Multisectoral Community Mobilization for Stunting Reduction
After close to 15 years of relatively successful nutrition policy development and programming, Senegal is at a crossroad to renew the policy and programming environment that will help the country deal with the more deep-rooted problems of malnutrition. This requires enhanced multisectoral engagement and community dialogue as outlined in the National Nutrition Policy and National Multisectoral Nutrition Strategic Plan.
A visit by the President of the World Bank, Jim Kim, in February 2018, during which he met with the National Executive Bureau of the National Commission on the Fight Against Malnutrition in the Office of the Prime Minister (CLM), highlighted the challenge by urging Senegal to become the first sub-Saharan African country with stunting rates below 10%. Senegal is among the first wave of countries that committed to the Investing in the Early Years initiative and is one of the early adopters of the Human Capital Project. Making nutrition programs sustainable means eradicating stunting as part of an early years investment program, which in turn will drive economic growth and investments. Following Jim Kim’s visit, Senegal set the ambitious goal of bringing stunting down to below 10% by 2025. For this to happen, Senegal seeks to learn from Malawi about new approaches for enhanced community dialogue and participation while strengthening multisectoral coordination of targeted service delivery.
Learning from Malawi – who found inspiration from Senegal’s own early journey and has now developed robust multisectoral community-based approaches – would greatly benefit Senegal as it embarks on a process to achieve its vision. A knowledge exchange supported by the South-South Facility provided the opportunity for Senegalese officials to learn from Malawi’s recent experience in community mobilization, and to gain an understanding of the policies, institutional requirements, and implementation arrangements that have supported such reforms.
The National Commission on the Fight Against Malnutrition (Cellule de Lutte contre la Malnutrition or CLM) was created in 2001 by the government of Senegal. Under the authority of the Prime Minister, it provides technical assistance in the definition and implementation of the national nutrition policy. Chaired by the Chief of Staff of the Prime Minister, the CLM is made up of representatives from the ministerial sectors (economy and finance, health, education, interior, trade, agriculture, industry, livestock, fishing, environment, family, water and sanitation, decentralization, communication, higher education and research, social protection, food security, child protection), local government and civil society.
With a National Executive Bureau (BEN) and six Regional Bureaux, responsible for day-to-day program management, the CLM coordinates the implementation of community nutrition activities organized by 18 Community Execution Agencies (AEC), on behalf of local communities.
Since 2002, it has implemented several projects and programs, focused on achieving the following main objectives: (i) improving the growth of children aged 0 to 5, living in poor urban or rural areas of Senegal and (ii) strengthening institutional and organizational capacities to implement and evaluate nutrition interventions.
In this context and to meet the country's commitments relating to global health targets, sustainable development goals and provide responses to the major determinants of malnutrition, the Government of Senegal, in 2015, approved a new National Nutrition Policy (PNDN) and in 2017 adopted a National Multisectoral Nutrition Strategic Plan (2018-2022) for its operationalization.
In its desire to address the causes of malnutrition in a sustainable manner, the country has adopted the multisectoral approach as the guiding principle of the PNDN. This approach requires greater involvement of the various stakeholders responsible for nutrition, mainly local authorities, civil society organizations, the private sector, and communities.
This policy emphasizes tackling the determinants of malnutrition in a sustainable way and it is operationalized by the National Multisectoral Nutrition Strategic Plan (PSMN), the implementation of which is driven by the CLM.
To support the government in the implementation of the PSMN, the World Bank has provided Senegal with new lending and a small grant for the implementation of new projects aimed at boosting the multisectoral approach to nutrition in all levels and more particularly at community level. The projects involved are: Senegal Investing in the Early Years for Human Development, Investing in Maternal and Child Health, and Building Resilience to Food and Nutrition Shocks.
Malawi, which has found a lot of inspiration from Senegal back in 2011, has developed a model of community mobilization with high levels of participation, based on so called “care groups”, that could inspire Senegal to strengthen the demand- and supply-side of nutrition-sensitive programming with strong community ownership and participation linked to a responsive service delivery system. Malawi has adopted an innovate care group approach that functions very well and has often been cited as a model for multisectoral community-based approaches. The care group model is part of a community mobilization strategy that organizes the entire community behind the objective of providing nurturing care to children under five. The care groups are supported by multisectoral working groups, involving public service providers from health, agriculture and education, traditional and religious leaders, community-based organizations and Traditional Authority (TA) at Ward and District levels.
