Political Economy of Nutrition Policy in Senegal

Senegal has a reputation for having one 
 of the most effective and far-reaching nutritionservice 
 delivery systems in Africa. Chronic malnutrition has dropped 
 to less than 20 percent, oneof the lowest in Sub-Saharan 
 Africa. The reduction in stunting in particular has been 
 deemed a success in Senegal with the prevalence of child 
 stunting one of the lowest in Sub-Saharan Africa in absolute 
 terms (Nene 2017). This success has at least in part been 
 attributed to broad-based government commitment to 
 nutrition, which has grown from US$0.3 million per year in 
 2002 to US$5.7 million per year in 2015, increasing from 
 approximately 0.02 percent to 0.12 percent of the national 
 budget. Yet concerns remain regarding whether the level of 
 government support for nutrition is sufficient and the 
 degree to which nutrition has been as effectively 
 “mainstreamed” across major line ministries, such as 
 agriculture, education, water and sanitation, 
 socialprotection and health, to support both 
 nutrition-specific and nutrition-sensitive interventions. 
 Moreover, the nutrition field as a whole is characterized by 
 a myriad of actors (international donors, NGOs, and 
 technical support agencies) whose interventions are not well 
 coordinated, leading to duplications of effort and 
 inefficiencies in the provision of services. A series 
 ofexternal shocks, including food shortages stemming from 
 drought, the global financial crisis, and the instability of 
 prices for local foodstuffs since 2007, has revealed the 
 continued need for additional investment in nutrition and 
 better intersectoral coordination of activities to counter 
 cyclical attention to nutrition and a predominant focus on 
 food insufficiency rather than abroader focus on nutrition. 
 To this end, the government of Senegal, through the CLM, is 
 in the process of drafting the new PSMN to develop a reform 
 agenda for the sector. The PSMN will lay out a framework and 
 timeline for the development of a nutrition financing 
 strategy that will requirespecific analysis of the sector 
 spending and financial basis, linking it to the coverage and 
 quality of nutrition services and assessing the contribution 
 of different sectors and actors to the budget. As part of 
 the Analysis & Perspective: 15 Years of Experience in 
 the Development of Nutrition Policy in Senegal series, the 
 World Bank commissioned this report to elaborate the 
 specific political challenges to and opportunities for 
 further raising the profile ofnutrition on the government’s 
 agenda and secure a sustainable effort to reduce maternal 
 and child malnutrition. The nutrition agenda is often prone 
 to political economy challenges when it competes for 
 government support, as the impact of nutritional 
 intervention is neither immediate nor tangible. Though the 
 benefits of proper nutrition are life-long and are 
 foundational to proper growth and development, nutrition can 
 fall by the wayside in policymakers’ inevitably 
 shorter-termoutlook. With this in mind, the objective of 
 this report was to identify the policy and political levers 
 that can be used to foster government leadership and 
 galvanize intersectoral coordination that mainstreams 
 nutrition into government policies and programs and 
 effectively, efficiently, and sustainably delivers nutrition 
 interventions in Senegal.


List of Figures
List of Tables

Executive Summary
A lthough adequate nutrition is considered pivotal for improving health and development in low and middle income countries, nutrition has frequently received less attention and funding from governments than other health issues, arguably due to its multisectoral nature: Without a single institutional home, nutrition has suffered from collective action dilemmas and the inability of stakeholders to work together to foster attention and action on the issue. As a result, political commitment to nutrition is often weak or lacking. This report conducts a case study of Senegal, a country considered to be relatively successful in multisectoral nutrition programming and nutritional outcomes, to analyze the politics of multisectoral nutrition governance.
Political economy analysis involves an exploration of the politics behind policy development, including an assessment of who stands to gain and who stands to lose from policy decisions and can consequently shed light on the reasons for high (or low) political commitment to an issue. Through in-depth interviews with thirty policy actors, document review, and drawing from existing political economy frameworks and public administration literature on multisectoral governance, the report analyzes the major strengths, weaknesses, opportunities, and threats (SWOT) to scaling up multisectoral nutrition governance in Senegal.
With the ultimate goal of delivering nutrition interventions in Senegal effectively, efficiently, and sustainably, the objective of this analysis is to identify the policy and political levers that can be used to promote (1)  Major results are as follows: ® Senegal is well poised to make significant progress in scaling up a multisectoral approach to nutrition programming with national coverage, but at the time of this writing this remains more of an aspiration than a reality.

