OPERATIONALIZING MULTISECTORAL NUTRITION PROGRAMS TO ACCELERATE PROGRESS: A NUTRITION GOVERNANCE PERSPECTIVE DISCUSSION PAPER December 2021 Ali Winoto Subandoro Silvia Holschneider Julie Ruel-Bergeron OPERATIONALIZING MULTISECTORAL NUTRITION PROGRAMS TO ACCELERATE PROGRESS: A Nutrition Governance Perspective Ali Winoto Subandoro, Silvia Holschneider, Julie Ruel-Bergeron December 2021 Health, Nutrition and Population (HNP) Discussion Paper 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. 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Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street, NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. © 2021 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433 All rights reserved. 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; asubandoro@worldbank.org; 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) /=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 REFERENCES Acosta, Andrés, and Jessica Fanzo. 2012. “Fighting Maternal and Child Malnutrition: Analysing the Political and Institutional Determinants of Delivering a National Multisectoral Response in Six Countries. A Synthesis Paper.” Brighton, UK: Institute of Development Studies. Baker, Phillip, Corinna Hawkes, Kate Wingrove, Alessandro Rhyl Demaio, Justin Parkhurst, Anne Marie Thow, and Helen Walls. 2018. “What Drives Political Commitment for Nutrition? A Review and Framework Synthesis to Inform the United Nations Decade of Action on Nutrition.” BMJ Global Health 3 (1): e000485. https://doi.org/10.1136/bmjgh- 2017-000485. Bhutta, Zulfiqar A., Nadia Akseer, Emily C. Keats, Tyler Vaivada, Shawn Baker, Susan E. Horton, Joanne Katz., et al. 2020. “How Countries Can Reduce Child Stunting at Scale: Lessons from Exemplar Countries.” Am J Clin Nutr 112: 894–904. Black, Robert E., Cesar G. Victora, Susan P. Walker, Zulfiqar A. Bhutta, Ricardo Uauy, Parul Christian, and Mercedes de Onis. 2013. “Maternal and Child Undernutrition and Overweight in Low-Income and Middle-Income Countries.” The Lancet 382 (9890): 427– 51. https://doi.org/10.1016/s0140-6736(13)60937-x. Brown, Rebecca, Natalie Sessions, Jeremy Shoham, and Carmel Dolan. 2020. “Multi-Sectoral Nutrition Programming—A Review of the Literature and Evidence.” Case study.Emergency Nutrition Network, Oxfordshire, UK https://www.ennonline.net/attachments/3337/MSP_Literature_v5.pdf. Busse, Heidi, Namukolo Covic, Ashley Aakesson, and Wellington Jogo. 2020. “What Is the Role of Civil Society in Multisectoral Nutrition Governance Systems ? A Multicountry Review.” Food and Nutrition Bulletin 41 (2): 244–60. https://doi.org/10.1177/0379572119877348. CARD (Council for Agriculture and Rural Development). 2019. “The Second National Strategy for Food Security and Nutrition (2019–2023).” Phom Phen, Cambodia. Devi, Dewiana. 2019. “Leadership and Issue Salience: A Case Study of How Nutrition Became a Policy Priority in Indonesia.” In Leadership for Inclusive Development, edited by Pamela Thomas, 67–81. Cranberra, Australia. Development Studies Network. Fritsche, György Bèla, Robert Soeters, and Bruno Meessen. 2014. “Performance-Based Financing Toolkit.” Washington, DC: World Bank Group. GFF (Global Financing Facility). 2020. “Countries Lead the Way: Delivering on the Global Promise of Better Health and Nutrition 2019-2020 Annual Report.” Washington, DC. Gillespie, Stuart, Mara Van Den Bold, Judith Hodge. 2019. “Nutrition and the Governance of Agri-Food Systems in South Asia: A Systematic Review.” Food Policy 82: 13–27. https://doi.org/10.1016/j.foodpol.2018.10.013. 38 Global Burden of Disease Health Financing Collaborator Network. 2019. “Past, Present, and Future of Global Health Financing: A Review of Development Assistance, Government, Out-of-Pocket, and Other Private Spending on Health for 195 Countries, 1995–2050.” The Lancet (April). https://www.thelancet.com/action/showPdf?pii=S0140- 6736%2819%2930841-4. Government of Malawi. 