Political Economy of Nutrition Policy in Senegal Ashley M. Fox ANALYSIS & PERSPECTIVE: 15 YEARS OF EXPERIENCE IN THE DEVELOPMENT OF NUTRITION POLICY IN SENEGAL Political Economy of Nutrition Policy in Senegal June 2018 Ashley M. Fox Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal © 2018 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW, Washington, DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved This work is a product of the staff of The World Bank and the Cellule de Lutte Contre la Malnutrition (CLM; Nutrition Coordination Unit of the Government of Senegal) with other external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. 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Examples of components can include, but are not limited to, tables, figures, or images. All queries on rights and licenses should be addressed to the Bureau Exécutif National de la Cellule de Lutte contre la Malnutrition (BEN / CLM), Rue 07 Point -E - BP 45001 Dakar – Fann, Sénégal; tél : 33 869 01 99; fax: 33 864 38 61; e-mail: ben@clm.sn. Cover photo: Adama Cissé/CLM Cover design: The Word Express, Inc. Acknowledgments T his report was written by Ashley M. Fox, PhD, MA. Acknowledgments to Abdoulaye Ka, Menno Mulder-Sibanda, and Marc Nene. The author would also like to thank Jennie Law for her assistance with the network mapping and graphics. Reviewers. We are grateful to all reviewers of the reports of the series—Elodie Becquey (IFPRI), Patrick Eozenou (World Bank), Dominic Haazen (World Bank), Derek Headey (IFPRI), Abdou- laye Ka (CLM), Jakub Kakietek (World Bank), Ashi Kohli Kathuria (World Bank), Christine Lao Pena (World Bank), Biram Ndiaye (UNICEF), Jumana Qamruddin (World Bank), Claudia Rokx (World Bank). They each generously dedicated their time and effort, and their invaluable input played an important role in the evolution of the series. Partners. We would also like to give thanks to the following members of the task force of development partner organizations, who provided guidance on the conceptualization, implemen- tation and finalization of the series: Sophie Cowpplibony (REACH), Aissatou Dioum (UNICEF), George Fom Ameh (UNICEF), Julie Desloges (Government of Canada), Aida Gadiaga (WFP), Laylee Moshiri (UNICEF), Aminata Ndiaye (Government of Canada), Marie Solange N’Dione (Consultant), and Victoria Wise (REACH). Client. Finally, our greatest appreciation is extended to the dedicated staff of the CLM, whose work is chronicled in the series, and the thousands of health workers and volunteers who are daily delivering life-saving nutrition services to vulnerable populations throughout Senegal. This work was conducted under the guidance of Menno Mulder-Sibanda (Task Team Lead and Senior Nutrition Specialist, World Bank). The series was prepared by a team led by Andrea L. Spray (Consultant). Aaron Buchsbaum (World Bank) supported publishing and dissemination, along with Janice Meerman (Consultant) and Laura Figazzolo (Consultant). Information regard- ing the financial support for the series is provided at the end of the report. About the Series T he government of Senegal, through the Cellule de Lutte contre la Malnutrition (Nutrition Coordination Unit) (CLM) in the Prime Minister’s Office is embarking on the development of a new Plan Stratégique Multisectoriel de Nutrition (Multisectoral Strategic Nutrition Plan) (PSMN), which will have two broad focus areas: (1) expanding and improving nutrition ser- vices; and (2) a reform agenda for the sector. The reform agenda will include policy reorientation, governance, and financing of the PSMN. The PSMN will discuss the framework and timeline for the development of a nutrition financing strategy, which will require specific analysis of the sector spending and financial basis, linking it to the coverage and quality of nutrition services. Senegal is known for having one of the most effective and far-reaching nutrition service delivery systems in Africa. Chronic malnutrition has dropped to less than 20 percent, one of the lowest in continental Sub-Saharan Africa. Government ownership of the nutrition program has grown from US$0.3 million a year in 2002 to US$5.7 million a year in 2015, increasing from approximately 0.02 percent to 0.12 percent of the national budget. Yet, these developments have not led to enhanced visibility of nutrition-sensitive interventions in relevant sectors such as agriculture, education, water and sanitation, social protection, and health. The absence of nutrition-sensitive interventions in the relevant sectors, combined with the recent series of external shocks, has favored continued fragmentation of approaches, discourse, and interventions that address nutri- tion. In addition, there is no overall framework for investment decision making around nutrition, which puts achievements made to date in jeopardy. Meanwhile, nutrition indicators are stagnat- ing and other issues with major implications (such as low birth weight, iron deficiency anemia, maternal undernutrition, and acute malnutrition) have received little or no attention. A review of policy effectiveness can help raise the importance of these issues, including house- hold and community resilience to food and nutrition insecurity shocks, as a new priority in nutrition policy development. This series of analytical and advisory activities, collectively entitled Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal (“the se- ries”), aims to support the government of Senegal in providing policy and strategic leadership for nutrition. Further, the series will inform an investment case for nutrition (The Case for Investment in Nutrition in Senegal) that will: (1) rationalize the use of resources for cost-effective interven- tions; (2) mobilize actors and resources; (3) strengthen the visibility of nutrition interventions in different sectors; and (4) favor synergy of interventions and investments. The series was produced with guidance from a task force of development partner organizations under the leadership of the World Bank, and in close collaboration with the CLM. The task force comprised representatives from the following organizations: Government of Canada, REACH, UNICEF and the World Bank. Documents in the series: Report Description Nutrition Situation in Senegal An analysis of the nutritional status of key demographic groups Marc Nene in Senegal, including the geographic and sociodemographic inequalities in nutrition outcomes and their determinants. Evolution of Nutrition Policy in An historical analysis of the nutrition policy landscape in Senegal, Senegal including the evolution of nutrition policies and institutions and Andrea L. Spray their respective implications for programming and prioritization of interventions. Political Economy of Nutrition An analysis of the policy and political levers that can be used Policy in Senegal in Senegal to foster government leadership and galvanize the Ashley M. Fox intersectoral coordination needed to mainstream nutrition into government policies and programs, and effectively, efficiently, and sustainably deliver nutrition interventions. Nutrition Financing in Senegal An analysis of the allocated funding to nutrition interventions in Marie-Jeanne Offosse N. Senegal from 2016 to 2019, estimates of budgetary capacity for financing nutrition by government, and estimated costs for selected high-impact interventions. Capacities of the Nutrition An analysis of the organizational and institutional capacities for Sector in Senegal addressing nutrition in Senegal, covering the CLM, key ministries, Gabriel Deussom N., Victoria and other stakeholders contributing to improvements in nutrition at Wise, Marie Solange Ndione, the central, regional, and local levels. Aida Gadiaga Cost and Benefits of Scaling Analysis of the relative costs and effectiveness of alternative Up Nutrition Interventions in scenarios for scaling up nutrition interventions in Senegal over the Senegal five years covering the PSMN. Christian Yao Risks for Scaling Up Nutrition Analysis of the potential risks to the scale-up of nutrition in in Senegal Senegal, their likelihood of occurrence, potential impact, and Babacar Ba potential mitigation measures. A Decade of World Bank The World Bank Independent Evaluation Group Project Support to Senegal’s Nutrition Performance Assessment Report, which evaluates the extent to Program which World Bank operations supporting nutrition in Senegal from Denise Vaillancourt 2002–14 achieved their intended outcomes and draws lessons to inform future investments. Acronyms Acronym English Acronyme Français AGETIP Executing Agency for Public AGETIP Agence d’Exécution des Travaux Works and Employment d’Intérêt Public ANPECTP National Agency of Early ANPECTP Agence Nationale de la Petite Childhood Development and Enfance et de la Case des Tout- Reception Centre Petits  BEN National Executive Bureau BEN Bureau Exécutif National CL Local Government CL Collectivités Locales Collectives CLM Nutrition Coordination Unit CLM Cellule de Lutte contre la Malnutrition CNP Community Nutrition Project PNC Projet de Nutrition Communautaire CNSA National Food Security CNSA Conseil National sur la Sécurité Council Alimentaire DPNDN National Policy for the DPNDN Document de Politique National Development of Nutrition de Développement de la Nutrition DSRP Poverty Reduction Strategy DSRP Document de Stratégie de Paper Réduction de la Pauvreté ENDA-EVE Environment Development ENDA-EVE Environnement et Développement Action in the Third World— du Tiers Monde—Eau, Vie, Water, Life, Environment Environnement FAO Food and Agriculture FAO Organisation des Nations Unies Organization of the United pour l’Alimentation et l’Agriculture Nations LPDN Nutrition Policy Letter LPDN Lettre de Politique de Développement de la Nutrition MAER Ministry of Agriculture and MAER Ministère de l’Agriculture et de Rural Equipment l’Equipement Rural MDG Millennium Development OMD Objectifs du Millénaire pour le Goal Développement MEN Ministry of Education MEN Ministère de l’Education MEPA Ministry of Livestock and MEPA Ministère de l’Elevage et des Animal Husbandry Productions Animales MSAS Ministry of Health and Social MSAS Ministère de la Santé et de Affairs l’Action Sociale Acronym English Acronyme Français NGO Nongovernmental ONG Organisation organizations Nongouvernementale PNDS National Health PNDS Plan National Développement Development Plan Sanitaire et Social PRN Nutrition Enhancement PRN Programme de Renforcement de Program la Nutrition PSE Emerging Senegal Plan PSE Plan Sénégal Émergent PSMN Multisectoral Strategic PSMN Plan Stratégique Multisectoriel de Nutrition Plan la Nutrition REACH Renewed Efforts Against REACH Efforts renouvelés contre la faim Child Hunger and et la sous-alimentation undernutrition SDG Sustainable Development ODD Objectifs de Développement Goals Durable SUN Scaling Up Nutrition SUN Mouvement pour le Movement Renforcement de la Nutrition SWAp Sector-Wide Approach SWAp Approche sectorielle SWOT Strengths, weaknesses, AFOM Atouts, Faiblesses, Opportunités, opportunities, and threats Ménaces UHC Universal Health Coverage CSU Couverture Santé Universelle UNICEF United Nations Children’s UNICEF Fonds des Nations Unies pour Fund l’enfance USAID United States Agency for USAID Agence des États-Unis pour le International Development Développement International Unless otherwise indicated, child nutrition indicators referenced in this report are taken from the UNICEF- WHO-World Bank Joint Child Malnutrition Estimates1. Contents Executive Summary 1 Introduction 5 Methods and Analytic Approach 13 Results 15 Discussion 31 Conclusion 35 Appendix A: List of Key Informant Interviews 37 Appendix B: References to Nutrition in Line Ministry Policy Documents 39 Appendix C: Categories of Nutritional Interventions 41 Endnotes 43 References 45 List of Boxes Box 1: Degree of Multisectoral Organizational Collaboration 8 List of Figures Figure 1: Conceptual Framework 7 Figure 2: Relationships among the Major Line Ministries by Type of Project 17 Figure 3: Networks Working on Nutrition-Related Activities 18 Figure 4: The Overlapping Mandates of Nutrition-Specific, Nutrition-Sensitive, and Agriculture and Food Security Initiatives 27 List of Tables Table 1: Summary of Evidence of Commitment to Nutrition 16 Table 2: Summary of Factors Influencing Government Commitment to Nutrition 21 Table 3: Most Important Problems Facing Senegal by Urban and Rural Populations During Food Crisis, 2008–09 25 Table 4: Percent of Population Considering Food Insecurity to be Senegal’s Most Important Problem, Relative to Other Concerns 26 Table 5: Opportunities to Advance Nutrition on the Agenda 29 Photo: Adama Cissé/CLM Executive Summary A lthough adequate nutrition is considered piv- opportunities, and threats (SWOT) to scaling up multi- otal for improving health and development in sectoral nutrition governance in Senegal. low and middle income countries, nutrition has frequently received less attention and funding from With the ultimate goal of delivering nutrition interven- governments than other health issues, arguably due tions in Senegal effectively, efficiently, and sustainably, to its multisectoral nature: Without a single institution- the objective of this analysis is to identify the policy and al home, nutrition has suffered from collective action political levers that can be used to promote (1) gov- dilemmas and the inability of stakeholders to work to- ernment leadership toward nutrition; (2) intersectoral gether to foster attention and action on the issue. As a coordination of nutrition programming; and (3) the result, political commitment to nutrition is often weak mainstreaming of nutrition into government programs or lacking. This report conducts a case study of Sen- and policies. egal, a country considered to be relatively successful in multisectoral nutrition programming and nutritional Major results are as follows: outcomes, to analyze the politics of multisectoral nutri- tion governance. ®® Senegal is well poised to make significant progress in scaling up a multisectoral approach to nutrition Political economy analysis involves an exploration of programming with national coverage, but at the the politics behind policy development, including an time of this writing this remains more of an aspira- assessment of who stands to gain and who stands tion than a reality. to lose from policy decisions and can consequent- ®® The government of Senegal has committed in sev- ly shed light on the reasons for high (or low) political eral concrete ways to nutrition policy since 2000, commitment to an issue. Through in-depth interviews setting it apart from peer countries: with thirty policy actors, document review, and drawing §§ The creation of the Cellule de Lutte contre la Mal- from existing political economy frameworks and public nutrition (Nutrition Coordination Unit) (CLM) in administration literature on multisectoral governance, 2001 under the Office of the Prime Minister with the report analyzes the major strengths, weaknesses, Political Economy of Nutrition Policy in Senegal 1 a direct mandate to coordinate nutrition activities multisectoral platform with the institutionalization throughout the country. of staff who serve as nutrition focal points in major §§ The existence of a budget line for nutrition in the line ministries and the development of relationships national budget, starting in 2001, with increases across sectors and organizations. over time, and a requirement for an explicit bud- get line for nutrition in local government budgets. Weaknesses §§ The institutionalization of a multisectoral ap- proach, in principle, leading each relevant ministry ®® Overlapping mandates. Territorial conflict be- to commit an explicit budget line to nutrition and to tween what falls under the domain of food security report on nutrition indicators as elaborated in the versus nutrition, and a lack of lay understanding of new Document de Politique National de Dével- the difference between food insufficiency and nu- oppement de la Nutrition (National Policy for the tritional deficiencies may compromise nutrition’s Development of Nutrition) (DPNDN). ability to advance its agenda. §§ The development and large-scale implementa- ®® The “invisibility” of nutrition. The inability to tion of the national Programme de Renforcement show or articulate the concrete effects of nutrition de la Nutrition (Nutrition Enhancement Program) programs in the short term masks the severity of (PRN), which reaches approximately 70 to 80 the problem and makes it difficult to demonstrate percent of all