policies and strategies, liaise with other ministries (e.g., education, health,
agriculture, etc.), mobilize resources, coordinate all interventions, and provide technical
assistance to the district level to operationalize and implement programs. At the district level,

17
the District Plan to Eliminate Malnutrition (DPEM) Committee is responsible for planning and
coordinating multisector participation in joint IECD activities; monitoring the implementation of
interventions; and ensuring full integration of DPEM into district development plans,
performance contracts, and budgets (NECDP 2018). In Indonesia, a coordinating mechanism
between the “center-of-government” coordination unit in the Vice President’s Office and the
Provincial and District Offices’ Stunting Task Forces was formed to manage the implementation
of StraNas at the subnational level. The strong engagement with the Ministry of Local
Government (i.e., Ministry of Home Affairs) and Ministry of Villages establishes clear roles and
responsibilities between the province, district, and village levels, enabling a policy and
institutional framework for implementation of StraNas at the subnational level, including
advocacy and alignment of regulations.

When the National Committee for Food and Nutrition was established in Nigeria, states were
encouraged to set up state- and local-level coordination platforms. An estimated 24 out of 37
states now have active committees. In Cambodia, the Second National Strategy for Food and
Nutrition (2019–2023) explains the country’s “Twin-Track Approach” to tackling malnutrition:
sector-led food security and nutrition (FSN) activities are carried out by relevant ministries within
their own objectives, resources, and capabilities. Joint actions requiring multisectoral
coordination are overseen by the Council for Agriculture and Rural Development (CARD)—the
national high-level coordinating body. CARD convenes the technical working groups for FSN
and social protection at the national level and the line ministries at the subnational level (CARD
2019).

In Malawi, the National Nutrition strategy is operationalized at the district level through various
multisectoral coordination committees at the district, area, and village levels. Each committee
includes subnational representation from health, agriculture, education, and civil society
organizations to guide the implementation of activities down to beneficiaries at the household
level. A district-level Nutrition Focal Point supports the coordination of these various committees
and nutrition activities from each of the ministries and at each subnational level. At the most
decentralized level, the Village Nutrition Coordination Committee is responsible for establishing
linkages with Area Community Leaders Action for Nutrition. This structure has been scaled up
nationally to coordinate care group volunteers responsible for community-level sensitization and
mobilization for nutrition.

In Guatemala, the dual vertical and horizontal governance of food security and nutrition is
supported by participative coordination mechanisms that stem from the national level, the
National Council for Food Security and Nutrition (CONASAN), and trickle down to the
Departmental Council for Food Security and Nutrition (CODESAN), Municipal Council for Food
Security and Nutrition (COMUSAN), and Community Council for Food Security and Nutrition
(COCOSAN) to reach the family unit (see Figure 4). At each administrative level, these
intersectoral and interinstitutional coordination mechanisms benefit from broad stakeholder
participation, representing various sectors, and with interventions all oriented toward improving
food security and nutrition. A detailed manual was developed in 2019 to guide the functioning
and governance of each of these coordination mechanisms at the departmental, municipal, and
community levels, including but not limited to specifics about member representativity, key roles
and responsibilities, frequency of meeting, and minimum quorum and consensus-building.

18
Figure 4: Interinstitutional and Intersectoral Coordination Mechanisms for Food Security
and Nutrition in Guatemala

Source: Guatemala Secretaria de Seguridad Allementaria y Nutricional (2019). Manual Funcionamiento de las Comisiones de
Seguridad Alimentaria Y Nutriticional a Nivel Deparmental, Municipal Y Comunitario (CODESAN, COMUSAN, COCOSAN)

MANAGEMENT CAPACITY AND FINANCING

Management capacity and accountability systems at the subnational level

Background

For many countries there are gaps in translating national MSPs to the district level
(Brown et al. 2020). Roadmaps—or subnational, multisectoral plans and budgets, such as
District Nutrition Action Plans—are helpful to guide districts in MSP implementation. Ideally,
these plans should align with national priorities and sector development plans (MQSUN+ 2020;
Brown et al. 2020; SNV et al. 2017).

Given that more countries are decentralizing service delivery to the local level, national
governments must establish a coordinated approach to improve subnational capacity to
manage their multisectoral programs from the district to the community level. Capacity-
building involves improving local-level ability to understand data, determining the local drivers of
stunting, as well as planning, budgeting, implementing, and monitoring programs. To build
capacity, subnational governments first need to be motivated to coordinate and implement the
multisectoral plans mandated by central governments (Acosta and Fanzo 2012; Brown et al.
2020). Country-level experience has shown that local officials tend to be more motivated if they

19
are involved in the design and planning of a multisector nutrition response; are given the direct
responsibility to implement it; and have sufficient resources, guidance, and support to do so
(Brown et al. 2020; MQSUN+ 2020; Acosta and Fanzo 2012). If national-level nutrition agendas
are promoted without subnational-level coordination, implementation at the local level will likely
be fragmented and siloed (Acosta and Fanzo 2012). Second, skills are needed at the district,
subdistrict, and community levels to mobilize local-level resources and draw up budgets for
nutrition interventions and to provide supportive supervision and M&E, and learn how to work
across a range of sectors with different stakeholders (SNV et al. 2017; Brown et al. 2020). Third,
clear guidance is required at the subnational level in terms of converging nutrition services
across sectors. The recent MQSUN+ review found that while there are several examples of
nutrition convergence of nutrition services, many Multisectoral Nutrition Plans and platforms do
not have clear guidance on achieving convergence in decentralized contexts. More work is
needed on how to fund, plan, implement, and monitor such efforts (MQSUN+ 2020).

Examples from countries

Some national programs include results conferences and performance contracts to

ensure commitment and build management capacity and accountability at the
subnational levels. In Indonesia, for example, Annual Stunting Summits are held at the district
and village levels to help secure local government leaders' commitment across different line
ministries and to create the necessary enabling environment for districts and villages to
implement multisectoral actions. District and subdistrict officials and village leaders agree on
stunting targets, commit to aligning village budgets, and then sign compacts to finalize their
commitments. An Annual National Stunting Summit hosted by the president or the vice
president converges national and regional leaders to jointly commit to achieving annual stunting
reduction targets. Similarly, in Nigeria, an annual Results Conference is part of the project.
Partners from the federal and state levels showcase their multisectoral nutrition results, practice
experiential learning, and chart a path forward. Given that the project is currently being piloted in
only one state, these discussions are intended to center on how to scale up the pilot. In the
DRC, through the GFF-cofinanced Multisectoral Nutrition and Health Project (MNHP), the
government is entering into performance-based contracts (PBCs) with nonstate actors to deliver
family planning services and recruit, train, and manage community health workers (CHWs) to
deliver a package of nutrition services at the household level.

Technical assistance, knowledge platforms, and financing are also being provided to
strengthen the subnational capacity to work multisectorally. The Investing in Nutrition and
Early Years (INEY) Project in Indonesia supports mobile multisectoral technical assistance (TA)
pools at the provincial level that could respond to local (district and village) requests for
supporting the implementation of the District Convergence Action Plan. Other initiatives include
launching a knowledge platform to share practical information vertically and horizontally among
peers. The implementation of TA and accountability tools to strengthen capacity of the
subnational (district and village) coordination and implementation platform have benefited from
the strong buy-in and engagement of the Ministry of Home Affairs (MoHA) and Ministry of
Village (MoV) as the critical line ministries to hold, respectively, their district and village
governments accountable. At the district level, for example, the MoHA ensures that the Stunting
Task Force and the DCAP process are well integrated into the regular subnational planning and
implementation process. At the village level, the MoV rolled out the Human Development
Workers (HDWs) program to coordinate frontline service delivery and support for the overall
program convergence of services. Convergence is being measured through a Village Scorecard
and a mobile application (e-HDW).