From the 24th to 29th November 2019, a delegation from Senegal travelled to Malawi to learn more about the care groups and the multisectoral approach implemented by the country to counter malnutrition. The delegation was composed of the Coordinator of the CLM, the Operations Manager (CLM), the Communication Advisor (CLM), the Local Governance Officer (CLM), the Regional Manager of the Kolda BER, the Mayor of Medina Chérif and the Head of the Planification Division of the Regional Development Agency of Kolda.
The mission began with a briefing session with the team from the Department of Nutrition, HIV and Aids (DNHA) of the Ministry of Health. This meeting was an opportunity to hear about the organizational structure in support of nutrition in Malawi, review the program of meetings at operational and strategic levels and discuss the expectations and interests of the delegation, specifically relating to the experience of Malawi in supporting multisectoral coordination of nutrition through care groups and the direct involvement in the nutrition of children.
Next, the delegation headed to visit the Lilongwe District. The first stop was a visit to the "District Commissioner", the head of the district administrative services. In Malawi, the decentralization of power takes place through 28 administrative and territorial entities, each headed by a Commissioner whose main mission is to implement state policies in his area of responsibility. He is supported by a technical team made up of specialists in fields as diverse as nutrition, health, agriculture, public works. This configuration facilitates multisectoral coordination and is based on co-responsibility.
This visit was followed by a meeting with the Lilongwe District Nutrition Coordinating Committee (DNCC). The exchanges covered the nutrition implementation framework, characterized by the existence of committees from the central to the operational level involving all categories of actors. This implementation framework ensures good multisectoral coordination and it ensures the involvement of local communities.
In relation to specific nutrition interventions, they are implemented at the operational level by State agents intervening either at a Ward level (group of villages) or at a village level. Non-Governmental Organizations (NGOs) implement nutrition specific or sensitive interventions, for example community initiatives such as latrines, small ruminants and other small animals, backyard gardens, etc. These interventions are carried out with the support of sectoral service providers and with the strong involvement of traditional chiefs at all stages of the process. The involvement of several actors highlights how much funding for nutrition in Malawi is still largely dependent on resources from external partners, which is one of the greatest challenges to ensure the sustainability of these programs.
Following the presentation of the DNCC, the delegation went to the village of Masinja, located in the Kabudula area, here the local population is at the heart of the implementation of nutrition interventions. The delegation visited community initiatives implemented in certain households, notably backyard gardens, chicken coop models and redistribution methods. The delegation also saw demonstrations on the implementation of certain specific nutrition interventions, including activities related to WASH and cooking demonstrations.
The visit was closed with the presentation of iron and folic acid supplementation activities at the community level and targeting children who are not in school, highlighting the various communication tools used in this context. These interventions are part of a strategy aimed at complementing the supplementation in schools.
The "care groups" particularly caught the attention of the delegation. The delegation learned that the "care group" is led by a female leader who is responsible for supporting at least 10 households, ensuring their good nutritional standing. These "female leaders" work under the supervision of a "Promoter" responsible for periodically taking stock with them on the households that they are charged with and to reinforce their capacity to support dialogue and exchange within the community. This approach, based on a meticulous distribution of tasks, guarantees the effectiveness of the services and their optimal follow-up.
On the following day, the delegation headed to the Dowa District. Just like in the Lilongwe District, this visit started with a meeting with the district’s team, a presentation of the current situation regarding nutrition, a conversation on the governance structure at local level and the challenges related to nutrition, in particular the strengthening of the alignment of certain partners with the priorities of the district and the heavy dependence on technical and financial partners for the financing of nutrition.
After the kick off meeting with the local authorities, the delegation visited the village of Ngomani together with the Nutrition Officer of the DNHA, the District Nutritionist and a team from the NGO Care International. During this visit, the delegation witnessed promotion activities organized on the topic of infant and young child feeding, like cooking demonstrations with recipes based on the principle of multiple food groups and the use of local products and iodized salt. In addition, the delegation heard about the activities of the program on Growth Promotion and visited the backyard gardens of certain households in the community. The delegation was particularly interested in communication tools to engage the community around nutrition. The ones discussed included a tarp-shaped poster and red, yellow and green-colored stickers indicating the village’s nutritional status.