children under age five. progress on meeting nutrition objectives.2 ®® Recent investments in nutrition from external do- ®® Competing priorities. President Macky Sall’s nors and the presence of the Scaling Up Nutrition administration is focused on universal health cov- (SUN) Movement coincided with the development erage (UHC) and maternal mortality and faces the in Senegal of the DPNDN and the Plan Stratégique increasing demand for attention to overnutrition as Multisectoriel de la Nutrition (Multisectoral Strate- opposed to undernutrition within the sector. gic Nutrition Plan) (PSMN). ®® Political will. Lack of both commitment to and funding of nutrition programming by line ministries. The following are the SWOTs that Senegal faces to ®® Partner coordination. Lack of coordination among facilitate the coordination of a national, multisectoral donors or willingness of donors to coordinate approach to nutrition programming and service delivery. activities. ®® Crowd out. Potential “crowd out” of government or line ministry funds by donor support and CLM Strengths activities. ®® Capacity constraints. Human resource and ca- ®® Institutional ownership. The existence of the CLM pacity constraints—the insufficient number of and its success as a coordinating body with a di- trained nutritionists at all levels (for example, in line rect seat in the Prime Minister’s office sets Senegal ministries and at the local level) has broad implica- apart from other countries by providing a platform tions for policy and programming. for multisectoral coordination of activities. ®® National nutrition program. Under the leadership Opportunities of the CLM, Senegal has successfully implemented a coordinated national nutrition program through ®® Multisectoral Strategic Nutrition Plan (PSMN). a national office and three regional offices and The successful advancement of the DPNDN in documented its efficacy at addressing nutritional 2015 has reanimated multisectoral discussions and problems. led to a general agreement on the need to better ®® Multisectoral governance network. Coordi- coordinate efforts across ministries, the accep- nated by the CLM, the country has developed a tance of a budget line for nutrition, and the explicit 2 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal measurement of nutritional outcomes in each rele- Threats vant ministry. The creation of the PSMN provides an opportunity to institutionalize attention to nutrition. ®® Double-edged sword of success. The perceived ®® New and existing partners. The recent interest of success in the reduction of stunting has helped sell new donors—particularly the European Union and the investment case for nutrition to the Ministry of the Government of Canada, as well as ongoing Finance, but has also caused donors to diminish moral support from the United Nations Children’s their concern about nutrition. The government may Fund (UNICEF)—has encouraged renewed mo- already believe it is doing what it can for nutrition, mentum in scaling up nutrition programming. and donors may want to place their funds in areas ®® Plan Sénégal Émergent (Emerging Senegal with greater need. Budget analysis may show there Plan) (PSE). Nutrition has historically been and are already substantial funds going to nutrition pro- currently is recognized as an important indicator of grams potentially leading to lower investment. development, and the country is eager to show it- ®® Lack of clear articulation of what specific pol- self as an emerging nation that does not suffer from icies will be effective at scaling up nutrition food insecurity or nutritional deficiencies. could lead to little happening in practice. There ®® SUN Movement. The presence of the SUN Move- is a need to more widely replicate results from the ment, though not currently the principal driver of PRN and other nutrition programs and seek nation- nutrition programming and coordination, also pro- al coverage of what works. vides an opportunity to draw further attention to ®® Insufficient incentives in line ministries to pri- nutrition both internationally and domestically. oritize nutrition and conflict between horizontal ®® Act 3 (decentralization). The adoption of Act 3 in and vertical implementation of nutritional in- 2013 has reaffirmed the responsibility of local gov- terventions. The community service delivery of ernments in financing and implementing nutritional nutritional interventions is currently horizontally programming. managed; that is, communities, nongovernmental ®® Problem framing. The demonstration of the im- organizations (NGOs), and local governments are pact of nutrition programs on outcomes as opposed horizontally organized institutions. By contrast, to outputs; for instance, rather than measuring cov- the ministries are organized vertically and follow erage of nutritional interventions (such as vitamin A separate service delivery systems with their own coverage or reductions in iodine deficiency), show- demarcation. Likewise, local government collec- ing the impact on cases of blindness and cognitive tives (CLs) do not coincide with any service delivery ability. Or finding more meaningful statistics, such planning level. As a result, the vertical systems do as the contribution of nutrition improvements to not connect with the decentralization structures, economic growth or a reduction in mortality. which may hamper the ability to mainstream nutri- ®® Align nutrition goals with emerging issues. tion programming within the sectors. These include: agricultural independence and ®® Weak state capacity. There are few trained nutri- climate change resilience, obesity, UHC, and ma- tionists in the country and limited capacity to train ternal mortality reduction. large numbers of nutritionists. Line ministry staff of- ®® Maintain attention. Capitalize on public attention ten do not have training in nutrition. to food insufficiency in the wake of the global food ®® Lack of donor coordination. In spite of efforts like crisis and the first 1,000 days initiative to educate the SUN Movement and the DPNDN to coordinate about nutrition. Build momentum for tackling nu- nutrition efforts, donors may still want to operate trition indicators for which there has not yet been independently of a broader framework and donor sufficient progress, such as reducing the prev- funds may crowd out national funds if the govern- alence of anemia in pregnant women to reduce ment sees a good deal of money and attention maternal mortality. going to nutrition. Political Economy of Nutrition Policy in Senegal 3 ®® Future role of the CLM in coordinating nutrition. ®® Outcomes change slowly and may be dependent Too much reliance on the CLM as an implementer on deep behavioral and cultural change. For in- rather than a coordinator of activities may result in stance, it will be hard to move the needle on certain the CLM being spread too thin. nutritional outcomes, particularly in northern Senegal where the traditional nomadic lifestyle impedes such nutritional interventions as crop diversification. 4 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal 1 Introduction S enegal has a reputation for having one of efficiencies in the provision of services. A series of the most effective and far-reaching nutrition external shocks, including food shortages stemming service delivery systems in Africa. Chronic from drought, the global financial crisis, and the in- malnutrition has dropped to less than 20 percent, one stability of prices for local foodstuffs since 2007, has of the lowest in Sub-Saharan Africa. The reduction in revealed the continued need for additional investment stunting in particular has been deemed a success in in nutrition and better intersectoral coordination of ac- Senegal with the prevalence of child stunting one of tivities to counter cyclical attention to nutrition and a the lowest in Sub-Saharan Africa in absolute terms predominant focus on food insufficiency rather than a (Nene 2017). This success has at least in part been broader focus on nutrition. attributed to broad-based government commitment to nutrition, which has grown from US$0.3 million per To this end, the government of Senegal, through the year in 2002 to US$5.7 million per year in 2015, in- CLM, is in the process of drafting the new PSMN to creasing from approximately 0.02 percent to 0.12 develop a reform agenda for the sector. The PSMN percent of the national budget. will lay out a framework and timeline for the develop- ment of a nutrition financing strategy that will require Yet concerns remain regarding whether the level specific analysis of the sector spending and financial of government support for nutrition is sufficient and basis, linking it to the coverage and quality of nutrition the degree to which nutrition has been as effective- services and assessing the contribution of different ly “mainstreamed” across major line ministries, such sectors and actors to the budget. as agriculture, education, water and sanitation, social protection and health, to support both nutrition-specif- As part of the Analysis & Perspective: 15 Years of ic and nutrition-sensitive interventions. Moreover, the Experience in the Development of Nutrition Policy in nutrition field as a whole is characterized by a myriad Senegal series, the World Bank commissioned this of actors (international donors, NGOs, and technical report to elaborate the specific political challenges support agencies) whose interventions are not well to and opportunities for further raising the profile of coordinated, leading to duplications of effort and in- nutrition on the government’s agenda and secure a Political Economy of Nutrition Policy in Senegal 5 sustainable effort to reduce maternal and child malnu- Fostering Political Attention to Nutrition: trition. The nutrition agenda is often prone to political Conceptual Framework economy challenges when it competes for govern- ment support, as the impact of nutritional intervention To analyze the factors influencing national attention to is neither immediate nor tangible. Though the benefits nutrition, this study draws on several existing political of proper nutrition are life-long and are foundational to economy frameworks. The conceptual framework for proper growth and development, nutrition can fall by this analysis is presented in figure 1. the wayside in policymakers’ inevitably shorter-term outlook. The framework suggests that political commitment (measured by verbal expressions of commitment and With this in mind, the objective of this report was to institutional and budgetary outlays) depends on (1) the identify the policy and political levers that can be used development of effective issue networks to promote to foster government leadership and galvanize inter- the cause of nutrition; and (2) the degree to which sectoral coordination that mainstreams nutrition into key actors in the issue networks take advantage of government policies and programs and effectively, windows of opportunity to advance nutrition. Political efficiently, and sustainably delivers nutrition interven- commitment is viewed as necessary to the effective tions in Senegal. scale-up of nutrition interventions and improvements in population nutritional status. Below we outline each The following were the major study questions: component of the model, including how political com- mitment is being operationalized. ®® What has been the level of success since approx- imately 2000 in raising the political visibility of nutrition, what have been the positive drivers, and Measuring Political Commitment to Nutrition what have been the barriers? ®® Why and when do political elites have incen- Lack of political commitment has been identified as a tives to implement and deliver effective nutrition primary reason for the low priority that food and nutri- policies? tion intervention receives from national governments ®® How can other actors including international orga- relative to the high disease burden caused by malnu- nizations, civil society organizations, and the media trition. However, the concept of political commitment is influence policymakers to continuously and trans- rarely adequately defined or empirically measured in a parently implement nutrition strategies? way that can assess whether it is having an impact on ®® When efforts are undertaken, how can they be tar- outcomes. How can we gauge whether a government geted at the most vulnerable sociodemographic has committed itself to advancing nutrition? groups, women and children in particular? Research suggests that political commitment has Political “visibility” or “commitment” was defined by three components: (1) expressed commitment; (2) three measurable indicators: budgetary commitment; and (3) institutional com- mitment (Fox et al. 2011; Heaver 2005). Expressed ®® The amount of funding committed by the govern- commitment is the weakest of the three forms of com- ment, at the central and at the local level, to the mitment—it involves only the rhetorical commitment nutrition agenda of high-level leaders to nutrition through speeches or ®® The salience of nutrition in key national policies and establishment of nutrition targets and the inclusion of programs nutrition indicators in government reports. Budgetary ®® The level of coordination among various sectors or commitment includes the translation of plans into bud- relevant government’s constituent parts gets and the provision of adequate resources to carry 6 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal FIGURE 1: Conceptual Framework Factors Influencing Political Commitment to Effective Issue Networks Nutrition (National and Local) Network and Actor Features Windw of Opportunity • Stated Commitment • Strategic framing • Problem Stream • Budgetary Commitment • Cohesive Governance (focusing event • Institutional Commitment • Leadership draws attention to • Nutrition Policies. (i.e., policy champions) the problem of poor Strategic Plan nutrition) • Nutrition Governance/ • Policy Stream Issue Characteristics Mains treaming (credible set of • Severity policy demands • Tractability ready to be (simple/uncontroversial Scale-up of advanced) solutions) Nutrition Programs • Politics Stream • Mobilized affected groups Across the Country (change in leadership • Nutrition Specific or openness External Environment • Nutrition Sensitive to an issue) • Donor finding/attention from external actors • Allies/Opponents/ Issue competitors • Norms (degree of controversy over issue) them out, which adds additional credibility to institu- Bilateral donors, technical agencies, and international tional commitments. An ideal budgetary commitment NGOs provide substantial additional sources of fund- would take the form of a dedicated budget line with ing for nutrition programming. Research suggests that annual increases. Institutional commitments are more donors are more likely to work in countries that have concrete and demonstrable, although they vary in already demonstrated a commitment to a given health the degree to which they are binding. These include issue. However, reliance on this support from donors the establishment of laws, decrees, national strategy may crowd out or displace government support. papers, or other institutional structures, such as the creation of a secretariat, institution, full-time technical The multisectoral nature of nutrition requires an addi- team, or the hiring of staff members dedicated to nutri- tional level of commitment to create a multisectoral tion. More concrete forms of institutional commitment governance structure that can effectively coordinate include the development and implementation of oper- among various sectors and constituent parts (such as ational plans. ministries of health, agriculture, livestock, and water and sanitation). Literature suggests that a successful Special role of the donor community in measuring multisectoral governance structure is one that fosters budgetary commitment in low- and middle-income collaboration and not just networking or coordination countries. One challenge of measuring budgetary across relevant line ministries (Natalicchio 2011). The commitment in low- and middle-income countries is degree of multisectoral organizational collaboration that the government may not be the only or even the pri- can be measured along a continuum, summarized in mary source of funding for health or nutrition services. box 1. Thus, an additional measure of government Political Economy of Nutrition Policy in Senegal 7 BOX 1:  Degree of Multisectoral Organizational improving their nutritional situation should