Is There an Enabling Environment for Nutrition-Sensitive Agriculture in East Africa? Stakeholder Perspectives From Ethiopia, Kenya, and Uganda.

BACKGROUND: There is growing recognition that "nutrition-sensitive" development is necessary to ensure nutrition security and reduce malnutrition. While agriculture has the potential to be a strong driver of malnutrition reduction and serves as the main source of livelihood for approximately two-thirds of East Africa's population, its potential to reduce malnutrition is currently not being realized. OBJECTIVE: Leveraging Agriculture for Nutrition in East Africa is a research study based in Ethiopia, Kenya, and Uganda that seeks to understand the enabling environment necessary for optimizing the contribution of the food and agriculture sector to nutrition outcomes. Its objectives were to explore stakeholder perceptions of nutrition-agriculture linkages, of political and institutional challenges and opportunities, of evidence that is available and influential for policy making, and of key issues with regard to capacity. METHODS: Open-ended and semistructured interviews were conducted with 53 stakeholders from government, civil society, donors, United Nations organizations, private sector, and research/academic institutions in Ethiopia, Kenya, and Uganda in 2014. RESULTS: Although policy opportunities and contexts are different between the 3 countries, stakeholders identified similar barriers to greater action, including a narrow focus on solely market-oriented and staple crop production, a lack of clarity and incentives within the agriculture sector about improving nutrition and how to translate policy into action, and lack of capacity in human and financial resources. Many actions to improve the nutrition sensitivity of agriculture were mentioned, including crop diversification, value chain activities and improved market access, nutrition education, and reduction in time and labor costs to women. CONCLUSION: Many opportunities exist to strengthen the impact of agriculture on nutrition in East Africa, but stronger formulation and implementation of policies will require adequate human resources, funds, timely data on the context, sector alignment on priority actions, and alignment on a framework or indicators for accountability.

An analysis of the costs of Uganda's Child Days Plus: do low costs reveal an efficient program or an underfinanced one?

BACKGROUND: Twice annually, Uganda implements Child Days Plus (CDP), a month-long outreach activity that distributes vitamin A capsules to preschool children and deworms children 6 months to 14 years old. Introduced initially as a temporary, interim strategy, CDP is now a decade old. OBJECTIVE: To assess how well CDP is implemented using an activity-based cost analysis. METHODS: In the absence of a cost-accounting system for CDP, we defined the six major CDP activities as cost centers and identified five important subactivities required to implement a round of CDP. Based on a purposive sample, we conducted a structured interview survey of 59 Ministry of Health facilities, 9 district offices, and national-level CDP staff. RESULTS: Only one-third of the facilities implemented all 11 CDP core activities. The survey revealed that Ministry of Health staff and volunteers are frequently paid substantially less in allowances than they are entitled to for their CDP outreach activities. Viewing these two practices--nonimplementation and less-than-full-reimbursement--as indicators of CDP's underfinancing, we estimate the program is underfinanced by the equivalent of 37% of its 'full implementation" costs. Two-thirds of underfinancing is manifested in nonimplementation and one-third as less-than full-reimbursement. CDP exploits economies of scale and scope and has an average cost per child served of US$0.22. We estimate that it annually saves 367,000 disability-adjusted life-years (DALYs) at an average cost of US$12.5, making it--despite its underfinancing--highly cost-effective. CONCLUSIONS AND RECOMMENDATIONS: Increased CDP funding would enable its vitamin A coverage rate of 58% and its deworming coverage rate of 62% to be increased, thereby increasing its effectiveness and efficiency. CDP should be "relaunched," as part of an effort to improve the structure of the program, set expectations about it, and earmark a minimum of resources for CDP. The Ministry of Health should demonstrate its new, greater commitment to CDP by introducing a program-specific budget line item, increasing CDP's budget allocation, and developing and implementing a training program that identifies the minimum uniform activities required to implement CDP.