Measuring Political Commitment to Nutrition
Lack of political commitment has been identified as a primary reason for the low priority that food and nutrition intervention receives from national governments relative to the high disease burden caused by malnutrition. However, the concept of political commitment is rarely adequately defined or empirically measured in a way that can assess whether it is having an impact on outcomes. How can we gauge whether a government has committed itself to advancing nutrition?
® Network and actor features include the existence of champions or policy entrepreneurs who promote the problem or issue, the governance and cohesiveness of the policy community, and the methods these actors employ to strategically frame the issue to make it more appealing to policy makers.
® Issue characteristics describe the intrinsic nature of an issue that may make it more or less appealing to address, including its severity (for example, more prevalent or virulent illnesses with worse effects will naturally garner more attention), its tractability (how easy it is to address including the presence of acceptable solutions), and the power of the group(s) that it affects (the more general, less stigmatized the group, the more attention it will receive).

Windows of Opportunity to Advance Nutrition
Because governments face many issues that vie for their attention and scarce resources, literature on the policy process further finds that the issues that are successful at moving to the top of government agendas are those whose network actors effectively exploit "windows of opportunity" that open in relatively predictable ways though with unpredictable timing. Kingdon (2003) suggests that windows of opportunity to advance policy issues open when three largely independent streams converge at the right moment:

Existing Research on Political Commitment to Nutrition
Previous research on political commitment to nutrition has shown that, compared with other health issues, nutrition suffers from several intrinsic issue characteristics that make it more difficult to advance on a national agenda. These include (1)

Analysis
The accuracy of interviewees was tested by triangulation with other informants and documentation. Formal coding of interview transcripts and notes was not con-ducted, but the author looked for emerging themes that cut across interviews and therefore surfaced as most prominent.

Operationalization of the Conceptual Model
The main outcome of interest in this analysis is the degree to which the government is committed to nutrition policy. To assess the country's degree of political commitment, we examined evidence of each type of commitment separately. To assess this, we used the following search terms in a set of official documents from each ministry: "nutrition," "securité alimentaire," and "carences en micronutriments." Together, we defined a "credible commitment" to nutrition as a commitment that becomes increasingly difficult to rescind as it becomes institutionalized over time.
To examine how issue networks and windows of opportunity influenced political commitment, the stakeholder interviews were open-ended but probed the presence of specific nutrition champions, problem-framing strategies, issue characteristics, and organizational tensions, among other factors that have been shown to affect overall government commitment to nutrition in previous research. The researcher also consulted available public opinion data to examine public demand for nutrition and food security initiatives, urban-rural differences in policy preference, and impression of the governments' performance on nutrition.

Recent Political Commitment to Nutrition in Senegal
Senegal has committed itself to nutrition in several concrete ways: symbolically, institutionally, and through its budgets (table 1)

Expressed Commitment
In terms of its expressed commitment to nutrition,

Budgetary Commitment
Senegal has also committed itself to nutrition through

Institutional Commitment
Senegal is also committed institutionally to nutrition in several ways that have been particularly instrumental to the further promotion of nutrition objectives in the country. Senegal is one of 18 countries that recognize a "right to food" in its constitution (article 98) and which recognize the primacy of international law over national law, which arguably commits the country legally to nutrition promotion. 9 Although a "right to food" technically exists in the constitution, the interviews indicate that the nutrition policy community did not use this as an advocacy lever. Senegal adopted     Thus, the actual level of institutional commitment within the multisectoral governance framework is less than first appears. A full appropriation of responsibility for nutrition by leadership in the line ministries is lacking.

Network and Actor Features
Strategic framing • Misapprehension that food security and nutrition are one and the same • Further opportunities to portray food security as necessary but not sufficient for improved nutrition, for example, using a map showing overlay of food insecurity and poor nutrition • Potential opportunity to combine government attention to agricultural independence with crop diversity efforts • Underexploited opportunities to pair nutrition programming with UHC, maternal mortality, agricultural self-sufficiency, and obesity and noncommunicable diseases Cohesiveness and multisectoral governance • The CLM has been an effective coordinating body; placing the CLM in the Prime Minister's office has elevated the priority of nutrition • Nutrition has secured high-level attention, an updated national nutrition plan (DPNDN) has been adopted, and a national strategy (PSMN) is being developed • CLM wants to mainstream nutrition by transferring some of its implementation responsibilities to the ministries Leadership • The CLM, in conjunction with the World Bank and donor partners, has become pivotal in the degree of commitment to nutrition in the country • Effective leadership of the CLM has raised the profile of nutrition and promoted coordination across line ministries