not overly Collaboration favor urban areas and should instead favor pro-poor nutrition policies. Factors Determining Political Commitment to Nutrition Effective Issue Networks Although adequate nutrition is considered pivotal for improving health and development in low- and mid- dle-income countries, nutrition has frequently received less attention and funding from governments than oth- er health issues. Studies that examine government commitment to nutrition is the degree of multisectoral attention to different health threats have found the coordination and ownership achieved. emergence of effective policy communities or issue networks to be crucial to fostering attention and re- A government that is deeply or credibly committed to sources. An issue network3 is a set of organizations nutrition will embed policies, programs, and governance with a stake in an area of public policy. Issue networks structures within its political institutions and provide ad- exhibit a close, stable, cooperative relationship among equate resources to deliver nutrition interventions at a set of interest groups and may partner with govern- scale. A government can be said to be credibly commit- ment (Jordan 2011). ted to nutrition once nutrition is effectively mainstreamed within the system, or in other words, once various sec- Previous literature has identified three overarching tors or relevant government’s constituent parts have factors that influence the emergence of effective issue dedicated responsibilities to nutrition that are backed networks as shown in figure 1: (1) network and actor up by official policy and underwritten by adequate and features; (2) issue characteristics; and (3) external recurring funding streams, all of which are unlikely to be policy environment (Shiffman et al. 2016). reversed even if there is a change in regime. ®® Network and actor features include the existence Targeting of Vulnerable Groups. Previous research of champions or policy entrepreneurs who promote on the political economy of nutrition and agriculture the problem or issue, the governance and cohe- has noted a distinctive urban bias in the orientation siveness of the policy community, and the methods of government policy. Bates’s (1981) seminal work on these actors employ to strategically frame the issue the topic found that postcolonial African governments to make it more appealing to policy makers. favored pricing policies that distinctly harmed rural ag- ®® Issue characteristics describe the intrinsic nature ricultural producers but helped urban populations by of an issue that may make it more or less appealing keeping the costs of food low to curb urban unrest. to address, including its severity (for example, more Nutrition policy in many countries, including Senegal, prevalent or virulent illnesses with worse effects will has appeared to follow the same logic. Food distribu- naturally garner more attention), its tractability (how tion programs have tended to target the urban poor easy it is to address including the presence of ac- rather than rural agricultural producers. Thus, in addi- ceptable solutions), and the power of the group(s) tion to an overall concern about nutrition status in the that it affects (the more general, less stigmatized country, governments that are genuinely committed to the group, the more attention it will receive). 8 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal ®® Finally, the external policy environment describes and includes the timing in a political cycle (such as factors outside the immediate control of the network the beginning or end of an administration’s term), that influences its potential effectiveness, including which can influence how much political capital can the degree to which donors or others in the interna- be spent on a particular issue. tional community are paying attention to an issue, the presence of powerful allies or opponents (such Effective issue networks are able to strategically ex- as in private industry), and the degree to which the ploit these moments of opportunity or are able to create issue violates deeply held norms or values (AIDS, moments of opportunity by generating attention in the for example, may come into conflict with norms of problem, policy, and political streams. Conversely, in- appropriate sexuality and sexual behavior). effective networks let these moments pass and do not actively advance problems and solutions or look for Windows of Opportunity to Advance political openings. Nutrition Existing Research on Political Commitment to Because governments face many issues that vie for Nutrition their attention and scarce resources, literature on the policy process further finds that the issues that Previous research on political commitment to nutrition are successful at moving to the top of government has shown that, compared with other health issues, agendas are those whose network actors effectively nutrition suffers from several intrinsic issue charac- exploit “windows of opportunity” that open in relative- teristics that make it more difficult to advance on a ly predictable ways though with unpredictable timing. national agenda. These include (1) its multisectoral Kingdon (2003) suggests that windows of opportuni- nature, which contributes to the lack of an obvious ty to advance policy issues open when three largely institutional home, such as a ministry of health or a independent streams converge at the right moment: ministry of agriculture; (2) its invisibility and irrevers- (1) a problem stream; (2) a policy stream; and (3) a ibility (that is, it is hard to garner attention for problems politics stream. you cannot see or show and for which prevention is the only cure); (3) diverse policy solutions requiring ®® An opening in the problem stream occurs when multisectoral coordination; (4) low actor power (the some event highlights an issue. This event may be lack of an institutional home disperses the policy com- the onset of a crisis, such as a famine, or more rou- munity, low engagement of experts, and weak voice tine, such as World Food Day highlighting statistics of those most affected); and (5) poor political context showing the poor state of nutrition in the country. (lack of donor or national ownership of the problem) ®® The policy stream refers to the existence of solu- (Heaver 2005; Natalicchio et al. 2009; Pelletier et al. tions. Problems that have simple policy solutions 2011; Reich and Balajaran 2012). that are politically uncontroversial will have the greatest likelihood of moving up on the agenda. In a comparison of Bangladesh, Bolivia, Guatemala, The presence of effective policy champions or en- Peru, and Vietnam, the Mainstreaming Nutrition Initia- trepreneurs can be helpful in identifying when the tive found that only 1 of the 12 factors explored was moment is right to advance a particular policy. crucial to building political commitment: The existence ®® The politics stream refers to changes in gov- of credible indicators of the problem (Pelletier et al. ernment occasioned by regular elections or other 2011). Issue networks within countries that were more scheduled events, as well as unpredictable events effective at demonstrating the severity of the problem (such as an economic crisis), that change the gen- were more likely to succeed in having the government eral political mood. The politics stream affects the commit resources to nutrition. Other overarching les- willingness of an administration to tackle issues sons included the fact that the generation of political Political Economy of Nutrition Policy in Senegal 9 commitment required sustained efforts from policy en- tangible incentives include advancing organizational trepreneurs and champions. In the absence of these goals (agency prestige or power, reducing risk, and champions, midlevel actors from ministries and external enhancing gain, for example) or personal and profes- partners had great difficulty translating political windows sional values and goals. of opportunity for nutrition into concrete operational plans, due to capacity constraints, differing professional Organizational Structures, Values, Culture, and Ex- views of undernutrition, and disagreements over inter- perience. Program structures are often designed to ventions, ownership, and roles and responsibilities. In follow a common, more sectorally restricted understand- addition, the pace and quality of implementation of nu- ing of an issue, resulting in traditional interventions that tritional interventions were severely constrained in most target traditional groups and needs. The training and cases by weaknesses in human and organizational ca- experience of nutrition workers differ considerably from pacities from national to frontline levels. the training and experience of workers in other disci- plines, even from that of other workers in the health Challenges of Fostering Multisectoral Coordina- sector. In a ministry of health, for example, the institu- tion. In addition to the challenges posed by nutrition’s tional focus and professional frame of discourse center specific issue characteristics, several common or- on disease. Nutrition activities tend to be relatively ganizational challenges hamper the formation of the small as a proportion of the budget and are usually not multisectoral collaborations necessary to advance perceived to be part of the ministry’s core focus. nutrition. Box 1 outlines a hierarchy of multisectoral collaboration with networking (or exchanging informa- For multisectoral action on nutrition to be effective, or- tion) as the weakest form and collaboration (enhancing ganizational structures may need to be redesigned to capacity for mutual benefit) as the strongest. Previ- allow for a focus on nutrition in line with the multisec- ous research has outlined a variety of organizational toral understanding of its causes. Strictly vertical or challenges to working multisectorally, which include top-down approaches will likely not work well if organi- factors related to both internal and external environ- zations need to reach across sectoral boundaries and ments.4 Some of the external factors have already integrate their actions—but partner organizations may been addressed in the discussion of the generation of operate exactly that way. effective issue networks (such as effective leadership, cohesion, and issue framing); internal factors that may Faced with the need to work with partners outside the jeopardize multisectoral collaboration include incen- organization, a high premium may need to be placed tives, capacity and organizational structures, values, on operational flexibility and on allowing supervisors cultures, and experience. and managers to facilitate such flexibility. Staff may need to work around the often rigid rules of bureaucra- Incentives. Obtaining extra resources, especially cies. Highly bureaucratic cultures, with multiple levels financial resources and staff, can provide a strong in- of approval or rules that provide only for restricted ways centive to coordinate, though additional financing is of doing things, make interagency collaboration more not the only incentive for cross-sectoral collaboration. difficult. Making sure decision makers understand the Legal provisions can also mandate that organiza- multisectoral causes of nutrition and are aware of how tions act together, which can initiate some forms of each agency contributes to the problem and its solu- cooperation. Institutional arrangements can support tion—a genuine focus on achieving results rather than interactions, but personal and organizational incen- defending institutional or bureaucratic prerogatives— tives must provide initial and sustaining motivations. may support attempts to build a more flexible structure. However, legal impositions are rarely enough to sus- tain cooperation, particularly in countries where law Organizational culture may undermine an appropriate enforcement and institutional capacity are weak. Less structure—working multisectorally is often new to most 10 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal partners, and staff will likely bring their own perceptions the challenges of working with others, even integrating of the problems and solutions to the table. Partici- the ideas or interventions of others into their own pro- pating organizations must be open to looking at and gram designs. Thus, overcoming sectoral boundaries understanding problems and solutions from different and finding ways of fostering multisectoral collabora- perspectives. They must be willing to find solutions to tion is a key facet of building commitment to nutrition. Political Economy of Nutrition Policy in Senegal 11 Photo: Adama Cissé/CLM 2 Methods and Analytic Approach T he challenges to developing effective health list). The interviewees included representatives from programs in developing countries are often the CLM, staff serving as nutrition focal points from viewed as technical. Political economy analy- the major line ministries involved in nutrition, repre- sis involves an exploration of the politics behind policy sentatives of major technical assistance partners, development, including an assessment of who stands donors financing nutrition initiatives in Senegal, rep- to gain and who stands to lose from policy decisions.5 resentatives of international and domestic NGOs with Policies cannot be developed without governments, a presence in the field of nutrition, local government and although the state bears the ultimate duty in the representatives, academics, and parliamentarians, policy process, considerations of state effectiveness, among others. Additional interviews and personal and therefore politics, are often not given explicit at- communications were conducted in New York with two tention in the field of nutrition or elsewhere. World Bank staff members associated with the nutri- tion program in Senegal. All interviewees consented To address this gap, this study used a prospective to participate in the research. Notes were taken during approach to political economy analysis (Reich and the interviews. Follow-up with interviewees was agreed Balajaran 2012), employing open-ended interviews to during the first interview and was done when infor- with 30 stakeholders, document review, and analysis mation was lacking or needed clarification. In addition, of relevant, available data on public attitudes, bud- the researcher made use of secondary data, including getary commitments, and mapping of multisectoral documents from the government of Senegal and the collaboration. World Bank. Open-ended stakeholder interviews Analysis During December 2015, the principal researcher con- The accuracy of interviewees was tested by triangula- ducted interviews in Senegal with key informants in tion with other informants and documentation. Formal the field of nutrition (see appendix A for a detailed coding of interview transcripts and notes was not con- Political Economy of Nutrition Policy in Senegal 13 ducted, but the author looked for emerging themes A detailed network mapping exercise recently iden- that cut across interviews and therefore surfaced as tified the range of nutrition projects operating in the most prominent. country and the organizations implementing and financing them. To examine organizational coordina- tion, we generated network maps that allow us to view Operationalization of the Conceptual Model which organizations work together, which do not, and how weakly or strongly different networks are coordi- The main outcome of interest in this analysis is the nated (figures 2 and 3). degree to which the government is committed to nutri- tion policy. To assess the country’s degree of political Participation in the SUN Movement could also be commitment, we examined evidence of each type of considered an indication of institutional commitment commitment separately. because membership requires that countries take cer- tain steps to foster multisectoral collaboration. ®® Expressed commitment was identified through mentions of nutrition in major policy documents, Finally, we were interested in the degree to which including the country’s recent PSE, which is the various line ministries had demonstrably committed national reference document for economic and so- themselves to nutrition by including nutrition out- cial policy, and other national development plans,6 comes (either deficiencies or food security) as an as well as a qualitative assessment based on the explicit indicator in official ministry reports or whether impressions of key informants in the nutrition field. there were mentions of nutrition in those documents. The presence of high profile, visible champions To assess this, we used the following search terms was also counted as a form of expressed commit- in a set of official documents from each ministry: ment. Participation in the SUN Movement could “nutrition,” “securité alimentaire,” and “carences en also be a form of expressed, symbolic commitment micronutriments.” that signals the world community that a country is interested in advancing nutrition goals. Together, we defined a “credible commitment” to nu- ®® Budgetary commitment was measured as the trition as a commitment that becomes increasingly amount and type of funding committed by the difficult to rescind as it becomes institutionalized over government, at the central and local levels, to the time. nutrition agenda and whether a budget line exists.7 ®® Institutional commitment was assessed in sever- To examine how issue networks and windows of al ways. First, the existence of key national policies opportunity influenced political commitment, the and programs was assessed. Countries that have stakeholder interviews were open-ended but probed an explicit body dedicated to nutrition should be the presence of specific nutrition champions, prob- considered more institutionally committed to nutri- lem-framing strategies, issue characteristics, and tion than countries in which this type of body does organizational tensions, among other factors that have not exist or is subsumed within a larger division in been shown to affect overall government commitment a line ministry, as it is likely that a more prominent to nutrition in previous research. The researcher division will garner more attention and resources. also consulted available public opinion data to ex- The development of national nutritional policies amine public demand for nutrition and food security and the level of coordination among various sec- initiatives, urban-rural differences in policy preference, tors or government constituents are also forms of and impression of the governments’ performance on institutional commitment. nutrition. 