20
In Rwanda, the Stunting Prevention and Reduction Project is providing grant funds to district
authorities to support the convergence agenda; build capacity to mount the multisectoral
response (e.g., strengthen multisectoral district planning, budgeting, coordination, supervision,
and monitoring); and ensure effective implementation of the DPEM, including the development
of the DPEM Scorecard. Through the Human Capital for Inclusive Growth Development Policy
Operation (DPO), the World Bank also supports reforms to strengthen local decentralized
entities (district, sector, and cell) in Rwanda to improve its function in coordinating and
monitoring IECD services and strengthen the accountability system. This will ensure that all key
implementing partners align their interventions with the NECDP Strategic Plan and its Single
Action Plan (SAP) and that services are delivered in line with the national standards for ECD
service provision. In the DRC, while there is agreement that all ministries and partners work
together on the multisectoral nutrition strategy at the subnational level, the implementation
varies by province, given the absence of predictable and sufficient funding and lack of technical
capacity at the subnational level. The MNHP is financing TA to improve horizontal coordination
across different sectors through cotargeting (different nutrition interventions targeting the same
individuals) and colocation (different interventions located in the same communities) with a pilot
scale-up in one province of a complementary package of services in health, social safety nets,
agriculture, and education.

Rwanda, Indonesia, Cambodia, Malawi, and Guatemala incentivize improved

management of programs, operationalization, and service delivery at subnational levels
using results-based financing. In Rwanda, the government is strengthening local-level
management and accountability by including nutrition indicators in Rwanda’s Imihigo (a contract
between the president of the Republic of Rwanda and local district authorities). The contract
serves as a combined performance management system and a planning tool and oversight
mechanism to facilitate the achievement of government priority programs such as nutrition
improvement. The World Bank and GFF–cofinanced projects in Cambodia, Guatemala,
Indonesia, and Malawi, are using disbursement-linked indicators (DLIs) to strengthen
management capacity at the subnational level. The INEY Project in Indonesia, for example,
uses DLIs to incentivize (i) the establishment of District Convergence Action Plans (DCAP) as
key management and accountability tools to strengthen evidence- and results-based planning
and budgeting at the district level and to improve the diagnosis of local drivers of malnutrition,
targeting of 1,000-day households for delivery of priority interventions, and prioritization of
district and village plans and budgets to address stunting; and (ii) annual performance
assessment of DCAP to ensure accountability for results. As previously explained, the role of
the MoHA is critical to strengthening the district management capacity and accountability
system. It also ensures that a management tool such as DCAP is well integrated into the regular
planning and budgeting process. The Cambodia Nutrition Project incorporates specific DLIs into
the National Committee for Subnational Democratic Development-Secretariat to strengthen
district and commune capacity to plan, budget, execute, and monitor service delivery grants
(grants that provide communes additional discretionary funds based on the quantity and quality
of commune support for nutrition, immunization, and neonatal survival) (see “Leveraging results-
based financing” section). In Malawi, two of the six DLIs focus on incentivizing not only the
capacity to implement nutrition and early child development interventions through formal training
(short- and long-term courses including diploma and master’s) for officers but also to disburse
allocated funds at the district level for nutrition and ECD activities.

21
Integrating a multisectoral nutrition program into regular planning and budgeting
processes to ensure sustainable financing

Background

To ensure that priority interventions identified in the Multisectoral Nutrition Plan (MNP)
are adequately financed, the MNP needs to be linked to the government planning and
budgeting process. A multisectoral nutrition program involves the delivery of interventions
across sectors and multiple levels of government, which often leads to fragmented financing
and siloed budgeting processes. It is critical for the institution that oversees the MNP to
understand the budget and planning process, including key dates of budget decision points and
the budget information system, to ensure that the priorities of the MNP are reflected in the
relevant sectoral budgets. Engagement from enabling ministries that play essential roles in
budget formulation and budget allocation, such as the Ministry of Finance (MoF) and Bappenas,
is critical to ensure coordinated engagement across sectors and different levels of government.
More specifically, this may include guidance from the MoF for relevant sectors (in the form of a
ministerial instruction or a budget circular) to prioritize high-impact interventions in the sectoral
plans and budgets and align them with MNP priorities.

To monitor the implementation of MNP priorities and ensure that the funds are allocated
efficiently, tracking multisectoral nutrition spending is crucial as countries cannot
manage or improve what they do not measure, even if coordination efforts are in place.
As noted in a recent Lancet article, 4 tracking financial resources (for health) is a prerequisite for
assessing health financing systems' performance, ensuring financial protection of health issues,
and assuring progress in transitioning toward domestic health financing (Global Burden of
Disease Health Financing Collaborator Network 2019). The multisectoral nature of nutrition
often creates challenges to properly track nutrition spending as nutrition interventions are
usually embedded in other sectors. It is not easy to codify/separate the relevant spending for
nutrition.

In recent years, there have been efforts to better capture nutrition spending across
sectors. However, this analytical work lacks sufficient granularity to inform policies,
programs, and investment opportunities. A review of 14 case studies of countries
implementing multisectoral nutrition programs found that most countries lacked robust finance
tracking systems. For example, some SUN member countries—Pakistan and El Salvador—
have used SUN budget analyses mainly for advocacy, highlighting misalignment between needs
and available funding (MQSUN+ 2020). The SUN budget analyses are based primarily on self-
reporting and on assessing budget allocations. They do not include actual spending or complete
and robust analyses, such as measuring efficiency, effectiveness, and distribution/equity at the
expenditure level. Some countries have also undertaken Nutrition Public Expenditure Reviews
(NPERs) to capture the complete picture of resources from different sectors dedicated to
nutrition and how they have been used. However, the NPER process is highly time-consuming
and cannot be done regularly.

4
Global Burden of Disease Health Financing Collaborator Network 2019.

22
Institutionalizing budget tracking and budget evaluation requires strengthening the
public financial management system. A nutrition responsive system is necessary to
effectively manage spending across multiple agencies from multiple funding sources. The public
financial management (PFM) system should enable the country to monitor budget releases
against planning to oversee nutrition-related activities in the budget across all agencies.
Furthermore, a strong PFM system should capture financial and performance data to adjust the
budget activities for more effective engagement (Qureshy et al. forthcoming). Tracking nutrition
spending using government systems such as the Integrated Financial Management Information
System (IFMIS) would involve creating a mechanism to identify nutrition-related activities in the
budget information system. This can be achieved in two ways: (i) introducing a nutrition-
dedicated segment in the chart of accounts, or (ii) identifying nutrition-related activities in the
budget proposal and tagging them to enable expenditure tracking. Identifying nutrition in the
budget will require a clear definition of nutrition activities across the various ministries and
implementing agencies.

Within the decentralized context where the subnational government is responsible for
delivering most nutrition interventions, fiscal policy to increase resources for priority
interventions at the subnational level may be needed. This may take the form of
programmatic fiscal transfers to align district development plans and budgets with MNP
priorities and help overcome the fragmentation of district financing for nutrition interventions. By
doing so, the national government could consolidate support for the subnational level and
incentivize it to put in place enabling regulations and capacity support for provinces and
districts.