Severity
• Conflation of food insecurity with nutrition means that food distribution efforts get political attention, but other less visible, nonimmediate nutrition issues (such as micronutrient deficiencies) get less attention • Food insecurity is a clear priority of the Sall administration, and nutrition is understood to be part of this • No single ideal indicator of the overall nutritional status of the population; hard for lay people to understand complex sets of outcomes • High performance on reducing stunting may lead to the perception that the problem is less severe, reducing attention to nutrition Tractability • Complicated set of multisectoral interventions involving behavior change, monitoring, service provision, partnering with the private sector, and agricultural interventions is required to effectively move the needle on nutrition • Need for multisectoral participation hampers action; not all parties recognize their role • The PRN is a concrete government program (as opposed to a project) that the government can lay claim to, but it has not been implemented nationwide • Good, but incomplete, evidence base in support of the PRN Mobilized affected groups • Those suffering from malnutrition or nutritional deficiencies are not mobilized because many nutritional deficiencies are invisible • Suffering populations tend to be poor and marginalized; more attention is paid to urban than rural malnutrition for political reasons • Those suffering most from malnutrition are culturally distinct and may resist lifestyle changes that would be necessary to reduce malnutrition  ) We aim to answer the questions of how effective the nutrition issue network in Senegal has been and how it can be strengthened.

External policy environment
Overall, we find that although there has been strong leadership from the CLM, which has built a degree of cohesiveness in the nutrition field and raised the profile of nutrition, more work remains to be done in building further cohesion and framing nutrition in a way that gets more attention. The PSMN presents an opportunity to work on building this cohesion and attention.

Network and Actor Features
As previously discussed, issue networks that are cohesive, have effective or high-profile leaders and champions and are successful at strategically framing their issues will be more successful at drawing attention to their preferred policy area than other issue networks. Below we discuss the network and actor features of Senegal's nutrition community.
Strategic framing. Although advocates for nutrition programming have been relatively successful at garnering government attention, there remain opportunities to strategically frame nutrition in ways that could raise its priority. According to most stakeholders in nutrition, the field of nutrition is not well understood among the media, policy makers, and the public at large. In particular, there is a widespread tendency among various actors to conflate nutrition with food insecurity. Food insecurity is believed to be the primary challenge to reducing malnutrition-increasing the amount of food available, as opposed to addressing the nutritional value of food, is believed to be the principal solution. Specific nutritional deficiencies (such as of vitamin A and iodine) and their effects are poor-ly understood by many not trained professionally in nutrition. There is room for improvement in the nutrition community to frame nutrition in a way that gets more attention. For instance, the phrase "food security is necessary but not sufficient for nutrition" helps to clarify that nutrition goes beyond lack of food. Maps of Senegal overlaying areas suffering from food insecurity with areas suffering from malnutrition, which demonstrate that they are not one and the same, may further underscore this distinction. As

Issue Characteristics
As the nutrition literature has previously identified, certain characteristics specific to nutrition militate against its achieving the level of attention it should be accorded given its overall contribution to health, well-being, and economic development. These characteristics of the solid work that has been done to raise attention to nutrition in Senegal, more strategic framing is needed to make nutrition a higher priority.

Severity.
Health issues with consequences that are perceived to be more severe may get more attention (Shiffman et al. 2016). Nutrition can be contrasted with diseases like HIV, malaria, or tuberculosis, for which disease status (yes or no) is relatively easier to count and report.
One potentially helpful indicator of the severity of malnutrition is the finding that nutrition contributes to at least 50 percent of child mortality, which is mentioned frequently in various reports (for example, Rice et al. 2000). This statistic comes from early work by Pelletier et al. (1994), which has been largely responsible for drawing wider attention to the role of nutrition in child mortality. Because malnutrition is rarely listed as a cause of death, the role of malnutrition in child mortality was easy to ignore prior to this finding. This  (table 4), and continues to be a leading concern among the general public. Next to unemployment and poverty, food shortages and famine and agriculture remain leading concerns for the public. Nutrition per se is rarely mentioned as a most important problem facing the country.  nutrition. Research shows that donors tend work more in countries that are already committed to an issue, likely because they believe they will be more able to make progress and have an impact in these countries (Lieberman 2009). However, an unintended consequence of this dynamic is the potential for the "crowd out" of government resources toward nutrition if the government believes it can take credit for donor-supported efforts. Indeed, the fact that donor resources were already allocated to nutrition seemed to be a barrier to the willingness of line ministry leadership to increase investment in this area.