14 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal 3 Results Recent Political Commitment to Nutrition in standing to the issue. Attention to food security has Senegal remained consistently high, particularly because of the food crisis of 2009. However, most references to Senegal has committed itself to nutrition in several con- nutrition by top officials appear to be more perfunc- crete ways: symbolically, institutionally, and through tory than genuine, suggesting this is not a deeply its budgets (table 1). Senegal has a long history of embedded personal priority of the present or former nutrition programming dating from the colonial and ex- administration. tending into the postcolonial era. In 2000, the focus of nutrition programs shifted from a predominantly crisis Budgetary Commitment management approach, which established interven- tions in response to the occurrence of a crisis (drought Senegal has also committed itself to nutrition through or devaluation) during the 1980s and 1990s, toward an its budget, with the creation of a direct budget line approach characterized by a political vision and long- for nutrition in the national budget in 2001, and with term strategy for the improvement of the nutritional increases over time. CLs are also required to have situation after 2000 (Spray 2017). a budget line for nutrition, though it is fairly widely recognized that the fulfillment of this budget line re- Expressed Commitment mains more an aspiration than a reality. Government investment in nutrition has grown from an estimated In terms of its expressed commitment to nutrition, US$0.3 million per year in 2002 to US$5.7 million per following the Millennium Development Declaration year in 2015 increasing from approximately 0.02 per- in 2000, Senegal has consistently included nutrition cent to 0.12 percent of the national budget.8 Donors targets in its poverty reduction strategy papers. Nutri- substantially supplement this budget and provide a tion was a major focus of the former First Lady, Vivian wide variety of nutrition-related programs across the Wade, which brought some additional attention and country. Political Economy of Nutrition Policy in Senegal 15 TABLE 1: Summary of Evidence of Commitment to Nutrition Type of Evidence of Commitment Room for Improvement Commitment Expressed • Mention of nutrition in the PSE • Although food security is an explicit policy objective for commitment • Mention of nutrition in speeches the Sall administration, nutrition is not Budgetary • Dedicated national budget line for • Donor commitment at the national level may be commitment nutrition with annual increases crowding out domestic commitment of resources • Requirement of a dedicated budget line • The line ministries count CLM support and donor for nutrition in local budgets assistance as part of their existing budgets, leading them to believe they do not need to commit additional resources to nutrition • CLs do not have adequate capacity to self-finance nutrition initiatives Institutional • The establishment of and continued • Participation of the ministries not deeply embedded; commitment government support for the CLM support at the top of the ministries is lacking • Recent development of the DPNDN • SUN Movement incomplete: Private and academic • Participation in the SUN Movement platforms need to be built as well as a multiactor platform. • Staff serving as nutrition focal points in major line ministries • Most line ministries do not currently include nutrition as an explicit or even implicit goal • Requirement that line ministries include nutrition as an explicit indicator in their • Few mentions of nutrition in ministry reports, except for policy documents those ministries implementing the PRN Institutional Commitment in 2001 by the new President of the Republic. Initial- ly housed under the office of the President, the CLM Senegal is also committed institutionally to nutrition in was moved to the Office of the Prime Minister where several ways that have been particularly instrumen- it could have more influence and work more inde- tal to the further promotion of nutrition objectives in pendently.11 The CLM was commissioned to assist the the country. Senegal is one of 18 countries that rec- government in developing a multisectoral nutrition pol- ognize a “right to food” in its constitution (article 98) icy and ensuring implementation of nutrition programs. and which recognize the primacy of international law It brings together representatives of several line min- over national law, which arguably commits the coun- istries, representatives of local governments, NGOs, try legally to nutrition promotion.9 Although a “right to and the private sector. Through the CLM, Senegal has food” technically exists in the constitution, the inter- institutionalized a multisectoral approach, in principle, views indicate that the nutrition policy community did requiring each relevant ministry to commit an explicit not use this as an advocacy lever. Senegal adopted budget line to nutrition and to report on nutrition indi- the Lettre de Politique de Développement de la Nutri- cators as elaborated in the DPNDN. tion (Nutrition Policy Letter) (LPDN) in 2001, updated it in 2006, replaced it with the DPNDN in 2015, and Act 3, adopted in 2013, reinforced Senegal’s move to- is in the process of developing the PSMN.10 In 2011, ward decentralization, spelling out the responsibilities Senegal decided to join the SUN Movement, which of Senegal’s over 500 local governance units. Respon- demonstrates to the broader international community sibility for public health and nutrition programming has its overall commitment to nutrition. now been transferred to the control of local CLs. More concretely than these largely symbolic actions, Senegal implements its nutrition policy through the Senegal’s institutional commitment to nutrition is PRN, its signature national nutrition program. The shown by the CLM. The CLM was created by decree CLM was created initially with a mandate to imple- 16 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal FIGURE 2: Relationships among the Major Line Ministries by Type of Project Source: Based on data from REACH 2015. ment the PRN. Prior to the development of the PRN, Economy and Finance, Decentralization, Trade, In- nutrition programming was conducted on an ad hoc dustry, and Agriculture, Family, Water and Sanitation, basis—individual projects operating in a relatively iso- Environment, Fishing, and Livestock). The major line lated fashion, usually within one sector, with a finite life. ministries involved in the implementation of the PRN The PRN represented a shift away from this project are the Ministry of Health and Social Affairs (MSAS), approach to a system-wide, multisectoral program that Ministry of Education (MEN), the Agence Nationale could ultimately serve as the national platform for im- de la Petite Enfance et de la Case des Tout-Petits plementing nutrition programs. Moreover, in contrast (National Agency of Early Childhood Development with previous approaches, the PRN was more explicitly and Reception Centre) (ANPECTP), the Ministry of targeted at rural areas. Institutionally, the PRN has its Agriculture and Rural Equipment (MAER), and the own personnel, but for operations it relies on multilevel Ministry of Livestock and Animal Husbandry (MEPA). and cross-sectoral collaboration with several minis- MEN implements iron supplementation and deworm- tries, NGOs, the private sector, local governments, and ing of school children in collaboration with the CLM, the communities themselves. The PRN is currently not as well as running school lunch programs and nutri- the responsibility of any line ministry but falls under the tion education in the schools, which have implications purview of CLM, though different ministries implement for improving nutrition. ANPECTP implements similar various parts of the PRN. CLs also assist in imple- programming in daycare centers, and MAER imple- menting the PRN, though there are concerns about ments nutrition-sensitive agricultural policies, cash their capacity to do so. The CLM is in the process of assistance, and microcredit programs, among others, transferring more responsibility for the implementation which have implications for household food security. of the PRN to the line ministries and the CLs. Figure 2 shows graphically the relationships among The CLM coordinates its activities with twelve principal the major line ministries and the types of projects ministries (Health and Social Assistance, Education, they work on. Visual inspection of this network graph Political Economy of Nutrition Policy in Senegal 17 shows that there is a dense set of actors working on a ed above (Natalicchio 2011; Garrett and Natalicchio number of core activities. Deworming, screening, and 2011). The loan between the government of Senegal growth promotion are examples of core activities with and the World Bank to finance the PRN obligated the multiple actors that work across the issues involved. government to fulfill these agreements and ensure in- Other nutrition activities are characterized by more teragency cooperation. This arrangement has further sparse networks, with actors that work only on a sin- entrenched nutrition institutionally and through the gle nutrition issue. For instance, MAER and the Food budget in Senegal. Technology Institute work only on small-scale fortifica- tion but no other nutritional issues. The CLM, however, Getting the institutions right appears to be a key is tied to every nutritional activity. challenge in nutrition, and Senegal has seeming- ly succeeded in institutionalizing the CLM as a core Figure 3 shows the relationships among each of the coordinator of nutrition policy and programming. major organizations working on nutrition-related activi- The good reputation of the CLM in terms of both its ties and their issue overlap. This network graph reveals governance and results has earned it considerable that there are many organizations working together on respect and the ear of the Prime Minister and other different issues. In figure 3, the CLM emerges as a high-ranking officials. In this respect, the government’s central bridge organization working across different commitment to nutrition appears credible. A previous nutrition activities and among the line ministries. attempt by a Prime Minister to eliminate the CLM and other government bodies housed in the Primateur’s The organizational arrangements created in 2001 office was quickly defused at least in part because of were supported by legal and budgetary obligations CLM’s reputation as a well-run organization. The CLM on the part of the government of Senegal. Execu- has weathered a series of different Prime Ministers tive Decree 2001-770, passed in 2001, created the and withstood attempts to merge it with the Conseil CLM and gave legal effect to the arrangements not- National de la Securite Alimentaire (National Food Se- FIGURE 3: Networks Working on Nutrition-Related Activities Source: Based on data from REACH 2015. 18 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal curity Council) (CNSA), which is also housed under The academic training in agriculture includes an el- the Prime Minister’s office, but focuses more on food ementary course in nutrition. The École Nationale relief. The CLM’s reputation for being well managed Supérieure d’Agriculture de Thies is the principal insti- has protected it on a number of occasions.12 tution for advanced training in agriculture in Senegal. Agricultural experts at government agencies generally It is also important to note the close relationship between acknowledge that they lack knowledge of nutrition. A the World Bank and actors on the ground in Senegal study of the nutrition sensitivity of the agriculture sector in the key decisions and advocacy approach that led in Senegal found that while agriculture specialists had to the creation of the CLM and the PRN. Workshops received a basic course in nutrition during their training organized by the Bank to develop the multisectoral in agriculture, this knowledge was perceived as inad- approach began in 2001 and brought together other equate and outdated (Lachat et al. 2015). Capacity in development partners with government representa- nutrition at the local level is particularly lacking. tives. Using an advocacy tool called PROFILES, which was designed to help decision makers at the national Summary: Current Political Commitment to level understand the benefits to the overall economy of Nutrition fighting malnutrition, nutrition advocates were able to convince key officials in the representatives of the Min- In spite of the apparent visibility of nutrition in Sen- istry of Finance and MSAS to revamp nutrition policy in egal, there are limitations and continuing challenges the country using CLM and the PRN approach (Natal- to sustaining attention and mainstreaming nutrition icchio 2011; Garrett and Natalicchio 2011). The World programming. Expressed, institutional, and budgetary Bank tied the making of its loan to the elaboration of commitments could be stronger. a nutrition policy. The PRN could begin only after the government of Senegal had drafted a nutrition policy Expressed commitment. Although nutrition has man- for the country. Were it not for this deliberate and for- aged to carve out a protected space in Senegal, it ward-thinking approach, it is unclear whether the CLM does not appear to be a top priority of the current gov- would have been created or that nutrition policy would ernment in terms of overall expressed commitment. have advanced to this point. In this sense, the creation Nutrition enjoyed some attention from the first lady and continual good management of CLM appears to be under former president Wade but does not appear quite pivotal in advancing nutrition policy. at the time of this writing to have prominent visible champions (in spite of having a number of behind the Human resources and capacity gap. Since 1998, a scenes champions, including the various heads of the Master of Science in nutrition has been offered at the Bureau Exécutif National (National Executive Bureau) Université Cheikh Anta Diop in Dakar. The two-year (BEN) of the CLM13 and other respected individuals program trains students for employment in nutrition in the nutrition community). The presence of the SUN and food science, with attention to public health nutri- Movement, which is learning