Examples from countries

Recent experiences from Rwanda highlight the opportunities and challenges of

integrating the MNP in the planning and budgeting process and institutionalizing budget
tracking and evaluation through the government system. The Rwanda Nutrition Public
Expenditure and Institution Review (NPEIR) highlighted a clear need to create a nutrition-
responsive PFM system to monitor and coordinate nutrition expenditures across different
government levels and against nutrition policy objectives. The review recommended strategic
public financing reforms to strengthen the integration of the MNP in the country planning and
budgeting process and enhance the NECDP’s oversight on the implementation and financing of
the multisectoral nutrition program. The review informed the formulation of policy reforms on
nutrition-responsive budgeting to address PFM challenges. 5 The MoF has recently issued
ministerial instructions and technical guidance (Budget Circular Call) on nutrition budget tagging
that requires sectoral ministries to prioritize high-impact nutrition services in the MNP and
enable tagging and tracking of relevant nutrition interventions through the country’s IFMIS.
Furthermore, nutrition budget evaluation reports will be conducted to assess the spending
against budget allocations and outcomes (Piatti-Fünfkirchen et al. 2020). This process will
contribute to improved spending efficiency and facilitate program course correction.

5
The reforms are part of the World Bank Human Capital Development Policy Operation series.

23
In Indonesia, the engagement of the Ministry of Finance and Bappenas during the
planning and budgeting phase has been essential to ensure that line ministries’ activities
are prioritized and aligned with the MNPs. Synchronized and effective planning and
budgeting processes are core enabling factors for convergence programs. Important financing
reforms were introduced in the country to address the weak links between planning and
budgeting and promote the adoption of a joint view of resource allocation and performance
achievement across multisectoral programs. As a first step toward redressing the misalignment
in planning and budgeting, following the launch of its National Strategy to Accelerate Stunting
Prevention, a government regulation (GR17/2017) was passed where the MoF and Bappenas
agreed to work jointly in tagging, tracking, and monitoring and evaluating outputs and using the
results in next year’s annual budget allocation (World Bank 2017a). The regulation also required
the two ministries to adopt consistent formats and classifications in their budget documentation.
To help operationalize this new budgeting process, in December 2018, the Ministries of Finance
and Planning issued the first technical implementation guideline for the GR 17/2017 regulation
that different sectors can use.

Indonesia has established a system for tagging, tracking, and evaluating its StraNas
budget at the central level to guide the resource allocation for nutrition. The MoF has
produced an annual budget tagging report that provides comprehensive information on
resources allocated for the MNP (StraNas). Furthermore, the MoF and Bappenas have
produced annual “Expenditure and Performance Review” reports in 2019 and 2020. The reports
provide programmatic cross-sectoral analytical work for nutrition-related interventions on
spending efficiency, output performance, and level of convergence, and measure findings
against stunting prevalence in select locations. They are used to inform the development of
subsequent year budgets, as reflected in the Budget Note, which now has a subchapter on
stunting reduction. Tracking and performance evaluation of national spending on priority
nutrition interventions has provided the national leadership with a comprehensive, cross-
sectoral monitoring tool that can be utilized to improve spending efficiency.

While Indonesia has made strides in tracking and evaluating national nutrition spending,
it still faces challenges in tracking and evaluating spending at the subnational level.
Indonesia has a highly decentralized system, in which most nutrition service delivery is the
responsibility of local governments. 6 However, the current Budget Classification and Chart of
Accounts (CoA) design for the subnational government does not enable tagging and tracking.
To address this challenge, the INEY Project supports the Ministry of Finance to reform the
subnational CoA and improve its systems for tracking subnational expenditure (district and
village) on core service delivery sectors relevant to nutrition.

Indonesia has also increased resources for a multisectoral nutrition program through its
fiscal transfers policy. In 2019, the government introduced a new fiscal transfer instrument to
districts (DAK Stunting) to incentivize the coordination and implementation of the convergence
program. This represents a significant institutional reform as it introduces a programmatic
approach to fiscal transfers instead of the traditional process of investing in one sector only.

6
The role of districts is even more important since the introduction of the Village Law in 2014. Substantial resources are
now being channeled to the village level from the central government through a “Village Fund” (Dana Desa).

24
Furthermore, the government has introduced a reform that incentivizes subdistrict and village
levels to allocate additional funding from the Village Fund (Dana Desa) to priority nutrition-
specific—and nutrition-sensitive—interventions. A reformed Village Budget Tracking System
focuses on improving the Village Fund's use for stunting prevention and complementary
spending to ensure inputs to help deliver services (e.g., top-up wages for midwives willing to
stay longer in the village). It will inform government policy on priority uses of village fiscal
transfers for nutrition and mid-program course corrections. The Village Fund's average share of
spending on nutrition-related interventions has also increased to 26.2 percent in priority districts
(GFF 2020).

Leveraging results-based financing to drive results

Background

Results-based financing (RBF) has emerged as a promising approach to incentivize

multisectoral coordination and accountability for improved nutrition and stunting
reduction (Levinson, Balarajan, and Marini 2013; Marini and Rokx 2017). RBF is an umbrella
term for pay-for-performance programs on both the demand and supply sides, encompassing
various approaches (Fritsche, Soeters, and Meessen 2014). RBF promotes collaboration
between the government, service providers, and communities, making multisectoral nutrition
programs more accountable to the communities they serve. Box 2 provides an overview of
these multiple terms, and Figure 5 shows how RBF mechanisms incentivize different
government levels, households, and individuals.

Most RBF programs use a

combination of different RBF Box 2: Results-Based Financing: Multiple Terms
approaches. Peru, for example,
has successfully used various Results-based financing (RBF): Encompasses the entire
results-based mechanisms to range of incentive approaches on both the demand and
address its malnutrition problem. supply sides.
Stunting rates in the country halved
in less than a decade due to Performance-based financing (PBF): Supply-side
performance-based budgeting incentives are predominantly for quantity of services
conditional on quality. Experiments are with lowering
(PBB), with budgets based on
demand-side barriers by subsidizing providers to apply user
expected results rather than inputs fee exemptions for vulnerable populations. Can be provided
or activities. The government at various levels—health facilities, district health teams,
rewarded regional health central medical stores, Ministries of Health, project
authorities with increased budgets implementation units, etc.
if they achieved intervention targets
for the most cost-effective and Disbursement-linked indicator (DLI): Incentives are
globally proven interventions to linked to certain policy actions or process measures.
reduce stunting. Other approaches Provided to governments at national and/or subnational
were also used, including a levels.
conditional cash transfer program,
Conditional cash transfer (CCT) program: Demand-side
which incentivized parents to take
incentives include cash rewards to clients on consuming
their children to health facilities for
certain social services (e.g., health or education). Target
regular check-ups and growth groups include users of services in targeted geographical
monitoring and promotion; a areas as well as vulnerable groups.
nutrition strategy with strategic
focus on selected interventions in Program for results (PforR): A results-based financing
instrument used by the World Bank, which is based on the
25 use of DLIs that serve as incentives linked to specific policy
actions or process measures.
the neediest areas; and increased health insurance coverage for the poor (Levinson, Balarajan,
and Marini 2013; Marini and Rokx 2017).

Figure 5: Results-Based Financing Mechanisms

Source: Adapted from Laviolette et al. 2016.

Examples from countries

Countries are using innovative RBF schemes in various ways at the central and
subnational levels. DLIs are being used to incentivize governments to manage and implement
interventions (Cambodia, Guatemala, Indonesia, Malawi, Nigeria); PBF and/or DLIs to improve
the quantity and quality of nutrition-related services (Cambodia, DRC, Malawi, Nigeria); PBF to
promote convergence (Nigeria and Rwanda); performance-based contracts (PBCs) to
incentivize nonstate actors as part of the multisectoral nutrition agenda (DRC, Nigeria), and to
protect the reliability of funding flows for key recurrent activities tied to the National Strategy in
the intervention areas (Guatemala, Malawi). Additional details about some of the countries’
activities are also provided in Annex 1.