2018. “National Multi-Sector Nutrition Policy 2018–2022.” Lilongwe. IFPRI (International Food Policy Research Institute). 2016. “Informe Final de Evaluacion de Impacto Del Plan Del Pacto Hambre Cero.” Washington, DC. Kennedy, Eileen, Masresha Tessema, Tesfaye Hailu, Dilnesaw Zerfu, Adamu Belay, Girmay Ayana, Desalegn Kuche, et al. 2015. “Multisector Nutrition Program Governance and Implementation in Ethiopia : Opportunities and Challenges.” Food Nutr Bull 36 (4): 534– 48. https://doi.org/10.1177/0379572115611768. Kruk, Margaret E., Anna D. Gage, Catherine Arsenault, Keely Jordan, Hannah H. Leslie, Sanam Roder-Dewan, Olusoji Adeyi, Pierre Barker, Nana A.Y. Twum-Danso, and Muhammad Pate. 2018. “High-Quality Health Systems in the Sustainable Development Goals Era: Time for a Revolution.” Lancet Glob Health 6 (November): 1196–252. https://doi.org/10.1016/S2214-109X(18)30386-3. Lamstein, Sascha, Amanda Pomeroy-Stevens, Patrick Webb, and Eileen Kennedy. 2016. “Optimizing the Multisectoral Nutrition Policy Cycle : A Systems Perspective.” Food and Nutrition Bulletin 37: 107–14. https://doi.org/10.1177/0379572116675994. Lamstein, S., T. Stillman, P. Koniz-Booher, A. Aakesson, B. Collaiezi, T. Williams, K. Beall, and M. Anson. 2014. “Evidence of Effective Approaches to Social and Behavior Change Communication for Preventing and Reducing Stunting and Anemia: Findings from a Systematic Literature Review.” United States Agency for International Development (USAID), Strengtheing Partnerships, Results, and Innovations in Nutrition, Globally (SPRING): Arlington, VA. Lateef, Asma. 2013. “Speaking Up for Nutrition: The Role of Civil Society.” In The Road to Good Nutrition: A Global Perspective, edited by V. Mannar, K. Kraemer, H.K. Biesalski, N. Bloem, J.S. Chen, M. Eggersdorfer, A. Lateef, et al. London: UK Department for International Development (DFID). https://doi.org/10.1159/000356006. Laviolette, L., S. Gopalan, L. Elder, and O. Wouters. 2016. "Incentivizing Nutrition: Incentive Mechanisms to Accelerate Improved Nutrition Outcomes." Washington, DC: World Bank Group Levinson, F. James, Yarlini Balarajan, and Alessandra Marini. 2013. “Addressing Malnutrition Multisectorally: What Have We Learned from Recent International Experience?” UNICEF Nutrition Working Paper. New York: UNICEF and MDG Achievement Fund. http://www.mdgfund.org/sites/default/files/Addressing malnutrition multisectorally-FINAL- submitted.pdf. Marini, Alessandra, and Claudia Rokx. 2017. “Standing Tall: Peru’s Success in Overcoming Its Stunting Crisis.” Washington, DC: World Bank Group. 39 Menon, Purnima, Rasmi Avula, Shinjini Pandey, Samuel Scott, and Alok Kumar. 2019. “Rethinking Effective Nutrition Convergence: An Analysis of Intervention Co-Coverage Data.” Economic & Political Weekly 52 (24): 1–6. Menon, Purnima, Adiba Khaled, Jean Baker, Kaosar Afsana, Edward A. Frongillo, Tina Sanghvi, Marie T. Ruel, et al. 2016. “Combining Intensive Counseling by Frontline Workers with a Nationwide Mass Media Campaign Has Large Differential Impacts on Complementary Feeding Practices but Not on Child Growth: Results of a Cluster—Randomized Program Evaluation in Bangladesh.” The Journal of Nutrition 146 (10): 2075–84. https://doi.org/10.3945/jn.116.232314. MQSUN+ (Maximising the Quality of Scaling Up Nutrition Plus). 2020. “From National Vision to Local Implementation: Multisector Collaboration for Improved Nutrition at the Subnational Level.” Washington, DC. MQSUN+. n.d. “MQSUN+ Guidance and Tools.” Accessed October 25, 2021. https://mqsunplus.path.org/resource/guidance-tools/. NECDP (National Early Child Development Program). 2018. “Rwanda Integrated Early Childhood Development Investment Case.” Kigali, Rwanda. Olney, D.K., R. Rawat, and M.T. Ruel. 2012. “Identifying Potential Programs and Platforms to Deliver Multiple Micronutrient Interventions.” Journal of Nutrition 142 (1): 178S–85S. Pelletier, David, Dia Sanou, Suzanne Gervais, and Jackson Tumwine. 