more from Senegal than tion in the form of nutrition interventions and nutrition it is providing in technical support, has the potential epidemiology. The program is open to students with to bring international attention to the issue of nutri- a variety of backgrounds, including agronomy and tion. The fact that the Sustainable Development Goals veterinary sciences. The university also offers a PhD (SDGs) will likely continue to include nutrition as a pri- program in nutrition. A recent study of nutrition training mary goal also bodes well for maintaining nutrition as programs across West Africa revealed that low capaci- a metric in the DSRP. ty for human nutrition training is a region-wide problem (Sodjinou et al. 2014). Many nutritionists in the region Budgetary and institutional commitments. In the receive their training abroad, for example at the Uni- current nutrition governance arrangements, each rel- versity of Alexandria in Egypt. evant line ministry has a staff member who serves Political Economy of Nutrition Policy in Senegal 19 as a nutrition focal point and is responsible for imple- capacity to raise adequate funds or implement nutrition menting some portion of the PRN. However, in reality, programming on their own. The central government’s there is a lack of both commitment to and funding of budgetary commitment to nutrition operates primarily nutrition programming by line ministries. An analysis through its allocations to the CLM, which, along with of major policy documents from each line ministry donors, finances nutrition programming. working on nutrition revealed that only MSAS, MAER, and ANPECTP included any substantive discussion The central government may believe that its budget- of nutrition, and none addressed the impact of its ary commitment to the CLM constitutes an adequate interventions on nutrition indicators. (See appendix allocation to nutrition. Donor financing of nutrition B.) A recent systematic analysis of policy documents initiatives may also crowd out further government fi- completed for Renewed Efforts Against Child Hunger nancing of nutrition—the government can claim credit and undernutrition (REACH) showed that few of the for the success of the PRN and the work of the CLM, documents reviewed contained explicit references to much of which continues to be primarily financed by nutrition (REACH 2015). Furthermore, a 2013 analy- donors. Furthermore, several large donor-funded pro- sis of 13 national policy documents, which examined grams are coming to an end. For instance, the Global the nutrition sensitivity of the country’s agricultural Alliance for Improved Nutrition’s and the Micronutrient policy, found that on average, the policy documents Initiative’s salt iodization, micronutrient supplementa- contained only 8.3 (49 percent) of the 17 character- tion, and food fortification programs are wrapping up. istics considered to enhance the nutrition sensitivity This could leave structural gaps in programming not of agricultural programs by the Food and Agriculture supported by additional funding. Organization of the United Nations (FAO) (Lachat et al. 2015). In addition, there is a human resources and capacity gap—not enough skilled people who have training in An additional challenge is that the nutrition focal point both nutrition and other sectors or who have training staff are viewed by ministry leadership in the line minis- in both nutrition and food security. Skilled individu- tries as implementing the CLM’s programs rather than als are needed to undertake the mainstreaming of implementing ministry activities. Likewise, ministry nutrition. leadership claim credit for funding nutrition programs, even though the funding comes from the CLM. Minis- Thus, the actual level of institutional commitment tries have not yet committed an explicit, independent within the multisectoral governance framework is less budget line to nutrition that is separate from the CLM’s than first appears. A full appropriation of responsibil- budget or the budget support of donors. The recent ity for nutrition by leadership in the line ministries is process to develop the DPNDN has reignited en- lacking. thusiasm for intersectoral collaboration, but there is concern among some that this accord could amount to empty pledges of support without external incentives RECOMMENDATIONS from the top in support of collaboration. Similarly, at the national level, although a budget line for nutrition exists, the total amount of government re- sources going to nutrition is considered insufficient, and donor funding for nutrition is not well coordinated. Much of the responsibility for financing and implement- ing nutrition programming has been transferred to the CLs, but it is widely accepted that CLs do not have the 20 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal TABLE 2: Summary of Factors Influencing Government Commitment to Nutrition Network and Actor Features Strategic • Misapprehension that food security and nutrition are one and the same framing • Further opportunities to portray food security as necessary but not sufficient for improved nutrition, for example, using a map showing overlay of food insecurity and poor nutrition • Potential opportunity to combine government attention to agricultural independence with crop diversity efforts • Underexploited opportunities to pair nutrition programming with UHC, maternal mortality, agricultural self-sufficiency, and obesity and noncommunicable diseases Cohesiveness • The CLM has been an effective coordinating body; placing the CLM in the Prime Minister’s office has and elevated the priority of nutrition multisectoral • Nutrition has secured high-level attention, an updated national nutrition plan (DPNDN) has been governance adopted, and a national strategy (PSMN) is being developed • CLM wants to mainstream nutrition by transferring some of its implementation responsibilities to the ministries Leadership • The CLM, in conjunction with the World Bank and donor partners, has become pivotal in the degree of commitment to nutrition in the country • Effective leadership of the CLM has raised the profile of nutrition and promoted coordination across line ministries Issue characteristics Severity • Conflation of food insecurity with nutrition means that food distribution efforts get political attention, but other less visible, nonimmediate nutrition issues (such as micronutrient deficiencies) get less attention • Food insecurity is a clear priority of the Sall administration, and nutrition is understood to be part of this • No single ideal indicator of the overall nutritional status of the population; hard for lay people to understand complex sets of outcomes • High performance on reducing stunting may lead to the perception that the problem is less severe, reducing attention to nutrition Tractability • Complicated set of multisectoral interventions involving behavior change, monitoring, service provision, partnering with the private sector, and agricultural interventions is required to effectively move the needle on nutrition • Need for multisectoral participation hampers action; not all parties recognize their role • The PRN is a concrete government program (as opposed to a project) that the government can lay claim to, but it has not been implemented nationwide • Good, but incomplete, evidence base in support of the PRN Mobilized • Those suffering from malnutrition or nutritional deficiencies are not mobilized because many nutritional affected groups deficiencies are invisible • Suffering populations tend to be poor and marginalized; more attention is paid to urban than rural malnutrition for political reasons • Those suffering most from malnutrition are culturally distinct and may resist lifestyle changes that would be necessary to reduce malnutrition External policy environment Donor funding • Donor activity and investment in the sector are high; near national coverage of nutrition interventions and attention through the PRN • Support of industry on fortification efforts • Increasing donor attention to obesity and chronic disease • Donor community not well coordinated, particularly across different types of interventions • Multiple subsystems of donors tackle different aspects of nutrition Opponents, • Few outright opponents except the processed food industry for obesity programs potential allies, • Undermining of fortification programs by informal salt vendors and competing • Competition from agricultural sustainability, food security, UHC, maternal mortality, and issues noncommunicable diseases could crowd out attention to nutritional deficiencies and undernutrition Norms • Capitalize on momentum of the SUN Movement to bring more international attention to Senegal as a success case for nutrition • Capitalize on inclusion of nutrition as a Millennium Development Goal (MDG) and an SDG to encourage explicit attention to nutrition in country’s development plans Political Economy of Nutrition Policy in Senegal 21 Factors Influencing Government Commitment ly understood by many not trained professionally in to Nutrition: Issue Networks and nutrition. There is room for improvement in the nutri- Opportunities to Advance Nutrition Policy tion community to frame nutrition in a way that gets more attention. For instance, the phrase “food security This section analyzes the major factors affecting the is necessary but not sufficient for nutrition” helps to degree to which actors in nutrition have been able clarify that nutrition goes beyond lack of food. Maps to focus government attention on nutrition as well of Senegal overlaying areas suffering from food in- as opportunities for improvement. (See table 2 for security with areas suffering from malnutrition, which a summary of main points.) We aim to answer the demonstrate that they are not one and the same, may questions of how effective the nutrition issue network further underscore this distinction. in Senegal has been and how it can be strengthened. Overall, we find that although there has been strong As the use of the PROFILES tool in 2001 demon- leadership from the CLM, which has built a degree strates, additional care could be taken to show the of cohesiveness in the nutrition field and raised the underlying economic and developmental effects of profile of nutrition, more work remains to be done in poor nutrition on human capital formation and the building further cohesion and framing nutrition in a contribution of poor nutritional status to other health way that gets more attention. The PSMN presents issues and related costs. an opportunity to work on building this cohesion and attention. Cohesiveness and multisectoral governance. Nu- trition frequently suffers from the fact that the nutrition Network and Actor Features policy community comprises a wide range of actors that focus on different aspects of nutrition (such as As previously discussed, issue networks that are nutritional deficiencies and food insufficiency) and cohesive, have effective or high-profile leaders and that may feel as if they are competing for resources. champions and are successful at strategically fram- The multisectoral nature of the causes of poor nutri- ing their issues will be more successful at drawing tion means that participation is required from sectors attention to their preferred policy area than other is- that may not even realize their impact on nutritional sue networks. Below we discuss the network and actor outcomes, such as agriculture, water, and sanitation. features of Senegal’s nutrition community. Consequently, nutrition issue networks have tended not to be very cohesive. Strategic framing. Although advocates for nutri- tion programming have been relatively successful at Senegal has made significant progress in overcoming garnering government attention, there remain oppor- these sectoral boundaries. With the institutionalization tunities to strategically frame nutrition in ways that of the CLM, nutrition has received the highest political could raise its priority. According to most stakeholders attention in Senegal for more than a decade. Under the in nutrition, the field of nutrition is not well understood impetus of the national government and in collaboration among the media, policy makers, and the public at with the World Bank, the country has successfully estab- large. In particular, there is a widespread tendency lished a dialogue with various stakeholders in nutrition among various actors to conflate nutrition with food and institutionalized structures for concerted action. insecurity. Food insecurity is believed to be the prima- Factors that contribute to this success are a clear man- ry challenge to reducing malnutrition—increasing the date and personal commitments from high-level policy amount of food available, as opposed to addressing makers and the effective leadership of the CLM, which the nutritional value of food, is believed to be the prin- have given it a well-regarded reputation that is recog- cipal solution. Specific nutritional deficiencies (such nized at the highest levels. In addition, much experience as of vitamin A and iodine) and their effects are poor- was gained from the completion of the second phase 22 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal of implementation of the PRN from 2007 to 2014. The to nutrition in Senegal, more strategic framing is need- new DPNDN was signed by the Prime Minister in Janu- ed to make nutrition a higher priority. ary 2016. The process of revising the DPNDN brought all stakeholders together, which reinvigorated the dis- Severity. Health issues with consequences that are course on multisectoral action around nutrition. perceived to be more severe may get more attention (Shiffman et al. 2016). Demonstrating the severity of The cohesiveness of the nutrition policy community is the impact of nutrition on health is made difficult by the likely at a peak at the time of this writing and engage- multiple conditions caused by poor nutrition and the ment will likely continue through the development of numerous indicators for each. For instance, few lay the PSMN. That said, there remain risks to the overall people appreciate the distinctions among acute and cohesiveness of the sector, in particular the need to find chronic malnutrition, wasting and stunting. Likewise, incentives for the sectors undertaking nutrition-sensi- the host of specific nutritional deficiencies (such as tive approaches to stay engaged in nutrition policy. anemia, vitamin A deficiency, and iodine deficiency), each causing different health effects (some chronic Leadership. Leadership has been instrumental in re- and others acute), makes summarizing the overall se- newing focus and attention, particularly the leadership verity of the issue difficult. The inability to describe the of the CLM itself and its core technical partner, the nutritional situation of the country in a single indicator World Bank, and with the assistance of renewed inter- (or even a small handful of indicators) may contribute est from Canadian and European Union donor partners. to a blunting of the impact of indicators on policy- Though there are a number of high-level, behind the makers’ assessment of the severity of the problem. scenes champions of nutrition in the country that have Nutrition can be contrasted with diseases like HIV, ma- been very effective at bringing attention to nutrition, one laria, or tuberculosis, for which disease status (yes or element that may be missing from the nutrition network no) is relatively easier to count and report. is a high-level, visible champion—someone well known and respected in the country to promote the issue of One potentially helpful indicator of the severity of mal- nutrition, especially nutritional deficiencies. A singer, nutrition is the finding that nutrition contributes to at a performer, or another widely visible individual would least 50 percent of child mortality, which is mentioned bring added attention to the nutrition issue. On the other frequently in various reports (for example, Rice et al. hand, politically contentious figures may be unable to 2000). This statistic comes from early work by Pelleti- bring positive attention to an issue. er et al. (1994), which has been largely responsible for drawing wider attention to the role of nutrition in Issue Characteristics child mortality. Because malnutrition is rarely listed as a cause of death, the role of malnutrition in child As the nutrition literature has previously identified, cer- mortality was easy to ignore prior to this finding. This tain characteristics specific to nutrition