The Cambodia and Indonesia projects use DLIs to incentivize different departments,
sectors, and levels of government to finance various components of the project that
contribute to the multisectoral nutrition agenda. In Cambodia, for example, DLIs are
provided to numerous government counterparts to (1) strengthen the functional and technical
capacities at national and subnational levels to enhance the effectiveness and sustainability of

26
project investments; and (2) strengthen district and commune capacity to stimulate demand and
accountability at the community level (see Table 1).

Table 1: Cambodia: Types of DLIs by Implementing Agency

Implementing agency DLI

National Committee for Subnational Democratic Building capacities and rollout of the verifying
commune/sangkat service delivery grants (C/S-
Development‐Secretariat
SDG) for women and children; ensuring timeliness
and oversight of payments to the subnational level;
conducting assessment and coaching for C/S-SDG

National Nutrition Program Ongoing readiness and quality of priority nutrition

services

Preventive Medicine Department Delivery of an integrated outreach package

including priority maternal child health and nutrition
(MCHN) services

National Maternal and Child Health Center Comprehensive coaching conducted for MCHN
Scorecard

National Center for Health Promotion Communications materials, training, and

supervision delivered for VHSGs and Health Equity
Fund (HEF) Promotion

Payment Certification Agency Sustainable institutional arrangements for HEF and

SDG payment and certification

Quality Assurance Office MCHN service quality monitoring enhanced and

mainstreamed in the MoH. Integrate MCHNS in the
regular NQEM process and make data available for
decision making

Department of Budget and Finance Timeliness of MCHN-SDG and HEF payments

ensured and continued FM capacity-building for
health centers

Department of Planning and Health Information Regularity of MCHN data availability enhanced.
Improved reporting forms and updated the HMIS
for nutrition

Source: World Bank (2019). Project Appraisal Document for Cambodia Nutrition Project.

Notes: VHSG = Village Health Support Group; DLI = Disbursement-linked indicator; SDG = Sustainable Development Goal; NQEM
= National Quality Enhancement Monitoring; MoH = Ministry of Health; FM = Financial management.

In Indonesia, for example, as mentioned previously, some of the INEY Project’s DLIs are
directly tied to strengthening national leadership critical to sustaining stunting reductions, such
as committing subnational leaders to explicit targets and actions for stunting reduction,
operating effective monitoring and de-bottlenecking processes, and establishing a system for
resource allocations based on need and performance. Other DLIs are used to strengthen district

27
governments’ implementation of district-level convergence actions to diagnose the local drivers
of stunting and improve the targeting and implementation of nutrition-specific and nutrition-
sensitive interventions that address those drivers. An annual performance assessment,
incentivized using fiscal transfers, is the key mechanism through which Bappenas and MoF, in
collaboration with the MoHA, will translate national stunting reduction targets into district and
village government plans, budgets, and action.

In the Cambodia Nutrition Project, PBF is linked to improved quantity and quality service
delivery, management capacity, equity, and accountability. As part of a more extensive
quality improvement process in the country, performance-based financing is provided to health
facilities for quality Reproductive, Maternal, Newborn, Child, Adolescent Health and Nutrition
(RMNCAH-N) services. Grants are given to (1) health centers based on their quality of care
performance scores assessed quarterly using scorecards; and (2) district and provincial health
departments based on their managerial performance scores. The government’s Maternal Child
Health and Nutrition (MCHN) Scorecard assesses (1) the availability of critical resources—
including the availability of equipment, supplies, medicines, and guidelines and transport
allowances given to poor and marginalized groups; (2) the health staff's knowledge and
competency about MCHN-related medical conditions (lactation counseling and support, growth
monitoring and promotion, etc.) aligned to national guidelines; and (3) outcomes of care
assessed through client interviews. At the community-level, performance-based financing is
being provided to (1) communes to deliver a package of community-based priority health,
nutrition, and promotion activities; and (2) districts to conduct performance assessments of
communes using a community scorecard that measures input, process, and outcome measures
related to multisectoral nutrition interventions. To enable the PBF implementation, districts
provide coaching to health centers, where they help them improve their performance scores.

In Rwanda, RBF is aligned among service providers, community health workers, and
households and coordinated geographically to promote convergence. The Stunting
Prevention and Reduction Project and Strengthening Social Protection Project, cofinanced by
the World Bank, GFF, and Power of Nutrition, leverages performance-based financing at the
health facility level and provides incentives for community health workers (CHWs) at the
community level and conditional cash transfers at the household level. Health centers in
targeted districts are being supported and incentivized through performance-based payments to
improve quality and coverage of an enhanced package of high‐impact nutrition and health
interventions for women and children (i.e., antenatal and postnatal care, micronutrient
supplementation, family planning, growth monitoring and promotion, infant and young child
feeding, deworming, micronutrient supplementation). As part of CHW reforms, CHWs are
evaluated and renumerated based on performance incentives that are distributed to CHW
cooperatives and individuals. A core set of nutrition indicators is being added to the community
PBF system to incentivize the delivery of priority nutrition interventions. Lastly, the government
is also scaling up a household CCT program that provides cash transfers to poor and vulnerable
households with pregnant women and children under two, to incentivize their utilization of
health, nutrition, and parenting services.

In Nigeria and DRC, RBF incentivize the involvement of nonstate actors in the
multisectoral nutrition response. In Nigeria’s Accelerating Nutrition Results Project, DLIs link
financing to states when they sign performance-based contracts with nonstate actors working in
communities. The DLIs will incentivize government delivery channels to focus on the following
results areas: (i) improved coordination of development partners who are active in the states; (ii)
sharper focus on nutrition during antenatal visits in facilities (specifically provision and

28
counseling on iron-folic acid tablets during pregnancy, counseling on early and exclusive
breastfeeding, and provision of presumptive intermittent treatment for malaria); and (iii) strong
management of the performance-based contracts as per agreed standards. The Nigeria
program also incentivizes five other sectors (health, agriculture, women affairs, education, and
social protection) to jointly establish and implement a community-based multisectoral plan that
includes promoting food security and diet diversity for vulnerable households through
homestead gardens; economic empowerment for women and girls; promotion of micronutrient
supplementation, WASH, and menstrual hygiene management among children and adolescents
in schools; and leveraging cash transfers and promoting social and behavioral change
communication using government-established social protection delivery channels. In DRC,
facility-based nutrition and family planning services will be delivered within the context of an
RBF platform that will incentivize the quantity and quality of these services. Moreover, a strong
referral system will be developed between nonstate providers/NGOs, CHWs, and RBF facilities
to ensure continuity of care and follow-up. As described above, the MNHP operation is financing
performance-based contracts with NGOs to reach children in the first 1,000 days (i.e., pregnant
women and children under two) with a package of high-impact nutrition interventions such as
counseling, referral, and key nutrition commodities (including micronutrient powders). These
contracts are based on performance in both coverage (quantity) and quality of these services.

In Guatemala, the GFF leveraged its grant financing in the form of a buy-down to
stimulate domestic resource mobilization reforms and uptake and utilization of health
services through disbursement-linked indicators. The release of the buy-down is based on
two conditions: the first is aimed at addressing interruptions of financing to the CCT program by
stipulating that the government earmarks resources that are freed up from debt payments due
to the GFF buy-down and matches them with domestic resources. This translates into
reinvesting a combined amount of $18 million into the CCT program, which gets priority in the
budgeting and disbursement process. The second condition is based more directly on a results-
based mechanism, where successful achievement of disbursement-linked indicators (DLIs) in
years two and four triggers the release of GFF Trust Fund resources for the buy-down of the
International Bank for Reconstruction and Development (IBRD) loan to more concessional
terms. The DLIs address two key aspects of undernutrition in Guatemala: child feeding practices
and access to health and nutrition services.