2018. “Boundary- Spanning Actors in Complex Adaptive Governance Systems: The Case of Multisectoral Nutrition.” International Journal of Health Planning and Management 33 (1): e293–e319. https://doi.org/10.1002/hpm.2468. Piatti-Fünfkirchen, Moritz, Liying Liang, Jonathan Kweku Akuoku, and Patrice Mwitende. 2020. “Rwanda Nutrition Expenditure and Institutional Review 2020.” Washington, DC: World Bank Group. Qureshy, L., M. Piatti, A. Subandoro, and K. Okamura. Forthcoming. “Strengthening Accountability for Nutrition Results.” Washington, DC: International Bank for Reconstruction and Development (IBRD)/World Bank. Rawat, Rahul, Phuong H. Nguyen, Silvia Alayon, Marie Ruel, Sunny S. Kim, Disha Ali, Kuntal Saha, and Purnima Menon. 2015. “Learning How Programs Achieve Their Impact: Embedding Theory-Driven Process Evaluation and Other Program Learning Mechanisms in Alive and Thrive.” Food and Nutrition Bulletin 34 (3_suppl2): S212–25. https://doi.org/10.1177/15648265130343s207. Reinhardt, Kristina, and Jessica Fanzo. 2014. “Addressing Chronic Malnutrition through Multi- Sectoral, Sustainable Approaches: A Review of the Causes and Consequences.” Front Nutr 1 (August): 1–11. https://doi.org/10.3389/fnut.2014.00013. Rokx, Claudia, Ali Subandoro, and Paul Gallagher. 2018. Aiming High, Indonesia’s Ambition to Reduce Stunting. Washington DC: International Bank for Reconstruction and Development (IBRD)/World Bank. 40 Ruel, Marie T., and Harold Alderman. 2013. “Nutrition-Sensitive Interventions and Programmes: How Can They Help to Accelerate Progress in Improving Maternal and Child Nutrition? Lancet 382 (9891): 536–51. Shekar, Meera, Jakub Kakietek, Julia Dayton Eberwein, and Dylan Walters. 2016. An Investment Framework for Nutrition: Executive Sunmary. Washington, DC: World Bank Group. https://doi.org/10.1596/25292. Shrimpton, Roger, Nkosianthi Vusizihlobo Mbuya, and Anne Marie Provo. 2016. “The Double Burden of Malnutrition in East Asia and the Pacific: Evidence and Lessons Learned for a Multisectoral Response.” Washington, DC: International Bank for Reconstruction and Development (IBRD)/World Bank. SNV, KIT (Royal Tropical Institute), CDI (Centre for Development Innovation of Wageningen UR), and SDC (Swiss Agency for Development and Cooperation). 2017. “The Power of Multi-Sectoral Governance to Address Malnutrition Insights from Sustainable Nutrition for All in Uganda and Zambia Sustainable Nutrition for All in Uganda and Zambia.” The Hague, Netherlands. SUN (Scaling Up Nutrition). 2019. “Scaling Up Nutrition (SUN) Movement Progress Report 2019.” https://scalingupnutrition.org/progress-report-2019/. SUN. 2021. “The SUN Civil Society Network Launches Its New 5-Year Strategy.” https://scalingupnutrition.org/news/the-sun-civil-society-network-launches-its-new-5- year-strategy/. SUN Movement. 2020. “Strategic Review of the Scaling Up Nutrition (SUN) Movement, 2019– 2020,” April 2019–20. https://scalingupnutrition.org/wp- content/uploads/2016/09/SR_20160901_ENG_web_pages.pdf. WHO (World Health Organization). 2014. “Global Nutrition Targets 2025: Policy Brief Series.” Geneva: WHO. WHO. 2019. “Nutrition in Universal Health Coverage.” Geneva: WHO. World Bank. 2013. Improving Nutrition through Multisectoral Approaches. Washington, DC. https://doi.org/10.1016/j.envpol.2006.08.031. World Bank. 2016. “Indonesia’s Rising Divide.” Jakarta, Indonesia. World Bank. 2017a. “Indonesia Economic Quarterly Upgraded.” Washington, DC. https://pubdocs.worldbank.org/en/519051497412363381/IEQ-June-2017-ENG.pdf. World Bank. 2017b. “Rwanda Nutrition Situation Analysis and Policy Implications.” Washington, DC. World Bank, and the Republic of Indonesia, MoH (Ministry of Health). 2017. “Operationalizing a Multi-Sectoral Approach for the Reduction of Stunting in Indonesia: An Application Using the 2007 and 2013 Riskesdas.” Working paper. Washington, DC. 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 (askhnp@worldbank.org, tel 202 473-2256). 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