militate against example illustrates that careful attention to the crafting its achieving the level of attention it should be accord- of compelling indicators can move an issue out of its ed given its overall contribution to health, well-being, silo and into the public spotlight. Replicating this sta- and economic development. These characteristics tistic with Senegal-specific data could draw additional include the confusion caused by the complex set of attention to nutrition. indicators related to nutrition and the complicated package of multisectoral interventions required to ad- The long time frame between exposure and outcomes dress nutrition. The low relative power of those most can also dampen attention to nutrition. Nutritional de- seriously affected by malnutrition poses a further chal- ficiencies in youth, such as an iodine deficiency, can lenge to drawing attention to nutrition. Overall, in spite lead to cognitive delays or failure to flourish later in of the solid work that has been done to raise attention life, but making the causal link between a deficiency in Political Economy of Nutrition Policy in Senegal 23 early childhood and later cognitive delay is challeng- trition, other activities, including microcredit programs, ing. The effects of acute malnutrition are much more and agricultural initiatives aimed primarily at increas- visible and immediate. ing crop diversification rather than crop yield, require justification to count as nutrition-sensitive. The increasing prominence of obesity and chronic dis- ease as an emerging priority globally and nationally in Governments want to be able to take credit for doing Senegal also poses a potential challenge to more tra- something to address the problem and ideally be able ditional nutrition programming aimed at under- rather to show that their efforts have paid off. If everything than overnutrition. As overnutrition gains attention, that might potentially improve overall nutritional status policymakers may believe that the problems of un- were to count as falling within the field of nutrition, it dernutrition have been resolved. Keeping a focus on might look as if the country is already doing a great the “double burden” will be important to creating a deal to address it. Counting only nutrition-specific in- strategic link with overnutrition while not allowing it to terventions, however, is too narrow. overshadow undernutrition. The existence of the PRN and the move from a project Likewise, Senegal’s success at reducing stunting orientation to a multipronged program has likely helped could be a double-edged sword. On the one hand, nu- to address the tractability issue because government trition has received a good deal of positive attention in can look to the PRN as the concrete government-sup- Senegal for the improvement of key indicators, such ported policy that is being implemented; but given its as stunting over time, and its relatively high perfor- complexity, understanding what parts of the package mance compared with peer countries. Graphs showing work or whether only the package taken as a whole Senegal’s high performance on stunting have helped will work, continues to be an ongoing challenge. nutrition programming gain traction with the Ministry of Finance, but the success story may lead to reduced The PRN is also not the only multisectoral program investment in nutrition from donors. Carefully framing being implemented in Senegal. A number of pilot ini- the nutrition success case as a work in progress can tiatives and programs that address various aspects of help avoid oversimplifying the measurement of com- nutrition and agriculture exist throughout the country. plex outcomes. Project Yaajeende for instance, funded by the U.S. Agency for International Development (USAID), is a Tractability. Nutrition further suffers from the fact nutrition-led agriculture program that promotes im- that multiple interventions are required to address the proved agricultural and wild-food products and at the underlying causes of poor nutritional outcomes, and same time reduces identified nutritional deficiencies each may require the coordination of diverse sectors. by incorporating microfinance and school-based nu- Appendix C summarizes seven overarching sets of trition initiatives. Parallel food fortification efforts, often interventions required to address the various aspects conducted with industry and donors as partners, add of nutrition. Each subset is complex and often multi- another layer of activities to coordinate. How to de- sectoral itself, such as breastfeeding promotion and cide which of the number of nutrition-related activities prevention of malaria in pregnant women. to pursue as a primary focus of public policy remains an open question. Competition from other programs Given nutrition’s multisectoral scope, defining what is makes attributing success in improving nutrition to and is not a nutritional intervention can be a challenge. government efforts a challenge. The nutrition community has dealt with this complexity by dividing interventions into nutrition-specific and nutri- A final challenge to the tractability of nutrition is the tion-sensitive interventions. Although nutrition-specific fact that deeply embedded cultural practices are a interventions fall quite clearly within the domain of nu- principal reason for continued high rates of malnutri- 24 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal TABLE 3:  Most Important Problems Facing Senegal by Urban and Rural Populations During Food Crisis, 2008–09 (Percent) Problem or affected sector Total Urban Rural Food shortage or famine 33.60 35.10 32.30 Management of economy 13.20 17.70 9.40 Farming and agriculture 11.80 4.80 17.60 Unemployment 9.70 11.60 8.00 Water supply 5.60 1.10 9.30 Health 5.10 4.30 5.80 Poverty and destitution 4.00 4.10 4.00 Electricity 2.20 1.40 2.90 Education 2.20 3.10 1.50 Source: Afrobarometer, http://www.afrobarometer.org. Note: Respondents were asked to list the three most important problems facing the country at the time of the survey to elicit the salience of different issues in the minds of the public. The table presents the percent of those surveyed giving the response as the most important problem. tion and nutritional deficiencies in certain regions of remain leading concerns for the public. Nutrition per the country, such as Matam and Podor. The nomadic se is rarely mentioned as a most important problem lifestyle of groups living in this region contributes to facing the country. the region’s food insecurity and limited food diversity. Policies may therefore need to be culturally tailored External Policy Environment and may be less effective with this group. Donor funding and attention from external actors. Mobilized affected groups. The overall visibility of The prominence of nutrition in international policy doc- nutrition is also reduced because the groups most uments, including the fact that improving nutrition and vulnerable to malnutrition and other nutritional defi- reducing hunger are stand-alone MDGs and SDGs, ciencies tend to be rural and poor. Affected groups are has made nutrition attractive to individuals working in- therefore not highly mobilized. Many may not even be side and outside the health sector and has brought aware they are suffering from nutritional deficiencies. additional attention to the nutrition issue. Likewise, ac- There are no organized groups representing the hun- tors cite the Lancet series (Lancet 2008; Lancet 2013) gry or those suffering from a vitamin A deficiency as and the SUN Movement as having brought additional there are for people living with HIV/AIDS. attention and organization to the nutrition issue. The Lancet series clearly articulated nutrition as a health The historical urban bias in food and nutrition pro- and development issue and provided a common plat- gramming continues, as shown by recent opinion form for evidence-based action. The MDGs and SDGs data (table 3). Food security and overall manage- provide an incentive to governments to show they are ment of the economy are leading preoccupations making progress on these indicators and to include (most important problem) among urban residents, indicators of nutrition in their policy documents. The whereas rural residents view agricultural policy and SUN Movement has also brought international atten- food shortages as primary concerns. Concern about tion to nutrition and can serve as a visible external food security rose sharply during the food crisis of symbol of country’s commitment to nutrition. 2009 (table 4), and continues to be a leading concern among the general public. Next to unemployment and At the same time, donor funding also significantly con- poverty, food shortages and famine and agriculture fuses the picture of what a government is doing on Political Economy of Nutrition Policy in Senegal 25 TABLE 4:  Percent of Population Considering Food Insecurity to be Senegal’s Most Important Problem, Relative to Other Concerns Problem 2002–03 2005–06 2008–09 2011–13 Unemployment 23.90 14.10 9.70 15.50 Poverty and destitution 8.50 7.00 4.00 19.70 Food shortages and famine 17.70 13.60 33.60 13.30 Agriculture 12.80 11.50 11.80 7.70 Management of the economy 4.70 5.10 13.20 1.10 Health 5.10 13.20 5.10 5.80 Crime and security 4.80 2.10 0.60 4.90 Water supply 7.90 6.70 5.60 4.80 Education 3.30 3.90 2.20 4.10 Wages, incomes, and salaries 0.40 3.80 2.80 1.60 Source: Afrobarometer, http://www.afrobarometer.org. Note: Respondents were asked to identify the most important problem facing the country at the time of the survey. The table presents the first response given by those surveyed. nutrition. Research shows that donors tend work more does not face heavy opposition from powerful in- in countries that are already committed to an issue, terests. In fact, biofortification efforts in Senegal likely because they believe they will be more able to appear to have been quite successful at fostering make progress and have an impact in these countries cooperation with industry. However, informal salt (Lieberman 2009). However, an unintended conse- vendors that sell uniodized salt at a cost lower than quence of this dynamic is the potential for the “crowd that for iodized salt pose a challenge to the effi- out” of government resources toward nutrition if the cacy of fortification efforts. Although these informal government believes it can take credit for donor-sup- vendors are not openly hostile to fortification, their ported efforts. Indeed, the fact that donor resources informal market power is difficult to challenge and were already allocated to nutrition seemed to be a regulate. barrier to the willingness of line ministry leadership to On the other hand, although obesity and over- increase investment in this area. nutrition still receive relatively little attention in Senegal, outside Senegal the food industry has For their part, donors want government to have more emerged as a powerful opponent of food regula- “skin in the game.” They may be able to entice govern- tion. If greater attention shifts toward overnutrition, ments to do so by tying their aid or asking for matching opposition from industry could pose a challenge. funds. Thus, donor attention and government attention to nutrition are inextricably linked. ®® Potential allies. Nutrition programming largely has the support of domestic NGOs. Unlike other issue Opponents, potential allies, and competing issues. areas, such as HIV/AIDS, in which domestic NGOs Issues with powerful allies and few opponents or other may be in opposition to government, the govern- issues to compete with have a better chance of being mental nutrition community appears to work closely prioritized by governments because they tend to be with domestic NGOs. Environnement et Dévelop- less contentious and will not raise the ire of powerful pement du Tiers Monde—Eau, Vie, Environnement interests. Overall, nutrition fits this description. (Environment Development Action in the Third World—Water, Life, Environment) (ENDA-EVE) in ®® Opponents. Unlike some highly contentious health particular has taken a leadership role in organiz- issues in which industry is a clear opponent, nutrition ing NGOs with a nutrition focus in both the SUN 26 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal Movement and in the recent development of the FIGURE 4:  The Overlapping Mandates of Nutrition- DPNDN. Nutrition also relies heavily on NGOs to Specific, Nutrition-Sensitive, and Agriculture and Food Security Initiatives implement much of its programming. The cross-cutting nature of nutrition provides strategic opportunities to leverage attention to maternal mortality, agriculture, and UHC, each of which are receiving elevated attention from the government at the time of this writing. Strategically Nutrition- Nutrition- Agriculture and linking to these “issue allies” could help keep nu- Specific Sensitive Food Security trition high on the agenda. For instance, drawing attention to the role of high rates of anemia in ma- ternal mortality or building basic nutrition screening into a UHC package could help maintain attention to these nutrition interventions. ®® Competing issues. Perhaps the larger challenge in nutrition is competition from within the nutrition the CLM and does not have as good a reputation. field between nutrition-specific and nutrition-sensi- For brief period of time, between 2012 and 2013, the tive interventions and the wider sectors that they are head of the CLM served as the head of the CNSA attached to, particularly agriculture and food securi- and combining the two programs was discussed, but ty initiatives that are not explicitly nutrition-sensitive the CNSA has remained independent and mainly fo- (figure 4). cuses on providing food assistance in urban areas. Ongoing tensions with the Ministry of Health, which In the wake of the 2009 food crisis, the government has been somewhat marginalized in nutrition, could has become heavily invested in agricultural resilience also pose a challenge moving forward as the CLM projects with a focus on agricultural independence.14 tries to offload some of its responsibilities for direct This fits into the government’s larger goal of charac- implementation. terizing Senegal as an emerging nation and serves national security interests as well as individual food An additional challenge to the nutrition field is the security interests. Although some elements of these double-edged sword of the government’s efforts to efforts, such as promoting the use of highly nutritious characterize Senegal as an emerging nation. The crops, crop diversification, and seasonal crop rota- government wants to show that it has overcome the tion may contain elements related to nutrition, these health problems associated with poverty such as elements are not clearly spelled out, and the goal malnutrition. The PSE consists of 26 specific activi- of agricultural independence could come at the ex- ties, including improving access to health care, safe pense of nutrition if, for instance, crops like rice are drinking water, and sanitation, as well as strength- stressed. ening nutrition to promote sustainable development with social solidarity and the rule of law at its base. Agriculture and food security programs may therefore However, the government may be more concerned either be allied with or opposed to nutrition. Because with increasing overall agricultural productivity than both are housed under the office of the Primateur, with ensuring the nutritional quality of agricultural the Conseil National de la Sécurité Alimentaire (Na- products. To the extent that there is a conflict be- tional Food Security Council) (CNSA) could also be tween producing a diversity of crops and producing perceived as a competitor to the CLM. Although the a surplus of food, the government will likely prioritize CNSA is more visible, it remains less powerful than quantity over quality. Political Economy of Nutrition Policy in Senegal 27 Norms (degree of controversy and global attention to ®® Nutrition suffers from characteristics that place it at the issue). Overall, nutrition is not a controversial issue. a disadvantage compared to other issues, including In contrast with contentious issues such as HIV, nutri- the complex set of indicators needed to measure tion interventions do not generally conflict with broader nutritional status and a lack of lay understanding societal norms. The broader challenge is convincing of different nutritional deficiencies and their effects. the public and policy makers to care about