The third day of the mission was devoted to a series of field visits to the district of Salima. The delegation first went to Katelera Elementary School to discuss iron and folic acid supplementation for school girls and visited the school feeding program. The iron supplementation strategy, targeting children 10-19 years of age is done in schools and continues during the school holidays by making tablets available to families. Regarding school feeding, the state provides schools with the budget for the purchase of ingredients and the community is in charge of organizing the preparation of the meals. This model, highlighting the role of school feeding, has made a major contribution to keeping children in school.
The visit to the village of Mvulyly was an opportunity to see multisectoral initiatives at the household level (latrines, chicken coops, hygiene interventions, improved stoves, storage of kitchen utensils) and cooking demonstrations promoting local products in the preparation of food for priority target groups of the nutrition interventions. The delegation also learned about recipe books on infant and young child nutrition, which have been developed and disseminated on the following topics: during pregnancy, 0-6 months and 6-23 months.
The mission ended with an exchange session attended by all the relevant stakeholders involved in promoting nutrition in Malawi, including civil society, private sector, academia, and the Committee of Parliamentarians. First, the DHHA presented on nutrition in Malawi, focusing, among other things, on the implementation framework for nutrition, the situation of the main nutrition indicators and the main challenges. According to the team, one of the key factors for their success is the existence of a national nutrition strategy, a unified and standardized coordination framework, a monitoring and evaluation framework and a robust communication strategy. The establishment of committees at central, district, ward and village levels and the of technical working groups around relevant sectors is a main characteristic of the implementation framework. These groups are key for the exchange and coordination of solutions and development of sectoral programs related to nutrition, thus facilitating multisectoral coordination at strategic and operational levels. The "Group of Advisers" caught the attention of the delegation. This representative group of technical experts, selected on the basis of their skills, is a kind of consultative and decision-making support body, particularly important when it comes to the development of policies and approaches to nutrition. Although not formalized, this group provides the necessary technical and critical insights before the validation of any studies in the field of nutrition.
Following the presentation by the DHHA, the different parts of society shared how they are involved in promoting nutrition. Civil Society Organizations develop advocacy actions at all levels (national, regional and community) for better management of nutrition in public policies. The private sector has focused on creating an alliance among small and medium sized enterprises and industries (SMEs and SMIs) to target a broad range of diverse actors, who are likely to contribute to the development of nutrition, in particular hotels, agri-food companies, etc. The main mission of this alliance in the private sector is to promote the development of economic models around nutrition and as such, it has strengthened dialogue with the local private sector actors. Academia contributes by strengthening national capacities in nutrition with the training of nutritionists in public universities. Their primary mandate is to share knowledge and generate credible evidence that can assist in decision-making and the development of flagship nutrition policies and strategies.
Lastly, the delegation heard from the Committee of Parliamentarians, which has been active for many years and constitutes an advocacy body for better introduction of nutrition in government guidelines and actions. The committee was renewed following the last legislative elections and in order to kickstart again its activities some orientation session on nutrition have been planned. This committee of parliamentarians, whose actions carried out both within the national institutions and at local level, made it possible to strengthen the mobilization of resources in favor of nutrition.
The visit and the different exchanges, allowed the Senegalese delegation to better understand the various activities carried out by the Government of Malawi at the national, district, ward and village levels. The participants also took this opportunity to share, with the DNHA team, their positive feedback on the delivery of nutrition services, multisectoral coordination methods, the high level of engagement of the different the actors and the quality of human resources. Malawi is well positioned to see substantial improvements in the main nutrition indicators, in particular the reduction in stunting. Some challenges remain, mainly around the mobilization of resources and strengthening the coverage rates of interventions.
While the organizational frameworks for implementing the nutrition policy at the national and local level are quite different in Malawi and Senegal, it was still possible for the delegation to establish some parallels and draw useful conclusions from the exchange. The main observations and lessons learned from the visit are the following:
- The multisectoral framework for the implementation of nutrition at the national, district, and village levels
This support system for the formulation, implementation and monitoring/evaluation of nutrition interventions at different levels constitutes a modality for the involvement of all decentralized actors. In the context of Senegal, this model could be applied at the strategic and operational levels. For the strategic level, this will involve supporting the establishment of technical working groups and linking them to the various pillars of the national nutrition development policy (PNDN). At the operational level, the strategy could be based on the one hand on the establishment of a departmental platform for multi-sectoral coordination around the Prefect of the department (the department being a territorial level located between the region and the district, and at the level of which the main technical support services are located). On the other hand, by strengthening the consultation frameworks of local authorities with the establishment of Village Development Committees, Inter Village Development Committees and Municipality (Commune) Consultative Committees.