External Policy Environment
For their part, donors want government to have more "skin in the game." They may be able to entice governments to do so by tying their aid or asking for matching funds. Thus, donor attention and government attention to nutrition are inextricably linked.

Opponents, potential allies, and competing issues.
Issues with powerful allies and few opponents or other issues to compete with have a better chance of being prioritized by governments because they tend to be less contentious and will not raise the ire of powerful interests. Overall, nutrition fits this description.   and combining the two programs was discussed, but the CNSA has remained independent and mainly focuses on providing food assistance in urban areas.
Ongoing tensions with the Ministry of Health, which has been somewhat marginalized in nutrition, could also pose a challenge moving forward as the CLM tries to offload some of its responsibilities for direct implementation.
An additional challenge to the nutrition field is the double-edged sword of the government's efforts to characterize Senegal as an emerging nation. The government wants to show that it has overcome the health problems associated with poverty such as malnutrition. The PSE consists of 26 specific activities, including improving access to health care, safe drinking water, and sanitation, as well as strengthening nutrition to promote sustainable development with social solidarity and the rule of law at its base.
However, the government may be more concerned with increasing overall agricultural productivity than with ensuring the nutritional quality of agricultural products. To the extent that there is a conflict between producing a diversity of crops and producing a surplus of food, the government will likely prioritize quantity over quality. ® The conflation of food security with nutrition poses an ongoing challenge.
® Solutions to address nutrition suffer from the same challenge-their complexity and multisectoral nature make it difficult to assess program inputs, outputs, and outcomes.
® There is a strategic opening in the agricultural sector, but there is a need to ensure that agricultural interventions are nutrition-sensitive.

Policy Windows and Opportunities to Advance Nutrition
Is there an opening to advance nutrition? Theory suggests that a convergence of openings in the problem, policy, and politics streams presents an opportunity to advance nutrition on the political agenda (table 5).
Overall, there appears to be a

Problem Stream
Nutrition is clearly an issue that has for some time

Policy Stream
The launch of the DPNDN in 2015, has provided a basis for coordinated action and brought together stakeholders in a productive exchange. There is an opening in the policy stream to make significant progress on nutrition, with the PSMN serving as the policy document that will spell out the obligations and responsibilities of each party. The nutrition community should move swiftly to solidify this progress. The SUN Movement can also serve as a platform for advancing a common nutrition agenda.
An important consideration in moving forward with the development of the PSMN will be the identification of

Threats
Nutrition may be overshadowed by other emerging issues. Although there is a great opportunity for nutrition, there is also a significant threat that nutrition will be overshadowed by other emerging issues or that the connections with nutrition will be overlooked, such as by agricultural resiliency projects that stress quantity of food production over quality. With global and national attention increasingly turning toward obesity and chronic disease prevention and treatment, will resources be diverted away from undernutrition and nutritional deficiencies?

5
Conclusion S enegal is poised to make significant progress in scaling up a multisectoral approach to nutrition programming with national coverage, but this remains more of an aspiration than a reality. Major recommendations to strengthen political support for nutrition include the following: ® Improve strategic framing of nutrition to increase attention to nutrition and differentiate nutrition from food security; ® Increase buy-in from top leadership in the ministries; ® More support to CLs to implement nutrition programming; ® More nutritional training for lay people, health care professionals, and within ministries; and ® More coordination of funding toward a common results framework. Malnutrition "La santé communautaire est mise en oeuvre avec la contribution de tous les niveaux de la pyramide sanitaire du pays et englobe les domaines de la lutte contre la maladie, de la santé de la reproduction et de la survie de l'enfant, l'alimentation et la nutrition, l'eau, l'hygiène et l'assainissement."; "... le suivi de la croissance, le dépistage de la malnutrition, la supplémentation, la distribution de moustiquaires imprégnées à longue durée d'action et les, campagnes de masse contre les maladies tropicales négligées."