nutritional ®® The conflation of food security with nutrition poses deficiencies that are often invisible or affect those who an ongoing challenge. do not appear “malnourished”. Whereas reproductive ®® Solutions to address nutrition suffer from the same health issues tend to be controversial, nutrition has an challenge—their complexity and multisectoral na- opportunity to paint its contribution as improving mater- ture make it difficult to assess program inputs, nal and child health, which tend to be less contentious, outputs, and outcomes. for instance, by emphasizing how early childbearing, ®® There is a strategic opening in the agricultural sec- short birth spacing, and maternal undernutrition, includ- tor, but there is a need to ensure that agricultural ing anemia, are major issues in child nutrition. interventions are nutrition-sensitive. In addition, specific efforts to alter traditional eating Policy Windows and Opportunities to habits could pose a challenge for nutrition interven- Advance Nutrition tions. For instance, changing norms to promote exclusive breastfeeding or, in northern Senegal, ef- Is there an opening to advance nutrition? Theory sug- forts to promote food security could come into conflict gests that a convergence of openings in the problem, with nomadic lifestyles. policy, and politics streams presents an opportunity to advance nutrition on the political agenda (table 5). The SUN Movement, of which Senegal is a member, Overall, there appears to be a clear opening in the has brought more international attention to nutrition policy stream and may be an opening in the prob- and works to ensure that the international community lem stream. Actors in nutrition should pay attention remains attuned to it. Senegal’s nutrition governance to building the profile of nutrition and leveraging cur- model is already being highlighted by SUN as a suc- rent political attention to related issues. The policy cessful model to emulate (Mokoro Ltd. 2015). Nutrition network should also clarify its demands from govern- is a stand-alone MDG and remains a stand-alone SDG ment—what exactly does it want? More funding? For even though other health goals have been collapsed what specifically? The report elaborates below on both into a single goal. The Lancet series has also brought opportunities and constraints to building attention to together the international community around a more nutrition in each stream. coherent nutrition agenda. These international norms raise the profile and cohesiveness of policies aimed Problem Stream at nutrition within countries that are members of the nutrition issue network. Nutrition is clearly an issue that has for some time been receiving and continues to receive attention from Summary: Analysis of Issue Networks and the government, as shown by the government’s over- Prospects for Raising the Profile of Nutrition all budgetary and institutional support. The CLM can largely be credited with raising and maintaining atten- ®® In comparison with peer countries, Senegal ap- tion to nutrition. pears to have a relatively cohesive nutrition issue network with good leadership that has made prog- However, more work could be done to highlight nutri- ress in framing nutrition as a problem worthy of tion as an ongoing problem. The food crisis of 2009 government attention. significantly heightened public and political attention 28 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal TABLE 5: Opportunities to Advance Nutrition on the Agenda Openings Opportunities to Advance Nutrition Problem Stream • Nutrition suffers from issue characteristics that place it on a lower rung in the problem stream. Recommendations: • Simplify existing nutrition indicators and show them in a compelling manner, drawing on indicators for which Senegal remains weak, such as anemia and breastfeeding • Distinguish nutrition from food security using maps or rhetorical devices • Highlight nutritional connections with other issues, such as agricultural independence, maternal mortality, and UHC Policy Stream • The development of the PSMN presents a clear opportunity to advance nutrition policy. Recommendations: • Clearly define what counts as nutrition policy as opposed to food security policy • Expand PRN to focus funding and attention on nutrition policy • Better coordinate existing nutritional activities across ministries and across donors using the PSMN and SUN as a platform for coordination • Provide additional support and incentives to CLs Politics Stream • No clear opening in the politics stream, but capitalizing on openings in the policy stream may help build political support. Recommendations: • Build momentum from the recent adoption of the DPNDN • Leverage the good reputation of the CLM • Build Senegal’s international reputation as a nutrition success to the issue of food insufficiency and acute malnu- mortality, harm to human capital formation, or the trition, but it is not clear that this attention has been ways that individuals can have enough food but still channeled toward nutrition efforts as much as toward be malnourished could help further elevate nutrition food security efforts. There may be opportunities to as an issue. leverage attention to food insecurity and sustain- able agriculture to make sure nutritional concerns Policy Stream are addressed in these initiatives. At the same time, the difference between nutrition and food security The launch of the DPNDN in 2015, has provided a needs to be clarified to avoid conflating the two and basis for coordinated action and brought together to ensure that resources are dedicated specifically to stakeholders in a productive exchange. There is an nutrition. For instance, it should be made clear that opening in the policy stream to make significant prog- Senegal cannot meet its emerging nation goal if the ress on nutrition, with the PSMN serving as the policy public continues to suffer from present rates of nutri- document that will spell out the obligations and re- tional deficiencies. sponsibilities of each party. The nutrition community should move swiftly to solidify this progress. The SUN More generally, the confusing set of indicators used Movement can also serve as a platform for advancing to document the nutrition situation could be made a common nutrition agenda. more accessible to the lay public, which might im- prove its understanding of the issue. Highlighting An important consideration in moving forward with the clear statistics showing nutrition’s contribution to child development of the PSMN will be the identification of Political Economy of Nutrition Policy in Senegal 29 specific proposals. Will the goal be to further scale ®® Incentives are needed to induce the ministries to up the PRN nationally? Just as nutrition relies on a take a leadership role in implementing nutrition confusing set of indicators, the multisectoral policies programming designed to address nutrition also make progress on scaling up difficult to measure. The PRN provides a Politics Stream clear package of interventions for funding, but it is not clear that this is the “policy” that the nutrition commu- Although the CLM currently has a good relationship nity is advancing. With the CLM taking a back seat with the national government, there is no opening in in implementation and acting as a coordinator, will the political stream. The government is focused on the line ministries take the lead on implementation? solidifying Senegal’s status as an emerging nation. Alternatively, is the goal of the PSMN to ensure that Agricultural resilience, particularly in rice production, the current patchwork of services provided by a variety is a large piece of this agenda. Although agricul- of actors is coordinated and covers the whole country, ture has clear links with nutrition, the government’s but not necessarily the expansion of the PRN? If the primary concerns are economic development and goal is to increase government financing of nutrition, national security. Demonstrating that agricultural resil- then having a clear plan of what this funding will sup- ience requires a diversity of crops, including those with port is critical. nutritional value, may help better link current political priorities with the nutrition agenda. Some ongoing challenges to the nutrition policy net- work include the following: The recent interest of the European Union and Cana- da in nutrition, and their partnership with the CLM and ®® Contracting out services can raise issues of ac- the World Bank, also presents opportunities to enlist countability, and it becomes hard to distinguish other donors to pool efforts toward a common results government policy from donor-funded projects framework or Sector-Wide Approach (SWAp) for nu- ®® The CLs may lack the capacity to finance and im- trition.15 Both the government and donors need to be plement nutrition programming on their own coaxed to pool their current efforts. 30 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal 4 Discussion T he analysis suggests a window of opportunity to in policy documents. The government has committed further nutrition policy in Senegal. The process itself both in its budget, through the creation of direct of developing the DPNDN has reinvigorated the budget lines for nutrition at the national, local, and nutrition policy community, which, led by the CLM, is ministry levels, and institutionally through the creation now embarking on the development of the PSMN to of the CLM and the recent process of developing the spell out more clearly the roles and responsibilities of its DPNDN and the PSMN. The creation of a stand-alone different actors. Nutrition is receiving renewed attention nutrition unit under the aegis of the Prime Minister from several large donors, including the Government of has been a successful institutional innovation that has Canada and the European Union. Many development served as a critical lever to foster multisectoral nutri- projects want to use improvement in the nutrition- tion programming. al status of the population as a metric, and the SUN Movement continues to focus global attention on nu- Externally, nutrition is also gaining attention interna- trition. The following analysis summarizes the SWOTs tionally with the rising awareness of the critical role that the nutrition community in Senegal faces. of nutrition in the first 1,000 days of life. Nutrition is increasingly being framed as a critical human devel- opment issue and is a stand-alone SDG, just as it SWOT Analysis of the Nutrition Field in was a stand-alone MDG, continuing to give the issue Senegal prominence. The SUN Movement is further building momentum and providing a common results frame- Strengths: High national and international work and approach to raise attention to nutrition. political commitment since 2000 There are few powerful opponents to nutrition, except perhaps the food industry with respect to obesity is- The level of attention accorded to nutrition since 2000 sues and the agricultural sector, which may prioritize has been quite high. There is a deeply embedded, quantity over quality. Overall, nutrition is not a con- credible commitment from the government toward nu- tentious issue and its tight link to child health makes trition that goes beyond stated references to nutrition nutrition an issue of compassion. Political Economy of Nutrition Policy in Senegal 31 Weaknesses single policy solution to improve nutrition; rather, there is a complex set of nutrition-specific and nutrition-sen- Although nutrition is receiving a good deal of attention, sitive interventions, many of which need to be carried genuine multisectoral governance of and further atten- out through community-based delivery systems. tion to nutrition face the following challenges: Opportunities: Strategic framing and pairing Low buy-in, capacity, and cohesiveness in the nu- with other emerging issues trition community. There is a need for more buy-in from the top leadership within line ministries. Analysis The nutrition community should look for opportunities to of recent policy documents from most line ministries show the strategic importance of nutrition to achieving shows little explicit attention to nutrition. As the CLM other emerging goals such as UHC, maternal mortal- transitions away from implementation and toward ity, reduction of obesity, and agricultural and climate oversight, implementation might suffer if the line resilience. Moreover, there appears to be mounting in- ministries do not take over the reins. In addition, low ternational attention to child health, and particularly to capacity at the local level means that the CLs will need the importance of the first 1,000 days of life, with the more support to carry out their mandate. There was economic development field broadly focusing attention general agreement among members of the nutrition on early childhood development. Senegal can benefit community that the CLs do not have the resources to from its image as a nutrition success and the mounting take charge of local nutrition programming. However, global attention to nutrition, although it will have to be clear solutions to this problem have not been spelled careful continue to maintain its progress in the face of out. Moreover, although the process of drafting the its good reputation. DPNDN has brought various actors in the nutrition field together to focus their efforts on uniting behind a Threats national nutrition policy, there remain divisions within the field (such as between food security and nutrition) Nutrition may be overshadowed by other emerg- and it is not clear that the sectors are committed to ing issues. Although there is a great opportunity for working toward nutrition goals. nutrition, there is also a significant threat that nutri- tion will be overshadowed by other emerging issues or Nutrition has an image problem. Nutrition’s specific that the connections with nutrition will be overlooked, issue characteristics militate against its gaining atten- such as by agricultural resiliency projects that stress tion unless the issue is simplified for a lay audience. quantity of food production over quality. With global The nutrition field is highly technical and not well un- and national attention increasingly turning toward obe- derstood by most people and would benefit from efforts sity and chronic disease prevention and treatment, will to clarify its message. The nutrition community needs resources be diverted away from undernutrition and to develop clear indicators, clear messages, and clear nutritional deficiencies? solutions. For many lay observers, nutrition is synony- mous with hunger. Nutrition actors, on the other hand, Competition rather than coordination among seek to distance themselves from this oversimplifica- sectors. To achieve the goals of multisectoral coor- tion and emphasize quality over quantity of food intake. dination and mainstreaming of nutrition, the nutrition Nutrition actors should make the connection with food field needs to coordinate across sectoral boundaries, security explicit while at the same time highlighting which breeds collective action dilemmas. In spite of the independent importance of nutrition to achieving the progress made so far in bringing together stake- health and development goals. The multisectoral de- holders from a variety of sectors and institutions, turf terminants of nutrition force nutrition advocates to work wars and lack of consensus may stifle action, es- across sectors, complicating their efforts. There is no pecially with the large number of interventions and 32 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal activities required to see sustained improvements in necessitate an independent coordinating party, and nutrition. it may be strategically beneficial to frame nutrition as a human development issue that goes beyond health per se. On the other hand, nutrition may also prove to Overarching Issue: Is nutrition better off as be quite successful if it is prominently placed within the a stand-alone issue or connecting with other Ministry of Health and may benefit more broadly from issues and sectors? attention by the health sector, particularly connecting with the issue of child health. Senegal illustrates that housing nutrition in a stand- alone body can assist in attracting attention to the In Senegal, the creation of a stand-alone nutrition unit issue, but the overarching strategic question remains under the aegis of the Prime Minister has been a suc- whether the nutrition field should associate most cessful institutional innovation, but