- The existence of nutritionists in sectoral ministries
Each ministry involved in multisectoral nutrition policy has nutritionists on its staff. These are recruited and placed in the relevant ministries by the DNHA and contribute to ensuring the proper introduction of nutrition in the plans and programs of the ministries. This strategy of placing nutritionists in ministries has been successful because Malawi has a critical mass of trained nutrition specialists in public universities. However, this approach would be difficult to implement in the short term in Senegal, because of the current shortage of nutritionists, especially those trained in public universities.
- The establishment of care groups at community level
The existence of these groups makes it easier to hit the policy target. The approach consists of setting up several groups of women in a village or zone and having a leader for each group who ensures the effectiveness of the service that is delivered to the children of group members (maximum of 11 families per group).
- Supplementation, at the community level, of iron and folic acid targeting girls not attending school
This approach makes it possible to fight effectively against anemia: the beneficiary adolescent girls are identified through the families that are members of the care groups. Girls enrolled in school and supplemented at school serve as intermediaries in raising community awareness.
- The implementation of community initiatives at village level
It is not based on targeting households, instead all households can be beneficiaries provided that they respect a certain number of conditions: build the enclosure for the animals, raise the fence for the backyard gardens, build latrines and set up a hand washing station.
- Targeted communication (for instance to women during pregnancy, families with children 0-6 months and 6-23 months) allow beneficiaries to better understand the key elements of infant and young children nutrition.
This segmentation of communication tools has the advantage of making it easier for community actors to interact with families and communities, to focus on the key messages linked to the age bracket and the health of the audience concerned and to strengthen the adoption of recommendations.
- The multisectoral approach in the implementation of initiatives at the household level
This approach guarantees that the children of the household have access to all food groups: through backyard gardens, small ruminant farming, poultry farming all with the support of technical services.
The lessons learned during the mission allowed the delegation to identify the achievements of Senegal, namely the existence:
- Of a network of parliamentarians focusing on nutrition;
- Working groups that perform the technical monitoring, evaluation and communication around the Multisectoral Nutrition Strategic Plan (PSMN); and
- Recipe booklets focusing on the diet of pregnant women, infants and young children.
Beneficiaries / Participants
- National Executive Bureau of the National Commission on the Fight Against Malnutrition (BEN/CLM):
- Officer in charge of the Local Governance
- National Coordination
- Communications Advisor
- Officer in charge of Operations
- Officer in charge of the Regional Bureau of Kolda
- Regional Development Agency of Kolda, Chief of the Planification Division
- City of Medina Cherif, Mayor
Senegal wants to immediately move forward with starting the care group model pilot in the Commune of Médina Chérif. Upon their return to Senegal, the Mayor of Médina Chérif drafted an action plan that the CLM will support to roll out the pilot. The experience will be documented so that appropriate tools will be developed to be disseminated to the other Communes and stakeholders in the program.
Senegal is also keen to replicate the different organizational structures for coordination, notably at national level. The CLM is assessing the feasibility to set up exchange platforms for academia and law makers. Based on the results, terms of reference will be developed and the platform(s) will be launched.
Based on the lessons learned during the visit to Malawi, the delegation decided that, in order to promote greater responsibility and involvement of the various stakeholders and especially of the local government in the planning, implementation and monitoring/evaluation of nutrition interventions, it would pursue the following two actions in the year 2020:
1. Organize a pilot, at the level of the city of Médina Chérif, on the implementation of multisectoral frameworks and governance. This follows closely the main lessons learned from the experience of Malawi. The pilot would focus in particular on: strengthening of the service delivery system related to nutrition, defining a new approach for community initiatives, developing more appropriate communication messages and channels to support community dialogue around nutrition and better empowerment of care groups.;
2. Establish, at the departmental level, a multisectoral nutrition framework based on the operational implementation framework for nutrition at the district level in Malawi. This framework will promote, among other things, greater support for Nutrition Sector Action Plans developed by decentralized Technical Services and the availability of the technical support necessary for the planning, implementation and monitoring and evaluation of nutrition interventions at the local level.
- Malawi Ministry of Health
- Department of Nutrition, HIV and Aids (DNHA)
- Lilongwe District Commissioner
- Lilongwe District Coordination Committee
- Local counterparts in the village of Masinja, Ngomani, Mvulyly
- Dowa District Commissioner
- Dowa District Coordination Committee
- Malawi Parliamentarians Committee
Results Story Author: Emilia Galiano