In Malawi, the Investing in Early Years Project uses DLIs to support the implementation
and impact of the government’s Nutrition and Early Child Development Programs. The
DLIs in this project incentivize results throughout the program results chain, thus including
financing for process, output, outcome, and development indicators. For example, one DLI
finances the development of training materials and implementation of cascade training (process
and output indicators). At the same time, another DLI focuses on improved breastfeeding
practices for children 0–6 months of age (outcome/impact indicator). This multilevel approach
presents yet another model for supporting the achievement of improved outcomes at the
household and individual levels and for all activities and processes that need to be adequately
financed and implemented to make those results possible.

29
 RESULTS MEASUREMENT, MONITORING, AND ACCOUNTABILITY

Strengthening performance monitoring systems and promoting the use of data to

improve program implementation

Background

Countries that have succeeded in reducing malnutrition tend to have invested in

resources to gather quality data and have developed consensus around indicators and
data collection methods. High-quality nutrition data accessible in real time and reviewed and
analyzed for decision making helps show government transparency and track gaps and
successes. Unfortunately, there is limited availability of frequent nutrition outcome and service
utilization data. Large nationally representative household surveys, such as the Demographic
Health Surveys and Multiple Indicator Cluster Surveys, while useful, are typically conducted only
every five years and thereby are limited for accountability purposes. These surveys also do not
provide sufficient granular information at community and district levels (Acosta and Fanzo
2012).

Improving the availability of quality and timely nutrition data and performance monitoring
systems is key to enhancing program implementation, informing decision making,
enabling course correction, and enhancing accountability. Although countries have made
progress in establishing multisectoral platforms and coordinating committees, there remains a
need to improve M&E at the national and subnational levels and ensure that data performance
monitoring is part of their multisectoral plans. By establishing regular public reporting of the
progress toward performance targets, program implementation and accountability are
strengthened. This may entail building capacity at both national and district levels to obtain
relevant data, improve data quality where needed, analyze it, and set targets for government
planning (Brown et al. 2020).

The results framework of the National Multisectoral Strategies can be an important tool
to consolidate and monitor progress on key indicators across the various sectors
relevant to nutrition. The careful placement of high-level coordinating bodies uniquely
positions them to engage across ministries and should be inclusive of a mandate to extract data
from each ministry to track nutrition progress multisectorally. Some countries have started
enabling such multisectoral nutrition monitoring by developing interoperable digital platforms at
both national and community levels to improve monitoring, evaluation, accountability, and
learning. In Ethiopia, for example, an innovative digital approach for tracking multisector
nutrition interventions is being piloted in selected food-insecure woredas (districts) with
cofinancing from the GFF and the Power of Nutrition. The Unified Nutrition Information System
for Ethiopia combines both nutrition-specific and nutrition-sensitive indicators from six sector
ministries (Health, Agriculture, WASH, Education, Social Protection, and Women’s Affairs); and
it is being integrated into the government’s District Health Information System 2 (DHIS2), an
open-source software platform that allows governments and organizations to collect, manage,
and analyze health and nutrition data.

Tools that collect information about the “convergence of services” are particularly
important for tracking the utilization of priority services from different sectors and for
measuring convergence at the community and household levels. Scorecards are being
used in several countries to measure interventions across core sectors included in the
convergent action planning, to hold facilities or communities accountable for results, and to

30
improve the quality of care. Again, a key challenge to achieving this accountability for
convergence is the limited availability of credible data. India’s government is trying to address
this gap by (1) providing smartphones to frontline program staff to capture interventions and
indicators on a real-time basis, and (2) conducting third-party biannual household surveys that
track process and infrastructures indicators that can affect nutritional outcomes (Menon et al.
2019).

Examples from countries

In several nutrition programs, the governments invest in interactive, interoperable, and

agile monitoring systems that routinely collect quality outcomes, output, and input
indicators and track the convergence of priority nutrition services. This is the case in
Indonesia, Rwanda, Guatemala, and Malawi, where large data systems are being developed or
revamped to track key nutrition indicators. In Indonesia, at the national level, the Vice
President’s Office created a publicly available performance dashboard to enable public
monitoring of the overall progress (dashboard.setnas-stunting.id), and at the subnational level,
the Ministry of Home Affairs established the district monitoring dashboard to track
implementation progress of the District Convergence Action Plan (DCAP). The dashboards are
helping to inform programmatic and strategic adjustment, as needed.

In Rwanda, the World Bank and GFF support technical assistance to allow for interoperability of
civil registration, national ID, health, and social protection information systems for seamless
identification and delivery of benefits to eligible families and children. This builds on the
significant progress made on the Civil Registration and Vital Statistics system. It strengthens
birth registration and certification by assigning a unique national identifier at birth and
establishes a modern system for real-time electronic registration and certification of vital events.
An integrated ECD performance monitoring dashboard is being developed to bring together
performance data across sectors and enable comprehensive budget reviews to inform program
course corrections, including at the district level.

In Guatemala, the COVID-19 vaccination rollout was used as an entry point to revamp the
decrepit HMIS system, SIGSA, which has also opened the door for interoperability with the
Food and Nutrition Security National Information System (SIINSAN) in the future. SIINSAN
tracks and centralizes indicators from other routine information systems to report on essential
food security and nutrition indicators. For example, routine data on growth monitoring and
promotion services from the SIGSA are reanalyzed to report on higher-level nutrition indicators
of interest such as stunting, wasting, and overweight. The reengineering of SIGSA, which
enables a shift toward digital, integrated, and individual-level health data will further facilitate the
role of the Secretariat for Food Security and Nutrition and interoperability with the SIINSAN
information system, to streamline analytic processes to improve the review and analysis of data
for decision making.

In Malawi, a Multisector Nutrition Information System was established in 2017 to address the
challenges of having multiple information systems at the district level. To operationalize this
system, M&E bottlenecks at the district level had to be identified; nutrition indicators had to be
harmonized across different sectors; indicators needed to be included in data collection tools;
district M&E teams had to be trained on data collection, data quality, and data analysis; and
standard operating procedures had to be developed on graphing and reporting (Brown et al.
2020).

31
Some countries are including additional indicators in large national surveys to improve
the availability of timely nutrition data. In Indonesia, the Central Bureau of Statistics and the
MoH added anthropometric measurements in their annual household survey to improve the
availability of nutrition outcome data at the national and regional levels. The first annual Survey
Status Gizi Balita Indonesia (SSGBI) was completed and published in 2019. It includes data
from 412 districts (including all 160 priority stunting districts), which showed a decline in the
national stunting prevalence rate by 3.1 percent from 2018 to 2019. The disaggregated data
have also enabled the development of the District Convergence Index, which measures
convergence across six dimensions (health, nutrition, water and sanitation, food security,
education, and social protection) and tracks performance ranking across provinces. In Nigeria, a
new iteration of the National Food Consumption and Micronutrient Survey 2021 is being
conducted, given that the last food consumption survey in the country was completed in 2001.
Also, additional nutrition indicators will be included in the National Nutrition and Health Survey,
which will be carried out at the end of 2021.

New tools are being developed to track nutrition data and service use at the health
facility, community, and household levels. In Nigeria, a web-based and Android mobile
application has been launched to record and report on community-based delivery of a basic
package of nutrition services by nonstate actors and the delivery of nutrition-sensitive antenatal
care packages in public primary health centers. The Nigerian Ministry of Finance, Budget, and
National Planning has also developed a virtual dashboard that records implementation progress
by the multisectoral response. In Indonesia, a digital monitoring and mapping application—e-
HDW—is being rolled out. HDWs can use this application to collect routine programming data
and simplify the reporting and tracking of convergent nutrition-related services. They also can
be used to collect information on the convergence of five services (maternal and child health,
nutrition counseling, WASH, ECED, and social protection), covering the Village Scorecard
indicators. 7 In Rwanda, a Child Scorecard is being developed that tracks 22 key interventions
received or missed by pregnant women and children under two years of age that contribute to
stunting reduction. The scorecard consolidates data on the accessibility and usage of integrated
interventions at the child level during the first 1,000 days of life. It also provides nutrition data to
key stakeholders to help identify gaps and develop solutions and guidance in a timely fashion.
In Cambodia, the performance monitoring system—the MCHN and community scorecards—will
have electronic-assisted data collection and management dashboards to improve the use of
data for program implementation.

Citizen engagement, community mobilization, and social accountability

Background

Community engagement is essential to encourage local participation in setting

nutritional goals, demanding accountability for quality services through community

7
Scorecards will be used in planning stunting reduction programs at the village level. They will also provide input to the annual
reports on Village Funds by the Ministry of Finance and district/municipal governments. Villages have to submit village scorecard
reports to receive Village Funds (Dana Desa).

32
scorecards, and addressing knowledge and behavioral and cultural barriers to
malnutrition through Social Behavior Change Communication (SBCC). Community-level
actors, including civil society organizations, are vital for local advocacy and awareness-raising,
providing nutrition-related information, services, and referrals, mobilizing constructive feedback
on services, and participating in planning and resource allocation. These are some of the
important elements of social accountability that are critical for ensuring quality services.
However, community engagement in multisectoral nutrition programs is often hampered by
challenges, including the low capacity of community-level actors to implement interventions,
engage in SBCC, and provide regular monitoring and supportive supervision of frontline workers
(Brown et al. 2020; Shrimpton, Mbuya, and Provo 2016).

As mentioned before, community-based engagement models should be part of the

national multisectoral strategy and its coordination platforms. In general, there has not
been a lot of clarity of the roles of community-level actors, such as CSOs in subnational
governance systems. A recent review of national case studies of Civil Society Networks
involved with the SUN movement identified six roles CSOs should ideally play related to
multisectoral nutrition governance: (1) identify needs of all community members, including the
ability to reach traditionally marginalized groups; (2) mobilize members and build capacity for
civic engagement; (3) advocate for political commitments (i.e., sustained funding, human
resources, and policy initiatives); (4) inform design and evaluation of interventions; (5) ensure
accountability mechanisms and surveillance systems for public institutions to track impacts of
nutrition policies; and (6) report successes and challenges using the media (Busse et al. 2020).

In addition, communities need to be integrated into a larger SBCC effort that works at all
levels of government (from the community to the facility and national/policy level) and
uses multiple delivery channels (e.g., interpersonal communication and counseling,
community-based interventions, social marketing, mass and social media). Recent studies
on the effect of SBCC on infant and young child feeding show that the intensity of the
interventions (e.g., level of exposure to a specific SBCC intervention) and the number of
channels used to change behaviors tends to increase the positive effect of interventions
(Lamstein et al. 2014; Menon et al. 2016).

Examples from countries

Numerous World Bank/GFF–cofinanced projects actively engage communities in their

multisectoral nutrition interventions. Projects are encouraging local participation in
setting nutritional goals, demanding accountability through community data and
scorecards. As mentioned previously, in Indonesia, the StraNas Village Convergence
Scorecard will hold village and subdistrict heads accountable for delivering priority nutrition-
specific and nutrition-sensitive interventions. HDWs conducted social mapping to identify the
households’ current access to priority multisectoral nutrition services. The scorecard helps
identify service gaps, track progress on convergent services, and trigger conversations between
the community, service providers, and the local government to resolve service gaps. The eHDW
mobile app helps HDWs identify and monitor 1,000-day households. In Rwanda, the
government has rolled out an ECD Scorecard to gather citizen feedback on service quality to
enhance a "people-centered" approach. The government has also engaged CSOs to strengthen
monitoring for improved quality of IECD services. CSOs with experience as ECD service
providers are responsible for providing supportive supervision to ECD centers to ensure
adherence to service standards and to monitor service coverage and quality using standardized
reporting tools. Rwanda is using Child Length Mats to raise awareness on stunting at the

33
community level. The mats help empower communities and parents to visualize linear growth
and undertake corrective actions. As explained previously, the Cambodia Nutrition Project is
financing a community scorecard for districts to measure input, process, and outcome indicators
at the community level related to multisectoral nutrition interventions. The scorecard mirrors
processes developed under the Implementation of the Social Accountability Framework, such
as the public posting of data, citizen review of data, etc.

Projects are also implementing Social Behavior Change Communication to positively

influence knowledge, attitudes, and norms to improve nutrition behaviors and outcomes.
SBCC is being used to enhance community-level health worker performance, raise awareness
among families about malnutrition and its impact on child growth and development, and help
ensure sustained demand and access to services through community mobilization. In
Cambodia, for example, with assistance from the Cambodia Nutrition Project, the government
developed a national Maternal, Infant, and Young Child Nutrition (MIYCN) SBCC strategy. On
the demand side, the project supports developing and delivering an updated SBCC campaign
(including mass and social media and interpersonal communication at multiple levels) focused
on maternal nutrition, breastfeeding, complementary feeding, and on promoting child growth
and development. It also supports developing a standardized Commune Program for Women
and Children (CPWC) to serve as the community-based health and nutrition platform (including
group-based SBCC and community mobilization) and to deliver community mobilization and
interpersonal communication activities at the village level. As explained previously, these CPWC
activities will be financed through a performance-based grant for communes to conduct
activities to promote priority MCHN services Health Equity Fund utilization. On the supply side,
the project centers on performance-based financing to enhance the quality of counseling of
health workers and their adherence to clinical guidelines for priority MCHN services in health
centers. The project also works with government counterparts to develop new evidence-based
guidelines and communication materials to address previous SBCC MCHN implementation
challenges.

The Nigeria Accelerating Nutrition Results in Nigeria (ANRIN) Project, through the assistance of
the non-profit group ideas42, is piloting demand-side cash transfers for nutrition-related
behavior change in Gombe State. Adolescent girls, pregnant women, and mothers with children
under five years will be exposed to nutrition-related SBCC through home visits and community
events. Participants will be provided cash transfers based on their knowledge and intention to
take up services and practices. The subsequent behavioral change will be measured and
monitored.

In the DRC, a sizable Social Behavior Change Communication component is cofinanced by the
GFF to boost demand for nutrition, family planning, and nutrition-sensitive agriculture services;
to improve provider attitudes and behaviors; and to promote behavior change. The campaign
will include large mass media (i.e., radio) efforts, provider behavior change coaching, and
interpersonal communications at the household level through CHWs. The project team is
undertaking an impact evaluation in conjunction with the World Bank’s Development Economics
Research Group to evaluate if the addition of SBCC provides a marginal improvement in key
outputs and outcomes. This will build on the evidence base for investments in SBCC in the
context of multisectoral programs.

34
 PART V – LOOKING AHEAD
A multisectoral approach to malnutrition is conceptually appealing, yet country governments and
donors face operational challenges in implementing and financing these programs. As
demonstrated through the experiences highlighted in this paper, early implementation lessons
drawn from multisectoral malnutrition programs require the following: effective governance
through high-level political commitment and coordination platforms that work both vertically and
horizontally; a multisectoral nutrition policy that provides strategic direction and oversight for
multisectoral implementation across various government levels, stakeholders, and donors;
strategic budgeting and adequate allocation of resources across sectors; integrated planning
and M&E and accountability processes; broad stakeholder engagement across diverse sectors
and sets of stakeholders who may not always speak the same technical language or have the
same goals in mind; and continual coordination throughout policy and program implementation
and monitoring. Just as with any systems strengthening effort, a multisectoral nutrition program
may take time to achieve its goals: alliances and systems must be built to support the effective
implementation of multisectoral actions, which in themselves require sustained and broad-based
efforts.

This report has attempted to delineate valuable lessons from early implementation experiences
from the seven countries supported by the World Bank and GFF to facilitate cross-country
learning. The examples presented throughout the report vary by country and context. Also, all
programs are in different implementation phases, and what may work in one country may not
necessarily apply to another. As illustrated in this report, several countries have promising
emerging experiences, but more needs to be done to produce and use high-quality data to
better understand the impact of multisectoral governance approaches on improved delivery and
quality of nutrition-specific and nutrition-sensitive services, increased financing and financing
efficiency, and improved nutrition outcomes. Recommendations for the way forward thus
emphasize the critical roles of M&E and data use as the fundamental pathways toward the
sustained, dynamic, and responsive implementation of multisectoral nutrition programming.
These include the following:

Monitoring
• Support country investments in routine data systems that enable continuous feedback on
the population's nutritional status, service coverage/utilization, and quality of care. Improved
routine data collection will be useful for tracking changes in real time and in elevating and
maintaining nutrition as high priority on the political agenda.
• Improve information available on nutrition spending across sectors and levels of government
through budget tagging and tracking using the government’s IFMIS. This would enable a
thorough budget performance review to inform resource allocation and improve spending
efficiency.
• Invest in technologies that improve the collection and availability of high-quality nutrition
data, including those that enhance the interoperability and/or consolidation of different
sectoral and regional data systems (e.g., through digital dashboards and platforms such as
mobile phones)
• Strengthen the capacity of line ministries and subnational governments to implement a
thorough data quality assurance system. Enhance governments’ analytic capacity to build a
35
 robust integrated M&E system and optimize data utilization across all sectors and levels of
government.

Evaluation

Investments in process and impact evaluations are recommended. Examples of evaluation

activities include the following:
• Processes: Implementation research lends itself well to measuring processes and should
focus on the following:
o The impact of the governance interventions (highlighted in the report’s framework) on
process outcomes such as improved knowledge, skills, and coordination among
management to operationalize multisectoral programs and improved quality of
nutrition-related services.
o Sectoral capacity to implement multisectoral interventions at national and
subnational levels and factors or implementation arrangements that enhance
different sectors’ abilities to maintain minimum quality standards. Multisectoral work
is not just about having different sectors outside of health being nutritionally focused
but ensuring that their nutrition-related activities are implemented with quality to
ensure impact.
o Diagnostic analysis to identify suitable entry points to enhance convergence,
including integrated planning and budgeting, targeting, delivery platforms, monitoring
systems, community mobilization, and peer learning.
o Review budget evaluations to improve the methodology for robust budget
evaluations to generate recommendations on efficient resource allocations for
nutrition, including a clear theory of change as a basis for assessing spending
against performance.
o Citizen engagement and social accountability: Investigate ways to strengthen
community-level decision-making and accountability processes to strengthen the
demand for quality services and enhance program course corrections.
• Impact: Measures should focus on the impact of policies and programs on malnutrition and
quality impacts. Specifically, this includes conducting impact evaluations on the following:
o Impacts of efforts to enhance the quality of nutrition services: Analyze the effect of
efforts and mechanisms to improve the quality of multisectoral nutrition interventions.
Outcomes include improved health, competent health care providers, positive user
experiences, equity of care, and economic benefits (Kruk et al. 2018).
o Mix of interventions: Conduct impact evaluations to increase our understanding of
which combination of nutrition-sensitive and nutrition-specific interventions can
impact nutrition and their immediate determinants in different contexts (Brown et al.
2020). Studies that include analyses of impact pathways using process evaluations
can be beneficial for identifying why and how specific program or intervention
components contribute (or do not) to program impact in a given setting, which can be
used to inform program scale-up and intervention mix (Olney, Rawat, and Ruel 2012;
Rawat et al. 2015).
Use of data
• Enhance the use of data to strengthen the alignment of multisectoral programming priorities
with country planning and budgeting processes to improve oversight of nutrition budgets

36
 across sectors, secure financing from domestic resources, and course-correct program
implementation.
• Enhance the capacity at all levels to understand, analyze, and use data for decision making.
Although data from monitoring systems are ideally fed through the system from the
subnational to national levels, efforts should focus on closing the feedback loop by
developing mechanisms to feed data back to each level where it can be used to make
informed decisions.
• Improve documentation and dissemination of data from M&E systems and good multisector
nutrition planning and programming practices to enhance knowledge exchange and peer-to-
peer learning. Harvesting and documenting learning from country-level implementation and
making that learning available in various knowledge products and formats is key to
improving multisectoral implementation.

37
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41
 ANNEX 1. PROGRAM FEATURES BY COUNTRY

PROGRAM Cambodia DRC Guatemala Indonesia Malawi Nigeria Rwanda

FEATURES

High-level The Council for n.a. Secretariat for Food Vice President’s Office is Department of Nutrition, National Council for Political commitment from
leadership Agriculture and Rural Security and Nutrition leading the multisectoral HIV, and AIDS in Ministry of Nutrition (chaired by vice President’s Office
Development (CARD), sits under the Office of coordination body, Tim Health supported by three president of Federal
chaired by the deputy the President, with Percepatan Penurunan high-level committees that Republic of Nigeria)
prime minister, is oversight of Stunting provide oversight for
responsible for multisectoral activities Nutrition (Cabinet,
coordinating the in relevant sectors Parliamentary, and Principal
country’s multisectoral Secretaries)
approach to nutrition

Institutional CARD—national • National Multisectoral Multisectoral coordination Multisectoral coordination National Committee for Central, district, and
coordination coordinating body, MoH Multisectoral coordination platforms platform. Provincial and platforms at key Food and Nutrition, State community-level
mechanisms (executing agency), and Nutrition at key administrative district office stunting task administrative levels, Committees for Food and multisectoral platforms
NCCDS (implementing Committee (CNMN) levels, including forces to manage including national Nutrition, Local Government
agency), through the created in 2015. national (CONASAN), implementation of StraNas (Multisectoral Technical Committees for Food and
national program, Under the prime departmental at the subnational level. Nutrition Committee), Nutrition
minister, CNMN
technical departments, (CODESAN), municipal district (DNCC), area (ANCC),
brings together
and at provincial, (COMUSAN), and village (VNCC)
over a dozen key
district, commune, and ministries involved community
Federal Ministry of Budget
village levels in nutrition (CUCUSAN)
and National Planning
(MFBNP)

Management • MOH and NCDDS • Conducting DLIs • Annual stunting DLIs DLIs • Grant funds to district
capacity and have DLIs to diagnostic of summits authorities
accountability incentivize the management • DLIs • DPEM Scorecard
system at national level to capacity at • TA pools at provincial • Nutrition indicators in
subnational roll out activities subnational level level Imihigo contracts
to the subnational • HDWs to strengthen (tied to PBF)

42
level levels. citizen accountability
• SDG and C/S-SDG,
which create
incentives for
improved quantity
and quality of
implementation of
nutrition activities,
combined with
technical and
management
coaching

Public financial • Integrating • Conducting a • Enabling policy and • Looking into what • Enabling policy and
management nutrition into the diagnostic of how regulatory framework mechanisms are regulatory framework
system performance- well nutrition is • Technical needed to track
based SDGs, a part integrated into implementation nutrition and • Technical
of health sector PFM guideline for tagging, expenditures in the implementation
PFM reforms and tracking, M&E for PFM guideline for tagging,
decentralized expenditures related to tracking, M&E for
financing MSP expenditures related
• DAK (Special Allocation to MSP
Fund) guidelines
• Deploying the C/S- • Comprehensive budget
SDG and coaching tagging and tracking at
to enhance the
national and
planning,
subnational levels
budgeting, and
execution of local
government
expenditure on
nutrition

• Ongoing PFM
training and
coaching
1.
Results-based • Performance- • PBF to health • DLIs to • DLIs to incentivize DLIs at multiple levels of the • PBF of health facilities • PBF to health centers
financing linked and results- facilities (public incentivize governments to results chain to incentivize • Performance-based and CHWs
based mechanisms and private), health results, including manage and both implementation of contracts with • HH CCT

43
 at all levels of the centers, and first improved implement activities (training, capacity- nonstate actors
health system: level referral coordination interventions building, disbursement of • DLIs for improved
PHD, OD, and hospitals across sectors, financing to the local level), coordination of
health facility • PBF with district financing for the as well as achievement of development partners
• DLIs to various and provincial level conditional cash results in nutrition and early who are active in the
government health transfer (CCT) child development states; sharper focus
counterparts to (1) administration program, and on nutrition during
strengthen the • PBF contract with achievement of ANC visits in facilities;
functional and several national- impact-level
strong management of
technical level structures indicators
performance-based
capacities at • PBC with NGOs contracts
national and
subnational levels • DLIs for 5 nutrition-
to enhance the sensitive sectors to
effectiveness and implement a
sustainability of multisectoral nutrition
project response and to the
investments; and MFBNP to coordinate
(2) strengthen the response
district and
commune capacity
to stimulate
demand and
accountability at
the community
level
Monitoring • Digital platforms • Publicly accessible Nutrition information • Performance Multisector nutrition • New iteration of • Integrated ECD
systems to for the MCHN-S data dashboard system (SIINSAN) that Dashboard in SoVP information system National Food performance
track nutrition and C/S-SDG being and DHIS2 cloud- is fed by data from • Added anthropometric developed to consolidate Consumption and monitoring
progress developed will based database relevant ministries as data to annual and harmonize nutrition Micronutrient Survey dashboard
multisectorally include well as nutrition- Household data and data collection • Adding additional
dashboards for specific surveys, data Socioeconomic Survey from multiple nutrition indicators to
decision making (SUSENAS) the National Nutrition
collection, and analysis sectors/information systems
• E-HDW at the district level and Health Survey
• Web-based and mobile
• Strengthening the Android application
recording tools • Multisectoral results
and reporting of dashboard established
nutrition
and maintained by the
indicators in the
MFBNP
health
management
information

44
 system

Citizen • CPWC as • Community survey • Village Convergence Village savings loans scheme • Piloting demand-side • Child Scorecard
engagement, community-based for citizen Scorecard integrated into the care cash transfers for • Child Length Mats
community health and engagement and • SBCC regulation, group model as an activity to nutrition-related
mobilization, nutrition platform feedback strategy, and sustain nutrition and early behavior change
and social • Community implementation at the child development (ECD)
accountability scorecard priority districts promotion by community
• MIYCN SBCC 2. members (promoters and
strategy
cluster leaders)
• Beneficiary
feedback
components of
both SDG and C/S
SDG scores
• Child Length Mats
in MIYCN SBCC
• Demand-side
health equity fund
benefits for
increased nutrition
service utilization
for 1,000 day
beneficiaries

Source: Authors

Notes: MoH = Ministry of Health; NCCDS = National Committee for Sub-National Democratic Development; DLI = Disbursement-linked indicator; C/S-SDG =
Commune/sangkat service delivery grant; PFM = Public financial management; PHD = Provincial Health Department; OD = Operational District; MCHN =
Maternal, Child Health and Nutrition Scorecard; CPWC = Commune Program for Women and Children; MIYCN = Maternal, Infant, and Young Child Nutrition;
SBCC = Social Behavior Change Communication; DRC = Democratic Republic of Congo; n.a. = ; CNMN = National Multisectoral Nutrition Committee (DRC); PBF
= Performance-based financing; PBC = Performance-based contract; NGO = Nongovernmental organization; DHIS2 = District Health Information System 2;
CONASAN = National Council for Food Security and Nutrition (Guatemala); CODESAN = Departmental Council for Food Security and Nutrition (Guatemala);
COMUSAN = Municipal Council for Food Security and Nutrition (Guatemala); CUCUSAN = Community Council for Food Security and Nutrition (Guatemala);
SIINSAN = Food security and nutrition information system; TA = Technical assistance; HDW = Human Development Worker; M&E = Monitoring and evaluation;
MSP = Multisectoral Platform; SoVP = Secretariat of the Vice President ; DNCC = District Nutrition Coordinating Committee; ANCC = Area Nutrition Coordinating
Committee; VNCC = Village Nutrition Coordinating Committee; ANC = Antenatal care; DPEM = District Plan to Eliminate Malnutrition; CHW = Community Health
Worker; HH CCT = Housheold conditional cash transfer.

45
Malnutrition continues to be one of the world's most critical health and human development challenges, threatening
countries' Universal Health Coverage (UHC) goals and the achievement of the Sustainable Development Goals
(SDGs). Given the complex, multifactorial, and interlinked determinants of nutritional status and well-being,
multisectoral nutrition programming has been widely promoted as the most effective way to address the direct and
indirect determinants of malnutrition and to improve nutrition outcomes. Robust governance systems are essential
for implementing multisectoral nutrition interventions and creating cost-effective and sustainable programs.
The objectives of this report are to (i) document and synthesize implementation experiences, challenges, and
opportunities from seven countries supported by the World Bank and Global Financing Facility (GFF) in
operationalizing large-scale multisectoral nutrition projects that emphasize and strengthen governance (Cambodia,
the Democratic Republic of Congo, Guatemala, Indonesia, Malawi, Nigeria, and Rwanda); and (ii) facilitate cross-
country learning. Given that the seven countries used as examples in this report are still implementing their
multisectoral programs, the report focuses on documenting progress and lessons learned on implementation
modalities and innovations, rather than highlighting impact at this stage.

The report uses a multisectoral governance framework, adapted from Gillespie, Van Den Bold, and Hodge (2019), to
synthesize the implementation experiences across the World Bank/GFF–financed multisectoral nutrition projects.
The report provides eight lessons learned, organized under three broad categories: (1) Advocacy, leadership, and
institutional support for multisectoral nutrition; (2) Management capacity and financing; and (3) Results
measurement, monitoring, and accountability.

The report also discusses key issues that governments, donors, and program planners may want to consider when
moving forward with implementing such programs.

ABOUT THIS SERIES:

This series is produced by the Health, Nutrition, and Population Global Practice of the World Bank. The
papers in this series aim to provide a vehicle for publishing preliminary results on HNP topics to encourage
discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely
those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated
organizations or to members of its Board of Executive Directors or the countries they represent. Citation and
the use of material presented in this series should take into account this provisional character. For free copies
of papers in this series please contact the individual author/s whose name appears on the paper. Enquiries
about the series and submissions should be made directly to the Editor Jo Hindriks (jhindriks@
worldbank.org) or HNP Advisory Service ([email protected], tel 202 473-2256).

For more information, see also www.worldbank.org/hnppublications.

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