the extent to which closely with the health sector, with agriculture, else- this innovation was successful because of the solid where, or stand on its own? One argument in favor of leadership of the CLM or because of the institution- nutrition having a stand-alone agency is that, in con- al arrangement is difficult to judge. Furthermore, it is trast with an issue like malaria, where it is possible to doubtful that there is a one size fits all solution for all measure whether disease rates are falling, nutrition is countries. The institutional innovation itself may have more like an umbrella category for a variety of con- less to do with the successful advancement of nutrition ditions with myriad determinants. In this regard, the than did the process that led to the development of the nutrition field has a broad mission and mandate that institutional innovation. Political Economy of Nutrition Policy in Senegal 33 Photo: Adama Cissé/CLM 5 Conclusion S enegal is poised to make significant progress ®® Improve strategic framing of nutrition to increase in scaling up a multisectoral approach to nutri- attention to nutrition and differentiate nutrition from tion programming with national coverage, but food security; this remains more of an aspiration than a reality. Major ®® Increase buy-in from top leadership in the ministries; recommendations to strengthen political support for ®® More support to CLs to implement nutrition nutrition include the following: programming; ®® More nutritional training for lay people, health care professionals, and within ministries; and ®® More coordination of funding toward a common re- sults framework. Political Economy of Nutrition Policy in Senegal 35 Photo: Adama Cissé/CLM 36 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal APPENDIX A List of Key Informant Interviews Organization Name, Position Contact Date of Meeting Cellule de Lutte contre la Abdoulaye Ka, Director aka@clm.sn 12/17/15; 12/22/15 Malnutrition (CLM) Ministère de la Santé et Mamadou Bocar Daff, Directeur mdaff@gmail.com 12/10/15; de l’Action Sociale Direction Santé de la Reproduction et Survie de l’Enfant Dr. Maty Diagne, Chef Direction de matydiagne@yahoo.com 12/18/15 la Division Alimentation et Nutrition Ministère de Seynabou (Laye) Toure mmelaye@gmail.com 12/16/15 l’Agriculture et de l’Équipement Rural Ministère de l’Education Khady Diallo khadydiallo@hotmail.com 12/11/15 Nationale (MEN) Agence National de Petit Sophie Gueye Sow (Point Focal sowsophiegueye@yahoo.fr; 12/15/15 Enfance et Cas de Tous Nutrition), Abdou Karim Diouf papekarimdiouf@gmail.com Petits (ANPECTP) (Director de Finance) Ministère de l’Economie, Ndéye Mayé Diouf (Chargée … 12/10/15 des Finances et de la des programmes, MEF/DCEF), maguetten@yahoo.fr  Planification Maguette Ndiaye (Chargé Programmes Agriculture–Elevage) Keur Moussa- Nene Awa Sy (CLM); Ndeye Fatou; nsy@clm.fr 12/14/15 Collectivite Locale de Moustapha Sarr (Mayor de Pout); Pout Francoise Diouf (President de la Commission de la Corporation Decentralisée) USAID Hassan Yaradou hyaradou@usaid.gov 12/15/15 Project Yaajeende Awa Taye Sarr (Specialiste Suivi asdiouf@usaid-yaajeende.org; 12/14/15 (USAID) Evaluation); Karl Rosenberg (Chief krosenberg@usaid-yaajeende.org of Party/Directeur du Projet) Political Economy of Nutrition Policy in Senegal 37 Organization Name, Position Contact Date of Meeting UNICEF George Fom Ameh; Aissatou gfameh@unicef.org ; adioum@ 12/17/15 Dioum unicef.org WFP/PAM (REACH) Sophie Cowpplibony (Directeur sophie.cowpplibony@wfp.org 12/17/15 REACH) GAC (Global Affairs Julie Deloges; Aminata Ndiaye aminata_ndiaye@bacdi-senegal.org 12/18/15 Canada, Government of ; Julie.Desloges@international.gc.ca Canada) EVE (Eau, Vie, Abdou Diouf (Secretaire Executif) abdoudiouf@eve-sn.org 12/15/15 Environnement) Micronutrient Initiative Dr. Balla Moussa Diedhiou bdieddiou@micronutrient.org 12/14/15 (MI) (Directeur Sahel) European Union– Anne Simon—unavailable, Anne.SIMON@eeas.europa.eu Unable to schedule European External traveling meeting Action Service Dr. Mame Mbayame Nutritionist, Parliamentarian, mdioneba65@gmail.com 12/21/15 Dionne Member of the Health Committee; former head of nutrition at Ministry of Health Issakha Diallo Director Convergence Health for issakha.diallo@gmail.com 12/3/15 Development Issa Wone Professor of Public Health, Chiekh issawone@yahoo.fr 12/17/15 Anta Diop Global Alliance for Cheikh Ahmadou Lo (country rep) calo@gainhealth.org 12/22/15 Improved Nutrition Food and Agriculture Komiah Kwadjo (Nutritionniste komlan.kwadjode@fao.org 1/5/16 Organization of the FAO/Bureau Pays) United Nations (FAO) World Bank Menno Mulder-Sibanda; Claudia mmuldersibanda@worldbank.org; 1/27/16; 2/2/16 Rokx crokx@worldbank.org World Health Marietou Diop (Resident diop.yatou@gmail.com Unable to schedule Organization Represenative Dakar) meeting 38 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal APPENDIX B References to Nutrition in Line Ministry Policy Documents Nutrition Major policy References indicators Ministry Year documents searched to nutritiona included Reference Ministère de 2007 Lettre de Politique 1 None “Les produits de la pêche jouent aussi la Pêches Sectorielle des Pêches un rôle primordial dans l’alimentation et de et de l’Aquaculture des populations, avec une contribution l’Aquaculture de 70 percent aux apports nutritionnels en protéines d’origine animale.” Ministère de 2013 Politique Sectorielle 0 None n.a. L’Élevage d’Elevage et des Productions Animales Ministère de 2013 PRACAS (Programme 51 Malnutrition References throughout to “La sécurité l’Agriculture d’Acceleration de la aigue; alimentaire et nutritionnelle»; discussion et Équipage Cadence de l’Agriculture Retard of undernutrition and overnutrition; Senegalaise croissance includes the goal of “(vi) améliorer l’état nutritionnel; la Nouvelle Alliance pour la Sécurité Alimentaire et la Nutrition des populations; carences en micronutriments Ministère de n.a. Lettre de Politique 0 None n.a. l’Agriculture Sectorielle de et de l’Hydraulique et de l’Hydraulique l’Assainissement en Milieu Urbain et Rural Ministère de 2011 Revue Annuelle 0 None n.a. l’Agriculture Conjointe du Secteur et de de l’Eau Potable et l’Hydraulique de l’Assainissement, Document de Travail Political Economy of Nutrition Policy in Senegal 39 Nutrition Major policy References indicators Ministry Year documents searched to nutritiona included Reference Ministère de 2014 Strategie de Securisation 0 None n.a. l’Agriculture de la Production dans et de le Perimetre Concede à l’Hydraulique l’Horizon 2025 Agence 2007 Document de 62 Malnutrition DANSE (Division de l’Alimentation, Nationale de Politique Nationale de de la nutrition et de la santé de la Case des Développement Intégré l’enfant); malnutrition; Programme de Tout-Petits de la Petite Enfance au Renforcement de la Nutrition (PRN); Sénégal surveillance de la croissance Ministère de 2013 Programme 11 État Programmes de nutrition; état l’Éducation d’Amélioration de la nutritionnel nutritionelle; “paquets de services Nationale Qualité, de l’Équité et des enfants intégrés: physique, pédagogique, de la Transparence améliorés de santé/alimentation/nutrition et (PAQUET) organisationnel” Ministère de 2015 Document de Politique 41 Bon état Several references to “Le programme l’Éducation de Sante/Nutrition/ nutritionnel de Santé/Nutrition/Environnement à Nationale Environnement dans le et sanitaire l’Ecole” Systeme Educatif Ministère de 2014 Lettre de Politique 0 None n.a. Gouvernance Sectorielle de Locale Développement (LPSD) de la Gouvernance Locale, du Développement et de l’Aménagement du Territoire Ministère 2009 Plan National de 7 Malnutrition Several references to enquêtes de la Santé Développement nutritionnelles; “(i) de lui rattacher et de la Sanitaire (PNDS) la division de la nutrition et de Prévention 2009–18 l’alimentation qui sera chargée d’élaborer la politique de nutrition et d’alimentation, d’apporter son assistance et son appui à la mise en oeuvre de la surveillance nutritionnelle ainsi qu’aux mesures de lutte contre la malnutrition, Ministère 2007 Plan National 31 Malnutrition Enquêtes nutritionnelles de la Santé Stratégique pour La et de la Survie De L’enfant Prévention 2007–15 Ministère de 2013 Politique Nationale de 2 Malnutrition “La santé communautaire est mise en la Sante et Santé Communautaire oeuvre avec la contribution de tous de l’Action les niveaux de la pyramide sanitaire Sociale du pays et englobe les domaines de la lutte contre la maladie, de la santé de la reproduction et de la survie de l’enfant, l’alimentation et la nutrition, l’eau, l’hygiène et l’assainissement.”; “... le suivi de la croissance, le dépistage de la malnutrition, la supplémentation, la distribution de moustiquaires imprégnées à longue durée d’action et les, campagnes de masse contre les maladies tropicales négligées.” Ministère n.a. Programme de 37 Malnutrition CLM; PRN; fortification; PAIN; enquête de la Renforcement de la aiguë nutritionnelle Commerce, Fortification Industrie et Recherche a “Nutrition,” “securité alimentaire,” and “carences en micronutriments” were searched for in the documents. 40 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal APPENDIX C Categories of Nutritional Interventions 1. Fight against chronic malnutrition 4. The fight against overweight, obesity, and excess §§ Monitoring and promoting growth micronutrients §§ Promotion of exclusive breastfeeding and com- §§ Prevention and management of obesity and plementary feeding overweight §§ Optimal supply of nutrition for a sick child during §§ Nutrition education for a healthy and balanced diet and after illness §§ Prevention and management of noncommuni- §§ Nutrition of pregnant and lactating women cable diseases related to excess micronutrients, §§ Prevention of malaria in pregnant women such as diabetes mellitus and hypertension 2. The fight against nutritional deficiencies 5. Food security §§ Promoting the use of highly nutritious crops §§ Routine supplementation for children from 6 to 59 §§ Promotion of small family farms months §§ Promotion of conservation and storage tech- §§ Campaign for supplementation for children from niques for production at household level 6 to 59 months §§ Promotion of diversification of food production §§ Supplementation of pregnant and lactating wom- §§ Promotion of off-season agriculture en with iron and folic acid §§ Food safety and hygiene §§ Deworming of children and pregnant women 6. The establishment of social safety nets §§ Prevention and management of diarrheal diseas- §§ School feeding programs es in children under five §§ Monetary transfers for social support §§ Fortification at home (including powder multinutrients) §§ Microcredit programs §§ Fortification of food at time of processing 7. Nutrition governance 3. The fight against acute malnutrition §§ Monitoring and evaluation §§ Prevention of acute malnutrition §§ Operational research §§ Support for moderate acute malnutrition §§ Development of policy and strategic documents §§ Management of severe acute malnutrition §§ Coordination §§ Nutritional support to patients with HIV, tubercu- §§ Advocacy and awareness losis, and Ebola §§ Capacity building Political Economy of Nutrition Policy in Senegal 41 Photo: Adama Cissé/CLM Endnotes 1. Joint Child Malnutrition Estimates, UNICEF (Unit- 4. These are discussed in depth in Garrett and Na- ed Nations Children’s Fund), WHO (World Health talicchio (2011). Organization) and World Bank (accessed 2017), 5. For a more thorough review of the political econo- http://datatopics.worldbank.org/child-malnutrition/ my of nutrition, see Reich & Balajaran (2014). 2. There are several ways in which nutrition may 6. All documents were searched for the term “nu- be “invisible.” First is hidden hunger, which is mi- trition” but references to food security or related cronutrient malnutrition or vitamin and mineral concepts were not counted as references to nutri- deficiencies that can compromise growth, immune tion; the presumption is that these two issues are function, cognitive development, and reproductive complementary but distinct. and work capacity but may not be visible except 7. See Offosse N. (2017) and Deussom N. et al. through diagnostic testing. Two billion people (2017) in this series for details regarding the ade- globally suffer from hidden hunger. Chronic un- quacy of budgetary efforts toward nutrition and the dernutrition—stunting—can also be “invisible” in identification of weaknesses. areas of high prevalence. Unlike acute undernutri- 8. See Offosse N. (2017) in this series for more in- tion (wasting), in which the physical manifestations formation on the total available resources for are obvious, children who are stunted simply have nutrition. shorter stature than their healthy peers. In com- 9. Right to Food in Constitutions. http://www.fao.org/ munities with a high prevalence of stunting, short docrep/016/ap554e/ap554e.pdf. stature appears to be normal. Finally, nutrition 10. See Spray (2017) for a summary and timeline of may be “invisible” in the sense that the long-term Senegal’s nutrition policies and their timing. benefits of good nutrition practices may take years 11. Natalicchio (2011) reviews the longer history of to become evident. nutrition governance in Senegal and describes a 3. We use the term “issue network,” which has previous policy phase under which the nutrition been used more often in the international litera- program was housed in the Agence d’Exécution ture, though we take it to be a synonym for “policy des Travaux d’Intérêt Public (Executing Agency community.” for Public Works and Employment) (AGETIP). Political Economy of Nutrition Policy in Senegal 43 AGETIP was an uncommon organization—a state sary in all cases, and a one-size-fits-all approach agency that had both managerial autonomy from is not what is being recommended. the government bureaucracy and a private-sector 13. The BEN is responsible for program management orientation. This arrangement was not very suc- and the implementation of community nutrition in- cessful and with the election of the new president, terventions in the 14 regions covered by the CLM. representatives of the World Bank, the Ministry of 14. These projects include Projet de Développement Health and Social Assistance (MSAS), and other de la Resilience (Resilience Development Project) donors (such as USAID and UNICEF) led by the and Projet sur Resilience Sahel (Sahel Resilience World Bank, recommended a new start for nutri- Project), funded by the Banque Islamaique de tion programming under the aegis of the Prime Développement. Minister rather than the President. 15. The SUN movement defines a common results frame- 12. It is important to note the contingent nature of the work for nutrition as including the following features: success of a stand-alone, multisectoral nutrition expected result for improvement of nutritional status; body in attracting and maintaining attention to defined populations in which these improvements nutrition in Senegal. Although this arrangement will be seen; interventions necessary to achieve appears to have been a driving force in nutrition the results and clear indications on the current cov- in Senegal, the good governance of this institution erage level and on the goal coverage; identified likely has more to do with its ability to draw atten- responsibilities of line ministries and sectors with- tion to nutrition than the fact it is a stand-alone in government for implementing the interventions; body. Other countries have been successful at the roles and responsibilities of nongovernment raising attention to nutrition with bodies housed in partners; a shared framework for performance mon- a ministry of health or elsewhere. Moreover, sim- itoring and evaluation; and a matrix of costs, which ilar types of institutional arrangements have not identifies the contribution of government (including guaranteed attention to other issues. 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Hoey, P. derstanding the SUN Movement CRF: Lessons Menon, T. Ngo, R.J. Stoltzfus, A.M. Ahmed, and Learned from Five Countries. Oxford, England: T. Ahmed. 2011. “Nutrition Agenda Setting, Policy Emergency Nutrition Network. Formulation and Implementation: Lessons from 46 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal 1818 H Street, NW Washington, DC 20433 Funding for the report was provided by the World Bank, the Government of Canada and the Japanese Trust Fund for Nutrition. The task force providing oversight of the series was composed of members of the following organizations: