OPERATIONAL RESEARCH ON ETHIOPIAN MULTI-

SECTORAL APPROACH FOR NUTRITION

Inception Report

Submitted to:
Nutrition Specialist, Nutrition Section of UNICEF
Addis Ababa, Ethiopia

September 30, 2020

ACRONYMS

AGETIP Agency for Works of Public Interest against Unemployment (translated from French)
CI Collective Impact
CIF Collective Impact Framework
CMAM Community-based Management of Acute Malnutrition
CMI Child Malnutrition Initiative
CNLM Commission for the Fight against Malnutrition (translated from French)
CONSEA National Council on Food and Nutrition Security (in Portuguese)
CSOs Civil Society Organizations
CWA Consolidated WASH Account
DNHA Department for Nutrition, HIV and AIDS
EPHI Ethiopia Public Health Institute
FAO Food and Agriculture Organization of the United Nations
FDRE Federal Democratic Republic of Ethiopia
FGD Focus Group Discussion
FMoH Federal Ministry of Health
IDS Institute of Development Studies
IFAD International Fund for Agricultural Development
IFPRI International Food Policy Research Institute
KII Key Informant Interview
HH Household
MAM Moderate Acute Malnutrition
MAN Multisectoral Alliance for Nutrition
MIDIS Ministry of Development and Social Inclusion (in Spanish)
NEP Nutrition Enhancement Program
NNCB National Nutrition Coordination Body
NNP National Nutrition Program

2
NNTC National Nutrition Technical Committee
NWCO National WASH Coordination Office
NWSC National WASH Steering Committee
NWTT National WASH Technical Team
PAN Strategic Nutrition Program (in Spanish)
PNC Community Nutrition Program (translated from French)
RNTC Regional Nutrition Technical Committee
SAM Severe Acute Malnutrition
SD Seqota Declaration
SISAN National Food and Nutrition Security System (in Portuguese)
SPRING Strengthening Partnerships, Results, and Innovations in Nutrition Globally
TOR Terms of Reference
UN United Nations
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
WASH Water, Sanitation and Hygiene
WFP World Food Program of the United Nations
WHO World Health Organization
WWT Woreda WASH Team

3
GLOSSARY OF KEY TERMS

Alliance Coordination, collaboration and/ or integration of organizations for

common purpose
Collaboration Exchanging information, altering activities, sharing resources, and enhancing one another’s capacity for mutual
benefit and to achieve a common purpose (Garrett and Natalicchio, 2011)
Conduct The way members of the multisectoral alliance for nutrition interact with each other, exchange knowledge, and
adapt to meet the purpose of the alliance.
Coordination Exchanging information and altering activities for mutual benefit and to achieve a common purpose (Garrett
and Natalicchio, 2011)
Effectiveness Delivering multisectoral nutrition interventions as planned.
Efficiency Delivering more results with existing resources or delivering the same
result with less resources.
Integration Working in a collaborative manner and ensuring that sectoral interventions or activities have shared indicators
and outcomes that have been planned and implemented together from the outset (SPRING, 2016)
Performance The achievements of the multisectoral alliance for nutrition towards meeting its purpose.
Structure The way the multisectoral alliance for nutrition is organized to meet its purpose
Sustainability The ability of allied organizations for multisectoral nutrition to maintain the rate and level of engagement
throughout the multisectoral nutritiona lliance life cycle.

4
TABLE OF CONTENTS

ACRONYMS.......................................................................................................................................2
GLOSSARY OF KEY TERMS..........................................................................................................4
TABLE OF CONTENTS....................................................................................................................5
EXECUTIVE SUMMARY..........................................................................................................................7
1. INTRODUCTION AND BACKGROUND................................................................................9
1.1 Introduction...........................................................................................................................................9
1.2 Rationale..............................................................................................................................................10
1.3 Objectives and Scope of the Research..............................................................................................11

1.3.1 Scope of the Research................................................................................................11

1.3.2 Objectives...................................................................................................................12
2. LITERATURE REVIEW.........................................................................................................13
2.1 Collective Impact Framework as a Theory of Change ofMSC for Nutrition Security...............13
2.2 International Experiences in Multisectoral Collaboration for Nutrition......................................15

2.2.1. Hisotrical Background of Multisectoral Nutrition Approach................................15

2.3 Experiences of Multisectoral Nutrition Coordiantion in Ethiopia...............................................21
2.4 Other Multisectoral Experiences in Ethiopia..................................................................................23
2.5 Synthesis of Literature Reviews and Field visit Reports of the Ethiopian delegation.................24
2.6 Synthesis of Literature Reviews in light of the Collective Impact Analytical Framework..........26

3. METHODOLOGY....................................................................................................................29
3.1 Research Gaps.......................................................................................................................................29
3.2 Study Design.........................................................................................................................................29

5
 3.3 Data Sources.........................................................................................................................................30

3.3.1 Secondary data sources....................................................................................................31

3.3.2        Primary data sources.................................................................................................31
3.4 Methods of Data Collection and Sample Size.......................................................................................32
3.4.1 Key informant interviews[1].................................................................................................................32
3.4.2 Focus group discussion.........................................................................................................................32
3.5 Recruitment of Data Collectors............................................................................................................33
3.6 Data Analysis.........................................................................................................................................36
3.7 Development of Strategic Document...................................................................................................37
3.8 Ethical Considerations..........................................................................................................................37
3.9 Perceived Risks And Mitigation Measures............................................................................................37

4 WORK PLAN............................................................................................................................39
5 REFERENCES..........................................................................................................................42
6 ANNEXES..................................................................................................................................46
Annex 1: Team Structure................................................................................................................................46
Annex 2: Data Collection Tools/ Instruments...............................................................................................48
Annex 3: Summary sheet - Challenges, suggested solutions and responsible bodies................................59
Annex 4: KIIs and FGDs Participant Profile Registration..........................................................................60

6
EXECUTIVE SUMMARY

This inception report for the operational research on multi-sectoral nutrition coordination is commissioned by the FMOH with

technical support from the UNICEF Ethiopia country office and through funding from the Power of Nutrition and Global Financing
Facility as part of the Investment Project Financing (IPF) component of the World Bank-financed Health Sustainable Development
Goals Program for Results Project (Health SDG PfoR),. Multi-sectoral coordination is believed to be essential vertically and
horizontally among related government sectors and ministries, and inside and outside of government for better nutrition outcomes.
The current research will look into the issues of multi-sectoral coordination mechanisms at different levels and from various angles.
 To assess current experiences of multi-sectoral coordination and identify the bottlenecks and facilitators for more functional
and effective coordination and monitoring at the Federal, Regional, Zonal, Woreda and Kebele levels;
 To assess the current multi-sectoral nutrition program design, planning, integrated supervision and monitoring and reviewing
mechanisms to improve nutrition specific and sensitive services; and,
 To explore facilitators and opportunities and develop an innovative strategy to improve the multisectoral coordination that
could be scaled up for better nutrition outcomes
The research geographically covers the Federal level and five regions which include Addis Ababa City Administration, Amhara,
Tigray, Oromia and Afar regions of Ethiopia, and the selection contextualizes diverse settings across the three major livelihood zones
of urban, agrarian, and pastoralist. In each region, the coordination at the different administrative levels i.e. regional, zonal, woreda
and kebele levels will be studied. A total of 20 woredas will be covered in the study.

The research employs the collective impact initiative approach as its analytical framework and pays attention to the five pillars of
collective success, i.e. common agenda, shared measurement, mutually reinforcing activities, continuous communication, and
backbone support. Qualitative data collection methods, i.e. key informant interviews and focus group discussions will be conducted
with government staff of the relevant sectors at different levels from the Federal to the Kebele levels, and with stakeholders.

It is implemented in two phases. In its first phase (Phase I), extensive literature reviews are made to learn from other countries’ multi-
sectoral coordination experiences for nutrition. Bangladesh, Brazil, Malawi, Senegal, Peru and Ugandan experiences have been
reviewed and included. The Ethiopian experience has also been documented based on some studies made in the field, published policy
and strategy documents and review of minutes from various coordination meetings.

7
The literature reviews revealed that various sectors engaged in nutrition specific and sensitive activities shared a vision and had a
common understanding of the nutrition problems for better coordination and response. A well-designed reporting mechanism
supported by technology has been noted where sectors report on the agreed up on indicators. Lack of timely reporting and poor data
quality has been reported in Ethiopia in this regard. Each sector is given a task considering the bigger picture and which is in tandem
with their specific roles. The coordination of the different sectors engaged in nutrition specific and sensitive activities by higher
political bodies has made continuous communication possible. In Ethiopia, however, the coordination is run by a line ministry, the
ministry of health, and the accountability mechanism has been weaker resulting in inconsistent attendance of meetings by concerned
sectors. It has also been noted in the document reviews that an independent dedicated staff, mainly from the coordinating body,
provided support and key functions for the sustained operation of the coordination for its success.
The reviews were instrumental in the development of the data collection tools that are aligned with the analytical framework and
enable to collect information under the five domains of the collective impact approach. The research aims to make an in-depth look
into the issues of multi-sectoral coordination mechanisms at different levels and from various angles. Individual and institutional
capacities will be explored; internal and external factors will be investigated; institutional preparedness in terms of understanding the
evidence and reason for participation in the coordination, budgeting, and sharing the common vision will be studied. Existing
opportunities and barring challenges will be explored; best practices will be documented, and implementation difficulties will be
learned. Based on the findings, innovative solutions that strengthen multi-sectoral coordination efforts will be proposed. In the second
phase (Phase II), recommendations from the first phase will be implemented for a year and data will be routinely collected to follow
up on improvements on the coordination mechanism. Hence, the research is expected to benefit all the stakeholders involved which
include government sector offices at different levels, donors, CSOs and the private sector for a common goal.

8
1. INTRODUCTION AND BACKGROUND

1.1 Introduction
Even though it was at a slower pace, Ethiopia has made progress in the reduction of stunting in the last two decades. The prevalence of
stunting has decreased from 58% in 2000 to 38% in 2016, depicting an average decline of 1.25 percentage points a year (EDHS,
2016). Although nutrition is a multi-dimensional issue necessitating multi-sectoral interventions, the response was primarily
dominated by the health sector and concentrated on emergency feeding and micronutrient supplementation and (Kennedy et al, 2015).
As the result of ongoing advocacy efforts, the policy environment has greatly changed, and considerations have been given to engage
other relevant sectors. Accordingly, the country set up its multi-sectoral nutrition governance and coordination in 2008 with the launch
of the National Nutrition Strategy (FMOH, 2008) and the National Nutrition Program (NNP I) (FDRE, 2008) in the same year. The
governance structure clearly recognizes that nutrition is affected bymany factors, including food production and access, health and
education impact onindividuals, families and communities.With this understanding, the NNP provides the framework for strategic
objectivesand interventions in all sectors including health, agriculture, education, water, labor andsocial affairs, women and children
and youth and sport affairs to mention some1. In addition to these core government sectors, other actors including members of the
bilateral and multi-lateral donor organizations, CSOs, and the private sector are thus represented in the governance structure.

Subsequently, the emphasis on multi-sectoral coordination and collaboration is further strengthened with the announcement of the
Seqota declaration (FDRE, 2015)2, the National Nutrition Program II that outlined the role of responsible sectors (FDRE, 2016) 3, and
the Food and Nutrition Policy (FDRE, 2018)4. Despitethese policy, strategy and programmatic landmarks, multi-sectoral nutrition
coordination led by the Federal Ministry of Health, and regional bureaus of health, has been ineffective for many reasons. These
include lack of accountability mechanisms; perceived coordinator bias; inadequate staffing and resources; and low priority often given
to programs resulting in undernutrition being side-lined to ‘competing priorities’ making implementation of a coordinated response
challenging (IDS, 2020).

1
The signatories include: Ministry of Health; Ministry of Education; Ministry of Agriculture; Ministry of Industry; Ministry of Water and Energy; Ministry of Trade; Ministry of Finance and Economic
Development; Ministry of Labor and Social Affairs; and Ministry of Women, Children and the Youth;
2
Seqota Declaration is the declaration of the government of Ethiopia to end child malnutrition by 2030 through multisectoral and multi-dimensional efforts.
3
Additional Ministries added: Ministry of Livestock and Fisheries; National Disaster Risk Management Cooperation Commission; and Ministry of Government Communication Affairs; and Ministry of
Youth and Sport.
4
It is the policy framework and accountability system governing the food and nutrition activities in Ethiopia.

9
1.2 Rationale

Theoretically, multi-sectoral coordination requires vertical and horizontal collaboration across interrelated sectors, ministries, and
actors both inside and outside of the government. As in any other multi-sectoral programs, experiences from other countries indicate
that internal and external factors affect the success of coordination (IFPRI, 2011). This is to say those internal characteristics of an
organization such as leadership; vision; technical, financial, and managerial capacity; organizational structures, values, culture, and
experience; and incentives for collaboration are all believed to have their own shares in affecting multi-sectoral coordination efforts
(IFPRI, 2011). In other words, sectors have their own visions and priorities, goals, routines, and procedures. These different sectors
and individuals may conflict in terms of technical understanding of the problem and devising appropriate solutions.

The factors associated with the external environment surrounding the partnership include having nutrition as a development priority;
the urgency of action; and the economic, social, cultural, political, and legal environments. Some factors that seem to help lubricate
the mechanisms of coordination include shared understanding and genuine participation and ownership among participants and
stakeholders; having clear roles, responsibility, and accountability mechanisms; and having the flexibility that allows the creation of
appropriate mechanisms and partnership types.

In Ethiopia, NNP I, among others, has resulted in creating a common understanding of nutritional issues among the implementing
partners to manage multi-sectoral nutrition program (FDRE, 2013). This technical understanding of the multi-dimensional and multi-
sectoral nature of nutrition helped to clearly outline the roles and responsibilities of each sector ministry in NNP II (FDRE, 2016).
However, poor nutrition governance remains to be a challenge particularly at the lower levels of administration in the government
resulting in weak multi-sector coordination and collaboration (Kennedy et al, 2015). Cognizant of this fact, UNICEF, the Federal
Ministry of Health (FMoH), the World Bank and other stakeholders are looking for better ways of implementing a collaborative
response among the different relevant sectors at all levels.

10
Commissioned by the FMOH with technical support from the UNICEF Ethiopia country office and funding from the Power of
Nutrition and Global Financing Facility as part of the Investment Project Financing (IPF) component of the World Bank-financed
Health Sustainable Development Goals Program for Results Project (SDG PfoR), the operational research aims at making an in-depth
look into the issues of multi-sectoral coordination mechanisms at different levels and from various angles. Following the Collective
Impact Framework (CIF) (Kania & Kramer, 2011) the effectiveness of the MSC for nutrition in Ethiopia will be evaluated based on
the pillars of collective impact: common agenda, shared measurement, mutually reinforcing activities, continuous communication, and
backbone support.

Finally, innovative solutions that strengthen multi-sectoral coordinated efforts will be proposed, implemented and data will be
routinely collected to follow up on improvements on the coordination mechanism. Hence, the research is expected to benefit all the
stakeholders, which include government offices at different levels, donors, CSOs and the private sector, involved for a common good.

1.3 Objectives and Scope of the Research

1.3.1 Scope of the Research

NNP II recognizes the five building blocks for effective nutrition governance as the best way forward to ensure implementation of the
various components by the different sectors. These include political commitment, consensus building and coordination, financing,
service delivery capacity, and transparency and accountability (NNP II FDRE, 2016). Multi-sectoral coordination, being one of the
elements in nutrition governance, is the operational framework that brings together all the different actors for timely and effective
implementation of the program. The institutional arrangements include the formation of the National Nutrition Coordination Body
(NNCB), the National Nutrition Technical Committee (NNTC) and the different steering committees to enhance efficient and
effective implementation and coordination of the NNP. Similar structures are cascaded down to Regional, Zonal and Woreda levels.
Multi-sector nutrition coordination led by the Federal Ministry of Health and Regional bureaus, however, has been ineffective for
many reasons (IDS, 2020).

Building upon previous studies in the MSC in the country, this study will add value by introducing the Collective Impact (CI) as an
analytical framework and assessing the effectiveness of the MSC based on the five principles of CI: common agenda, shared

11
measurement, mutually reinforcing activities, continuous communication, and backbone support (Kania & Kramer, 2011). Based on
these effectiveness assessment elements, the operational research specifically will examine the status quo of multi-sector coordination;
the many obstacles and impediments; challenges and difficulties, and barriers which need to be overcome if a better response to
nutrition is to be achieved. The research also examines opportunities and facilitators that need to be explored and built up on to bring
together the different actors for a common goal: ensuring nutrition security in the first phase (Phase I). In the following phase (Phase
II), the operational research routinely collected data to follow up on the implementation of recommendations from the first phase for
effective coordination among nutrition stakeholders.

The research covers the three major livelihoods: urban, agrarian, and pastoralist livelihoods. Addis Ababa city administration
represents the urban livelihoods and Amhara, Tigray and Oromia regions are known for predominantly agrarian livelihoods, while
Afar region symbolises pastoral livelihoods.

This operational research is implemented following the Operational research definition of WHO. WHO (2003) defines it as
a technique designed to inform program decision making to achieve a defined outcome. Thus, this research will address the multi-
sectoral coordination problem in the implementation of the nation’s nutrition program. The overall goal of this research is to generate
necessary information to the research team design and pilot the implementation of effective multi-sectoral coordination in nutrition
intervention.

1.3.2 Objectives
The objectives of the research are:
 To assess current experiences of multi-sectoral coordination and identify the bottlenecks and facilitators for more functional
and effective coordination and monitoring at the Federal, Regional, Zonal, Woreda and Kebele levels;
 To assess the current multi-sectoral nutrition program design, planning, integrated supervision and monitoring and reviewing
mechanisms to improve nutrition specific and sensitive services; and,
 To explore facilitators and opportunities and develop an innovative strategy to improve the multisectoral coordination that
could be scaled up for better nutrition outcomes.
In the process of meeting the above objectives, the research will answer the following key questions:

12
  What worked well/did not in the multisectoral coordination when implementing the nutrition-specific and nutrition-sensitive
interventions? How is the coordination reflected at the design, planning, implementation, supervision and monitoring? How
many of the activities were implemented and at which scale? What were the challenges during implementation and why? What
can be learned from the implementation process to inform the next phase of the program and future programming?
 How can the multi-sectoral coordination be improved at the Federal, Regional, Zonal, Woreda and Kebele levels? What
innovative strategies should be implemented at individual, organisational and systemic levels? How is this going to affect the
implementation capacity of the different actors?

2. LITERATURE REVIEW

2.1 Collective Impact Framework as a Theory of Change ofMSC for Nutrition Security
Nutrition is one of the social problems which need multisectoral collaboration to address it. Collective Impact (CI) is one of such
collaborative initiatives in which key actors from different sectors commit to addressing nutrition as a common agenda. Such

13
initiatives execute mutually reinforcing activities, implement continuous communication strategies, and adopt a shared measurement
system. Presence of a backbone organization which is independent and fully dedicated supporting the initiative is also the other
essential features of the CI (Kania and Kramer, 2011). These elements of CI from the Collective Impact Framework (CIF) depicted in
Figure 1 and served as a Theory of Change (ToC) to assess the effectiveness of the MSC for nutrition in Ethiopia

The Collective Impact Framework is developed by Kania and Kramer (2011). The authors stated that common agenda, shared
measurement, mutually reinforcing activities, continuous communication, and backbone support are the five critical success factors for
CI initiatives. This framework has been adopted as a planning and implementation tool to address multiple social problems, including
nutrition (Hanley Brown et al. 2012). The framework has been criticised for equity (McAfee et al., 2015) and community organising
(Wolff, 2016) perspectives. However, with relevant updates, the framework even becomes an important evaluation tool for collective
impact initiatives (Preskill et al. 2014; Michaud‐Létourneau et al. 2019). One of the relevant updates made to this framework was the
inclusion of influential leaders, a sense of urgency for the issue, and adequate resources as pre-conditions to CI (Weaver, 2014).

The current operational research examines the effectiveness of multi-sectoral nutrition coordination efforts with the CI lens. Each
sector’s efforts and level of understanding towards effective multi-sectoral coordination (the common agenda), execution of their roles
and responsibilities in a coordinated fashion (mutually reinforcing activities), their level of dedication for continuous communication
to build trust and common motivation, and monitoring of progress by a given set of indicators (shared measurement) will be assessed.
The level of engagement of an independent body that supports the critical functions for sustained operation (backbone support) will
also be studied. The following box summarizes the five pillars of the initiative.

Five Conditions for Collective Impact The following is the conceptual

1. Common agenda: All participants share a vision for change that includes a framework of the collective impact
common understanding of the problem and a joint approach to solving the approach for effective multi-sectoral
problem through agreed-upon actions. coordination for nutrition.
2. Shared measurement: All participants agree on how to measure and report on
progress, with a shortlist of common indicators identified to drive learning and
improvement.
3. Mutually reinforcing activities: A diverse set of stakeholders, typically across
sectors,
Mutually coordinate
reinforcing a set of
activities bydifferentiated,
the mutually
Backbone reinforcing
support set of actions.
by14an independent body
4. Continuous
different communication: All
sectors to address the common players engage
to the sectorsinengaged
frequent,
in structured
the multisectoral
communication
agendato build trust, assure mutual objectives, andresponse
nutrition create common
motivation.
5. Backbone support: An independent, dedicated staff provides support and key
 [Effective Multisectoral
Coordination]

Continuous communications among all the

Shared measurement to monitor progress
relevant stakeholders involved through
and learn from each others experience
regular meetings…etc

Figure 1 Collective Impact Framework.

2.2 International Experiences in Multisectoral Collaboration for Nutrition

2.2.1. Hisotrical Background of Multisectoral Nutrition Approach

Multisectoral nutrition approaches were introduced in the 1970s due to the growing understanding of the multidimensionality of
malnutrition and the inability to address it through a single sector. During this time, 26 countries established multisectoral planning
units with support from the U.S. Agency for International Development (USAID) and the Food & Agriculture Organization of the
United Nations (FAO). The purpose of the planning units was to coordinate policies and programs at the national level to improve

15
nutrition. Although they did not result in the desired outcome by the time due to overcomplexity and lack of ownership, they set a
foundation to the current multisectoral nutrition approaches (World Bank, 2014).

In recent years, the multisectoral nutrition approach is gaining momentum among stakeholders (Garrett and Natalicchio, 2011;
SPRING, 2016; World Bank, 2014). This can be partly attributed to advancements in nutrition knowledge and evidence base about the
need for multisectoral nutrition approaches. Studies showed that such initiatives have a significant impact on reducing malnutrition in
developing countries (Ruel et al. 2013). Due to such benefits, many national governments in low-income countries and their
development partners are adopting multisectoral nutrition approaches to address malnutrition (UN, 2016; UNICEF, 2015; USAID,
2014; World Bank, 2013).

2.2.2. Experience of countries implemented Multisectoral NutritionCoordination

2.2.2.1MultsiectoralNutrition Coordination experience in Brazil

Overall structure and nstitutionalarrangement of multisectoral approach in Brazil

Brazil is one of the model countries which benefited from multisectoral approaches to reduce malnutrition significantly. The
multisectoral system designed to reduce poverty, inequality, and food insecurity focused in income redistribution and universal access
to education, health, and sanitation services, and there was little or no focus on nutrition-specific activities. It is coordinated by the
National Council on Food & Nutrition Security (CONSEA), an advisory body where two-thirds of its members are representatives of
the civil society. Under the Council, there are technical committees and working groups, temporary or permanent. At the federal
government level, the Council is chaired by the Ministry of Social Development that is directly linked to the President. At the lower
structures in government such as state and municipal, the councils are established and led by the highest authority of their respective
government (United Nations, August 2013). The government introduced the ‘zero-hunger strategy, (2003 – 2010)’ which is followed
by ‘Brazil without misery, (2011 – 2014)’ and now they have an ‘inter-sectoral strategy for obesity reduction’(UN, August 2013;
Ethiopian delegates field visit report, FMoH, July 2015).

Beyond implementing policies and programs across sectors, the Brazilian multisectoral approach was funded in a way that it promoted
collaboration among the sectors at a local level. This was expressed to facilitate cooperation among ministries and within the different
levels of government (Keefe, 2016). This multisectoral element is fundamental in allowing the government to design linked-up

16
programs which address the factors affecting the food and nutritional status of diverse individuals and social groups, including
children, the elderly and families. The National Food & Nutrition Security System (SISAN) was developed in dialogue with several
public policy systems, including the health, education, social assistance, and agrarian ministries (IDS, 2017).

Effects of Multisectoral Approach on redction of malnutrition in Brazil

The overall prevalence of child stunting in Brazil was reduced by more than 80% between
1974/1975 and 2006/2007, and this is mainly attributed to a multi-sectoral approach and
coordination (Keefe, 2016). A further reduction in stunting, and elimination of child
wasting and underweight was achieved in 2011 (UN, 2013). 

2.2.2.2 Experience in Malawi

Overall structure and Institutional arrangement ofMultsiectoral Nutrition Approach in Malawi

The Government of Malawi recognizes the multi-faceted nature of nutrition and the necessity of the implementation of nutrition-
related activities by different sectors that need effective partnerships and coordination. This led to the establishment of the Department
of Nutrition, HIV & AIDS (DNHA) within the Office of the President in 2004 to oversee and coordinate the national nutrition
response (DNHA, 2018).

Malawi’s high-level commitment is further reflected in the establishment of high-level multi-sector and multi-stakeholder committees
that facilitate coordination and implementation of nutrition interventions. The multi-sector technical committee is composed of crucial
sector ministries, representatives of development partners, CSOs, academic, and think tank institutions. The committee provides
technical oversight in the implementation of the policy within each sector, provides technical guidance on the performance of the
nutrition policy, and provides technical advice to the Parliamentary, Cabinet and the Principal Secretaries’ committees on nutrition
and DNHA. The Government, therefore, encourages each sector to fulfil its mandate as stipulated in the National Multi-Sector
Nutrition Policy 2018–2022 and the Strategic Plan and continued to place nutrition high on the national development agenda (DNHA,
2018).

17
The multi-sector committee is composed of Principal Secretaries within each sector that will oversee the Nutrition, HIV and AIDS
activities and are accountable for operationalisation of the strategic interventions assigned to their sectors. This responsibility includes
ensuring that their respective sectors have been set adequate financial and human resources for nutrition, develop action plans for
implementation, establish clear objectives and targets, and develop reporting and review mechanisms for nutrition interventions.

Effects of Multisectoral Nutrition Approach on reduction of malnutrition in Malawi

Malawi’s achievement in reduction of malnutrition over the past two decades between
2004 and 2015-16 was attributed to the multi-sector nutrition programming and
increased investments in nutrition: stunting was reduced by 16 percentage points from
53% to 37%, underweight declined from 17% to 11.7%, and wasting declined from 6% to
2.7% (DNHA, 2018).
Challenges of Multsiectoral Nutrition Coordination in Malawi

Malawi has a decentralization policy and community structures through which multi-sector nutrition activities are implemented.
However, collaboration and coordination of nutrition programming at the district and community levels remains challenging because
of short term resource allocation and funding. Moreover, the nutrition interventions and programming are heavily dependent on donor
support which may limit sustainability (DNHA, 2018).

2.2.2.3. Expeiance in Senegal

Overall structure and Institutional Arrangement of Multsiectoral Nutrition Approach in Senegal
Senegal launched the Nutrition Enhancement Program (NEP) in 2002, which resulted in the formulation of the National Nutrition
Policy in the same year and the creation of greater integration of action across sectors. NEP operates under the supervision of the
Coordination Unit for the Reduction of Malnutrition (Cellule de Luttecontre la Malnutrition, or CLM). CLM is attached to the Prime
Minister’s Office and the institutional home for nutrition, once and for all, was moved to the Prime Minister’s Office (Spray, 2018).
NEP operates using a multisectoral and multi-actor approach, coordinating actions across ministries, donors, and non-governmental
organizations (NGOs).

Historical background and leasson learnt on multsiectorla nutrition appraoch in Senegal.

18
In 1994, a presidential decree had created a national commission, the National Commission for the Fight against Malnutrition
(CNLM). CNLM, placed in the President’s Office, was set up following recommendations that, because of the multisectoral nature of
nutrition, no line ministry or institution could, or should, be solely responsible for nutrition. It was composed of representatives from
the Prime Minister’s Office, the Ministries of Economy, Planning & Finance, Health & Social Action, Women’s, Children’s & Family
Affairs, Executing Agency for Works of Public Interest against Unemployment (AGETIP), and NGOs and civil society organizations.
CNLM was actively involved in the design and preparation of the Community Nutrition Program (PNC), which is launched in 1995
and became the first program to promote collaboration on nutrition among national agencies. The program was implemented by
AGETIP and coordination with the Ministry of Health, which was meant to be the leading partner, was unsuccessful. CNLM had
limited operational responsibilities, and its involvement in monitoring and evaluation of the program was minimal.

At the time, Senegal did not have a nutrition strategy or policy, and CNLM also did not produce one, and this led to the absence of
strategic guidance to the project. Apart from CNLM, the line ministries were not effective in executing the project, despite regular
attendance by their representatives at meetings. Their limited participation resulted in a little sense of ownership. These ministries also
acknowledged that their limited capacities made it hard for them to participate more actively. Their lack of human and financial
resources impeded their ability to effectively supervise activities and training and integration of actions across institutions. Parallel to
PNC, the National Food & Nutrition Service, which is the unit responsible for nutrition within the Ministry of Health, initiated and
implemented another national nutrition program. The two interventions used different approaches and conveyed distinct messages
resulting in duplication of efforts and adding further to the confusion. Based on the lessons learnt from PNC, Senegal launched the
Nutrition Enhanced Program (NEP) in 2002.

Effects of multisectoral approach in Senegal

There has been a considerable reduction in the prevalence of malnutrition after the NEP.
During the first phase (2002 – 2006), child stunting is reported to have decreased by 40%
and the program is then scaled up to all regions of the country. The experience of Senegal
suggests that when the multi-sectoral approach is implemented well, with appropriate
investments in capacity development and institutional arrangements, results can be
achieved (IFPRI, 2011).

19
2.2.2.3. Expeiance in Peru
Overall structure and Institutional arrangement ofMultsiectoral Nutrition Approach in Peru
The government launched a new strategy, the National Nutrition Strategy for Poverty Reduction & Economic Opportunities, CRECER
(in Spanish, ‘to grow’) in 2007 as an inter-institutional coordination platform. CRECER was led directly by the Prime Minister’s
Office, and officially under the Presidential Council of Ministers (PCM). Besides, new nutrition program funding mechanism, the
Joint or Strategic Nutrition Program (in Spanish, PAN), was initiated as one of the first pilots undertaken by the Ministry of Economy
& Finance, part of its new performance-based budgeting program. Under the new strategy, several changes have been introduced:

 Problems with targeting were noted, and the focus is now shifted to children under 2’s who are within the window of
opportunity available in the first 1,000 days of life, and geographically targeted areas where a child and maternal malnutrition
and poverty were most profound.
 Performance-based budgeting, where budget projections were made not for inputs or activities but rather for the outcomes and
impacts, was introduced to increase the efficiency and effectiveness of social programs;
 The focus shifted from treating malnutrition symptoms to the key determinants;
 Policy coordination and decentralization was introduced where the responsibilities of regional and district/municipal
governments are increased, and
 The resources allocated for the program was doubled between 2007 and 2011.

Background and leasson learnt onmultsiectorla nutritionappraoch in Peru.

In Peru, the demographic and health survey (DHS) of 2004 – 2006 revealed that there was no significant reduction in the prevalence
of stunting in the preceding decade. This was reported to be seven percentage points above the regional average and was taken by
surprise for a low middle-income country whose rate of economic growth was the second-highest in Latin America. The finding
pointed out that the status quo was not producing the required results and hence the necessity of new measures. Recognizing the
problem and following advocacy efforts by the Child Malnutrition Initiative (CMI), the government launched a new strategy, the
National Nutrition Strategy for Poverty Reduction and Economic Opportunities, CRECER (in Spanish, ‘to grow’) in 2007 as an inter-
institutional coordination platform. The new Peruvian government that came to power in 2011 continued to build upon what has been
laid before in a different way, and this time the coordination shifted from the Prime Minister’s Office to a new ministry, Ministry of
Development and Social Inclusion (in Spanish, MIDIS) which is a line ministry with a multi-sectoral nature. Under the MIDIS, district

20
targeting is based not only on a percentage of stunting but also numbers; more emphasis is given to WASH interventions; combined
psycho-social stimulation with early childhood nutrition interventions to bring about a complimentary positive effect on cognitive
development; introduced health and nutrition education in schools; and increased private sector participation. More importantly,
MIDIS promoted the creative introduction of incentives for results where regions can increase their allocations for PAN programming
by over 50pc if they meet targets on key indicators. This feature is growing to become the feature of multi-sectoral programming
internationally.

Effects of multisectoral nutrition approach in Peru

The primary elements of this multi-sectoral program included health interventions, conditional cash transfer, and rural sanitation
programs. The PAN program and the CRECER strategy successfully met the government’s target of a nine-point reduction in the
prevalence of stunting in the country with more significant reductions in rural areas.

2.2.2.4. Expeiancein Bangladish

Overall structure and Institutional arrangement of Multsiectoral Nutrition Approach in Bangladish
Bangladesh is one of the countries whose multi-sectoral coordination efforts have been evaluated by a team of experts contracted by
the United Nations. The country initiated the Bangladesh Integrated Nutrition Project (BINP) in 1996 where the activities were
divided among three ministries, the Ministry of Health responsible for the Community Based Nutrition Component (CBNC), the
Ministry of Agriculture responsible for the kitchen gardens, and the Ministry of Fisheries & Livestock responsible for the chicken
raring, with some assistance from NGOs. The Ministry of Health was playing the coordination role, and there is an inter-sectoral
consultative committee accountable for disbursement of funds through proposals. The other two ministries, apart from the Ministry of
Health, did not see the connection of these activities to what they consider their primary mandate. Results indicate that the inter-
sectoral collaboration was weak; their commitments were insufficient; and the community-level implementations were also poor, and
the desired results were not achieved.

Moreover, accountability was absent to any higher authority. This has led to the birth of the National Nutrition Program, which is
more focused on activities under the Ministry of Health. In 2011, the MDG-F (millennium development goal fund) program was
initiated by development partners (UNICEF, WFP, FAO) and their government counterparts. This has led to the implementation of
activities such as nutrition counselling, CMAM treatment of SAM and MAM cases, garden and small livestock assistance and school
programs (feeding, gardens and nutrition education) in the same areas. The multi-sectoral nutrition and food security convergence in

21
targeted regions led to the elimination of acute malnutrition from program areas. Other projects such as the SHOUHARDO program,
operated by CARE was also another example of a multisectoral project that, like the MDG-F program, adopted the convergence
approach of concentrating and combining key resources– both nutrition-specific and nutrition-sensitive interventions in the same
geographic areas..

2.2.2.5. Experience in  Uganda

Overall structure and Institutional arrangement of Multsiectoral Nutrition Approach in Uganda

Uganda has made significant progress in the last decade to establish a healthy nutrition foundation for the country’s development. The
government has developed the Uganda Nutrition Action Plan (2011 – 2016) to scaling up multi-sectoral efforts. The Ugandan
experience sharing visit made by a team of experts from Ethiopia observed that there were three levels of coordination frameworks,
namely Policy, Technical and Decentralization. The Cabinet Sub-Committee chaired by the Prime Minister is the highest body that
coordinates the nutrition work in the country which provides policy direction. There were other levels of coordination that include the
Food & Nutrition Council (FNC) responsible for reviewing progress on crucial nutrition indicators, analyzing budget and constraints
to implementation and provide strategic direction; the Parliamentary Sub-Committee that approves the critical policy and financial
decisions and the Nutrition-Sectoral Technical Committee that is responsible for the performance of these decisions. The coordination
structure was further cascaded down from the federal to the lowest administrative unit in government and is supported by policy and
legal frameworks. The Chief Administration Officer is the chairperson of the district nutrition coordination committee, and the head of
the health department is the nutrition focal person.

Moreover, there is a strong linkage between the Office of the Prime Minister and the districts through the Ministry of Local
Government which in turn strengthens ties of the national multi-sectoral coordination with that of the district levels. The visiting team
also learnt that all the signatories of the Uganda Nutrition Action Plan (UNAP) had got nutrition staff, and their number varies
depending on the extent of the nutrition-specific and sensitive activities each sector is responsible for. Nutrition staff are also available
in key positions at the district level.

2.3 Experiences of Multisectoral Nutrition Coordiantion in Ethiopia

2.3.1. Background

22
Despite significant improvements over the last two decades, malnutrition persisted as one of the development challenges in Ethiopia
(FDRE, 2018). One of the underlying reasons for this has been the dominance of the health-sector approach to address malnutrition.
Most nutrition interventions were initiated and implemented by this sector, acting independently. This lack of sectoral coordination
has deterred nutrition intervention outcomes (FMoH, 2008).

Recognizing this gap, the Federal Democratic Republic of Ethiopia (FDRE) launched the first National Nutrition Program (NNP I)
that was implemented between 2008 and 2012 and its revised version between 2013 and 2015 signed by nine ministries. The Federal
Ministry of Health houses and manages the organizational and management structure of the NNP, and the National Nutrition
Coordination Body (NNCB) consisting of 13 government sectors and a range of nutrition development partners including civil society
organizations, UN Agencies, the academia and private sector, is the main mechanism for leadership, policy decisions and coordination
of the NNP. The National Nutrition Technical Committee (NNTC) is the technical body reporting to the NNCB, and similar structures
exist at regional, zonal and woreda levels.

NNP was characterized by the fact that nutrition was not well reflected in some of the implementing sectors’ strategies and programs.
This has resulted in a missed opportunity to improve nutrition. Despite the establishment of the NNCB in 2008, the NNTC in 2009,
Regional Nutrition Coordination Body (RNCB), Regional Nutrition Technical Committee (RNTC) and Woreda level coordination
bodies in most of the agrarian regions to facilitate the implementation of the NNP; multisectoral coordination and integration were not
effective and horizontal ministerial-level inter-sectoral coordination mechanisms were limited. Lack of commitment and strong,
suitable governance structures to effectively mainstream nutrition into their core mandated activities, among others, were the reasons
for the difficulty in creating operational, effective linkages with relevant sectors at all levels (FDRE, 2016). Moreover, the structure
lacks clearly defined accountability mechanisms, and the nutrition information system to capture data from all the relevant sectors was
non-existent.

2.3.2. Rationale of the National Nutrition Program II( 2016-2020)

The second National Nutrition Program (2016 – 2020), among others, aims to strengthen multisectoral nutrition coordination and
capacity building and implementation of nutrition-sensitive interventions across sectors. The 13 ministerial signatories of the NNP II
is a clear indication of the government’s commitment for a multi-sectoral response, and the Federal Ministry of Health continues to
house and manage the organizational and management structure of the National Nutrition Program (FDRE, 2016).
23
2.3.3. Formulation of Food and Nutrition policy (2018)

The Council of Ministers has endorsed the first in kind Food & Nutrition Policy of Ethiopia in November 2018. The policy states;

“Nutrition has a multidimensional and multi-sectoral nature in terms of both effect and outcomes. Timely and effective
implementation of the policy requires multi-sectoral integration, coordination and linkage, an efficient operational framework as well
as appropriate leadership and implementation capacity (FDRE, 2018).”

This comprehensive understanding of nutrition demand that several sectors need to exert their efforts in a coordinated fashion. The
policy clearly spelt out the multi-dimensional nature of malnutrition and the necessity for a multisectoral response if meaningful
progress is to be made. The roles and responsibilities of the different sectors have been stated, and directives have been given (FDRE,
2018).

2.3.4. Challenges of Multsiectoral Nutrition Coordination in Ethiopia 

Multisectoral nutrition coordination is not moving forward as expected consequently impacting nutrition responses and outcomes in
the country. Experiences from other countries indicate translating the high level of national political consensus and commitment and
the available evidence into nutrition-specific actions delivered primarily through the health sector, and nutrition-sensitive actions
delivered through several other sectors was a huge challenge (IFPRI, 2011).

There have been multiple studies which assessed the performance of multisectoral nutrition approach in Ethiopia (EPHI, 2019;
Kennedy et al. 2015; Warren, 2016; IDS 2020). Kennedy et al. (2015) evaluated the governance and implementation
of multisectoral nutrition program of the country and identified the challenges and opportunities it faced to improve nutrition. Their
findings indicate that the country has made significant progress in terms of developing the policy, strategy, and program governance
framework. 

24
Despite acknowledging malnutrition, some sectors did not see how their interventions could be nutrition-sensitive. This was attributed
to lack of awareness about the legal and political framework for nutrition and implementation approach. Furthermore, issues related to
leadership and budget were mentioned as other challenges. 

The Ethiopian Public Health Institute (2019) also assessed the performance of the national nutrition program. The findings indicated
that multisector coordination and integration of nutrition program implementation are not satisfactory enough to bring the desired
outcome. This was attributed to a lack of suitable governance structure, and it resulted in a limited capacity of the alliance to ensure
responsibility and accountability of the collaborating sectors (EPHI, 2019). Poor planning, absence of separate budget line, weak
monitoring and evaluation, and lack of sense of ownership were challenges of the multisectoral nutrition alliance. Frequent leaders’
turnover among member organization due to the current political instability was also mentioned as a threat to some of
the multisectoral nutrition coordinations.

The study conducted by IDS concludes multi-sectoral nutrition coordination under the Federal Ministry of Health, and regional
bureaus of health have been ineffective because of lack of accountability mechanisms; perceived coordinator bias; inadequate staffing
and resources; and low priority often given to nutrition activities implementing a coordinated response challenging (IDS, 2020).

Cognizant of this fact, the Food & Nutrition Policy of Ethiopia states the necessity of establishing the Food & Nutrition Council. It
outlines that the highest government body would lead the Council at a national level (Prime Minister), Regional Presidents at the
regional level and Zonal and Woreda Administrators at zonal and woreda levels respectively to facilitate the implementation of the
policy, coordinate and support food and nutrition implementing partners and stakeholders to discharge their duties and responsibilities
(FDRE, 2018).

2.4 Other Multisectoral Experiences in Ethiopia

Apart from nutrition, there are other multi-sectoral collaborative efforts in Ethiopia for implementation of the flagship programs. The
ONE WASH National Program (OWNP) that is launched by the government and started to operationalize in 2013, which is currently
in its second phase is one example. There are four signatories, namely the Ministry of Water, Irrigation & Electricity (MWIE),
Ministry of Health (MoH), Ministry of Education (MoE) and the Ministry of Finance. Besides, development partners, civil society
organizations, private sectors, financial institutions (Banks and Micro-Finance Institutions) all work together to contribute their share

25
towards improving the health, and well-being of both rural and urban populations by increasing water supply and sanitation access and
the adoption of good hygiene practices equitably and sustainably. The highest governing body in the Program is the National WASH
Steering Committee (NWSC) whose members include ministers and state ministers from the four signatories.

The NWSC is chaired by the minister of Water, Irrigation and Electricity. The technical arm of the NWSC is the National WASH
Technical Team (NWTT) consisting of directors from the four WASH ministries, and a similar structure is prescribed at a regional
level. There is a National WASH Coordination Office (NWCO) which reports to the NWSC and is technically assisted by the NWTT.
There is a similar structure at the regional level too. The lowest level of WASH governance is at a woreda level where the WASH
activities are implemented by the Woreda WASH Team (WWT) led by the woreda administrator. Its members include the four WASH
sector offices with additional members from the Women Affairs and Agriculture offices. Development partners are represented by the
Development Assistance Group – Water Technical Working Group. Depending on their levels of engagement and types of
involvement, organizations are classified as Partners, Associated Partners and Collaborating Partners. There are ongoing advocacy
efforts to attract more organizations to be partners so that they contribute to the Consolidated WASH Account (CWA). There are also
plans to include more institutions and ministries in addition to the original four signatories. The staffing structure is also well
delineated from the federal to woreda level (One WASH, November 2018).

One WASH has been a very good example of how multi-sectoral coordination is

effectively administered. The establishment of a National WASH Coordination Office
(NWCO) with clear mandate reporting to the NWSC and technical assistance
from NWTT facilitates the multi-sectoral activity. Moreover, the gradual expansion to
involve more ministries and institutions as more experiences are gained, and the
engagement of the woreda administration chairing the WASH team at implementation
level gets the work done.
2.5 Synthesis of Literature Reviews and Field visit Reports of the Ethiopian delegation
Many decades have passed since the multi-sectoral response to nutrition is recognized as fundamental to bring about a meaningful
reduction in levels of malnutrition. However, bringing together the different sectors involved has remained to be a challenge.
Structural problems, insufficient capacity of implementation, and poor levels of commitments were the major bottlenecks observed.
Countries have been gradually learning from their past and from the experiences of other countries to overcome the challenges and

26
make the coordination happen. The following is what has been observed in literature reviews (Bangladesh, Brazil, Malawi, Peru, and
Senegal) and field reports of the Ethiopian delegations’ visits to Brazil (July 2015), Uganda (July 2015) and Peru (October 2019) of
the multi-sectoral nutrition coordination efforts that pay off. The lesson learnt is an input to the current operations research, which can
potentially contribute to the multi-sectoral coordination efforts in Ethiopia.

 Existence of a policy framework

There is a well written legal document that is guiding the food and nutrition activities alone or together with other social services in
each of the countries. This is a legally binding document clearly stating the governance structure, roles and responsibilities of the
sectors, and the monitoring and evaluation framework. Ethiopia does have a Food & Nutrition Policy which is an excellent guide. The
implementation manual, the National Nutrition Program, with clearly defined sectoral roles, also exist.

 High level coordination

The different sectors engaged in nutrition-specific and sensitive activities were being coordinated by higher political bodies such as
the Office of the President, Prime Minister’s Office or by a line ministry that is directly linked with the highest political figure in the
country, such as the Ministry of Development and Social Inclusion in Peru and the Ministry of Social Development in Brazil. This is
an expression of a high level of commitment in government and improved accountability of all sectors involved. In Ethiopia, however,
the Federal Ministry of Health is playing the coordination role of the NNP. At the same time, the Seqota declaration innovation phase,
a sub-national program involving two regions, is chaired by the Deputy Prime Minister’s Office. It has been indicated in the
Food & Nutrition Policy document that Food and Nutrition Governing Body will be established and led by the highest government
decision-makers from Federal and Kebele levels. Review of the minutes from the various multi-sectoral coordination bodies and
technical committees and supervision reports cited the lack of a robust system for ensuring accountability as a reason for poor
implementation of nutrition activities across sectors. Suggestions have been made to engage regional presidents to lead multi-
sectoral nutrition coordination efforts where sectors will be reporting nutrition activities as part of their monthly report to the
president. 

High levels of commitment and awareness of the shared vision

27
There was shared commitment and consensus across sectors and the different levels in government around the same goal of achieving
a reduction in malnutrition, elimination of hunger, ensuring food security, increasing income of the poor… etc. with clearly defined
entry to and exit from the program strategies targeting the most vulnerable. The level of awareness was also high both on the technical
and organizational aspect. There were agreed set of priorities across sectors and clearly defined interventions. Although the 13
signatories of the NNP agreed in principle, the practical applications and their level of commitment vary across sectors in Ethiopia.
This has been reflected in various review meetings at the national and regional levels where leadership commitment and low and
limited ownership of nutrition activities by sectors is reported to be a bottleneck to the multi-sectoral coordination. .
 Staffed with trained nutritionists

Staffing is key for it improves the implementation capacities of the different sectors involved. All sectors were staffed with nutrition
experts who understand and execute their sector share of the roles professionally. Besides, there is a team of experts in the form of
technical committees, advisory committee or think tank that technically supports the experts. In Ethiopia, most ministries do not have
a formal structure for the institutionalization of nutrition programs in their organizational system. The ministries (e.g., MoE), as well
as their regional, zonal, and woreda level structures, do not have fulltime nutrition experts. Instead, they assign focal persons for
nutrition-related activities. Some sectors, like the bureau of labour and social affairs, never cascaded down nutrition programs
to zonal and woreda levels. Human resource need assessments presented during national meetings indicate staffing gaps across all
government structures in Ethiopia that ranged from about 81% to 100%. Unpublished reports, however, show that each year more than
a thousand people graduate in nutrition, public health nutrition or food science and nutrition both at undergraduate and graduate levels
from 11 universities or colleges across the country. On the other hand, unemployment of nutritionists is reportedly high due to the
absence of a career structure that can absorb these graduates. The understaffing with trained nutrition experts makes program
implementations difficult. 

 Programs were well funded

The government allocated enough funds to run the activities. In some of the countries like Peru, the government adopted results-based
budgeting (and budget projections not for inputs or activities) and performance-based incentives to motivate districts and improve
service quality. Review of the minutes from the various coordination bodies and technical committees showed nutrition programs in

28
Ethiopia, like many other social services in the country, are insufficiently funded. Besides, many sectors are more inclined to activities
which they consider as their primary mandate leaving nutrition in the shelf.
 Technology is utilized

Technology is utilized at every level of service delivery to ensure the data-driven decision and real-time access to information at
different levels.It has been discussed during the review meetings that the weak monitoring system in Ethiopia is a barrier to the use of
information for decision making, affecting multi-sectoral coordination. The challenges include a lack of robust reporting system, poor
quality of the data, and untimely submission of reports. There is currently a unified nutrition information System (UNIS) that is being
piloted and have not yet become operational across sectors. In addition, there is no feedback mechanism to the lower government
structure.
 Availability of Incentive mechanisms

Performance-based incentives are being practiced in some countries like Peru, which is said to be motivational. There is no such
mechanism in Ethiopia, and therefore, the motivation among lower-level workers is reportedly not there.

 Gradual expansion to include more ministries

The OWNP is started with four signatories who have the lion’s share of contribution to the vision, mission and objectives of the
program and gradually expand to include more. Following this approach might help for the NNP to bring on board more ministries as
time goes on and focus on the few to start with.
 Highest government body involved at district (woreda) level

The woreda administrator leads the Woreda WASH team (WWT). Having the highest political figure to lead the multi-
sectoral coordination at the lowest implementation level will facilitate accountability and improves service quality.

2.6 Synthesis of Literature Reviews in light of the Collective Impact Analytical Framework

The current operational research employs the collective impact initiative as its analytical framework, as explained in detail in section
2.1 above. The purpose of this section is to examine the international and Ethiopian multi-sectoral coordination experiences through
the framework lens dissecting whatever has been done into the five pillars of the framework, i.e. common agenda, shared

29
measurement, mutually reinforcing activities, continuous communication, and backbone support. It is worth to note that none of the
country experiences included in the literature reviews had utilized the collective impact approach as their implementation modality
and therefore might not necessarily fit into the five conditions for the collective success. 

 Common Agenda

The different sectors engaged in nutrition-specific and sensitive activities shared a vision and had a common understanding of the
nutrition problems. In Ethiopia, this has been reflected in the NNP II where all sectors recognize that the high malnutrition rate in the
country is completely unacceptable. They all understand the need for better coordination for a meaningful response. This is reflected
in the shared commitment and consensus across sectors and the different levels in government around the same goal of achieving good
nutrition outcomes.

 Shared Measurement

There is a well-designed reporting mechanism supported by technology where different sectors report on the agreed-upon indicators.
In Ethiopia, however, lack of timely reporting and poor data quality has made an assessment of progress difficult.  The Unified
Nutrition Information System that is being piloted is expected to solve the problem whereby all sectors will be reporting progress on
the agreed-upon list of indicators to drive learning and improvement.

 Mutually Reinforcing Activities

Each sector is given a task considering the bigger picture in tandem with their specific roles. The goals, depending on the country,
include a reduction in malnutrition, elimination of hunger, ensuring food security, increasing income of the poor…etc. With clearly
defined entry to and exit from the program strategies targeting the most vulnerable. In Ethiopia, the job descriptions of the different
sectors and the contributions each can make to realize optimal nutritional status for all Ethiopians and to end hunger by 2030 have
been well stated in the NNP II. 

 Continuos Communication

30
The coordination of the different sectors engaged in nutrition-specific and sensitive activities by higher political bodies such as the
Office of the President, Prime Minister’s Office or by a line ministry that is directly linked with the highest political figure in the
country, such as the Ministry of Development and Social Inclusion in Peru and the Ministry of Social Development in Brazil has
improved accountability and made continuous communication possible. As the coordination is run by a line ministry, the ministry of
health, the accountability mechanism has been weaker in Ethiopia. Review of minutes from the various coordination meetings
indicated inconsistent attendance by the different sectors, which made continuous communication to be a challenge. 

 Backbone Support

The collective impact initiative emphasizes the need for an independent dedicated staff to provide support and key functions for the
sustained operation of the coordination for its success. The coordinating body, which in many cases is the highest level of government,
has been supporting the sectors involved. Technical staffs have been recruited by various stakeholders and seconded to the ministry of
health and other ministries in Ethiopia to support the nutrition work, including coordination. The Food and Nutrition Council, which is
currently at its infancy, is likely to provide the backbone support required in the collective impact initiative.

31
3. METHODOLOGY

3.1 Research Gaps

From the desk research about the MSC experience in Ethiopia, we can draw the following key points. First, we learned that Ethiopia
had made significant progress in terms of setting policy, strategy, and program governance frameworks for nutrition. It is noticed that
lack of uniform awareness about these frameworks across sectors and administrative levels, lack of nutrition experts, and targeted
budgeting for nutrition-sensitive programs are some of the challenges identified (Ayana et al. 2017; IDS, 2020). However, we do not
know about what has been done across sectors and administrative levels to solve the problems. 

Second, it is indicated that 13 sectors have co-signed the NNP II and represented in the MSC body. However, there is limited
information if the MSC governing bodies exist and properly function across all administrative levels. Besides, nutrition has not well
been reflected in some of the implementing sectors’ strategies and programs. There is no enough answer to why is it so, and the
32
accountability mechanisms put in place are not well understood. Furthermore, despite joint review meeting initiatives among
the MSC sectors, lack of a unified nutrition information system across sectors has hindered the timely exchange of quality data from
tracking the progress of the MSC.

Third, to the best of our knowledge, no systematic study has been done to assess the effectiveness of the MSC as a process or
approach. There is no national-level study that covered agrarian, pastoralist, and urban areas that will give an overall picture of the
coordination at the national level. Moreover, the studies done so far were mainly focused on nutrition outcomes and impacts, and not
on the coordination process from the individual, organizational and systemic perspective.

Therefore, this study aims to fill these gaps through assessing the process of MSC interventions within urban, agrarian, and pastoral
livelihood settings across the different administrative units in the country. Besides, the use of the Collective Impact Framework
(Kania& Kramer, 2011) as an analytical framework in this study will add value to the MSC evidence base in the country through
generating critical insights related to common agenda, shared measurement, mutually reinforcing activities, continuous
communication, and backbone support mechanisms.

3.2 Study Design

To achieve the objectives, a case study design will be used in this process evaluation (Balbach, 1999; Garrett et al., 2010b; USAID,
2013). The study will use a qualitative method through key informant interviews (KIIs) and focus group discussions (FGDs) on
collecting primary data from stakeholders involved in the nutrition sector. Moreover, the qualitative data will also be transformed into
quantitative data whenever applicable. Also, secondary documents such as multisectoral nutrition plan, sector-specific strategy and
plan, budgeting, coordination meeting minutes and organizational structures will be reviewed. This design helps to undertake an in-
depth description and analysis of the gaps we identified through the desk research. This study design allows us to gain a detailed
picture of the missing elements in the design, planning, implementation, and monitoring and evaluation of the MSC through
conducting KIIs, FGDs, and collecting related data. Furthermore, a case study allows us to assess the multisectoral approach as a
whole and its implementation contexts (USAID, 2013). 

The case study design is recommended if the evaluation is at the initial stages of exploration where a qualitative explanation of what is
happening and why is important. As our research purpose is to investigate and describe, not to undertake a causal analysis, the case

33
study design is ideal. This approach helps to develop further the implementation model of the multisectoral approach guidance for
working multi-sectorally (Garrett et al., 2010b).

The limitation of the case study design is its vulnerability to evaluators’ bias, selection bias, and alternative explanations (USAID,
2013). The evaluators’ bias refers to unconscious or intended biases introduced by the evaluators who involved in the design and
implementation of the case study. To avoid evaluators’ bias, we will make everyone who will be involved in this study aware of and
limit influence. Also, we will follow collaborative outcome reporting (i.e. mapping existing data against the theory of change and
using a combination of expert review and community consultation to check for the credibility of evidence whenever necessary).
Furthermore, we will practice multiple lines and levels of evidence (i.e. reviewing a wide range of evidence from different sources to
identify consistency with the theory of change) (BetterEvaluation, 2013). Moreover, proper data sources (relevant and reliable),
collection methods (e.g. recording, transcribing, and storing), and analysis techniques (coding, triangulation, and cross-case analysis)
will be employed.  

Selection bias refers to biases introduced due to inappropriate selection of study cases either by the researcher or the research
stakeholders. To avoid this problem, we will develop a clear selection criterion for our study cases (key informant interview and focus
group discussion participants). Bias can also be introduced due to a lack of accounting alternative explanations. This will be addressed
through the process of assessing and revising assertions during the research process and debriefing workshop (USAID, 2013). Besides,
collaborative outcome reporting and multiple lines and levels of evidence approaches will be employed whenever necessary
(BetterEvaluation, 2013).

3.3 Data Sources

In this operational research, data from both secondary and primary sources will be used. The secondary data sources aim to understand
the whole process of the multisectoral approach and identify gaps that will be used to design and employ the primary data sources.    

3.3.1 Secondary data sources

Data collection from secondary data sources are the first step in this operational research, and the documents to be reviewed include:

 National nutrition and related policy, strategy, and program planning and implementation documents;

34
  Nutrition and related program monitoring and evaluation reports, and other related documents available at all administrative
levels;
 Donor and implementation partner documents and related to multisectoral nutrition approaches will also be used as secondary
data sources; and,
 Published and unpublished research findings related to multisectoral approaches for nutrition and beyond in Ethiopia and other
countries in low-income countries will also be used as secondary data sources.

3.3.2        Primary data sources

The second step in the research involves a collection of data from primary data sources, which include:

 Key informant interviews (KIIs) with the chair, co-chair, secretary and members of the federal and regional nutrition
coordination bodies and technical committees; The listing will be developed and reviewed in consultation with the client.
 Key informant interviews with donors and other partners participating in national level nutrition coordination body and
technical committees that are playing a key role in the multisectoral nutrition approach. Individuals who participated in-
country experience sharing tours and from ONE WASH program will also be included.
 Focus Group Discussions (FGDs) with Woreda and Kebele level and sector officials who are members of
the Woreda and Kebele level multisectoral nutrition taskforces [or Key informant interviews with Woreda sector officials who
are members of the multisectoral nutrition taskforces if FGDs are not feasible.] Considerations will be given to the power
dynamics of the FGD participants to enable everyone to speak during the discussion freely. 

Besides, workshop-based discussions will generate collective information on multi-sectoral coordination issues. The participants will
be key personnel from federal, regional, zone, and woreda government offices, partner organizations, and donors.  The listing will be
developed and reviewed in consultation with the client.

35
3.4 Methods of Data Collection and Sample Size

3.4.1 Key informant interviews[1]

Key informant interview (KII) will be used to collect primary data. KII is a loosely structured conversation with people who have
specialized knowledge about the topic under study. Experienced and trained interviewers conduct face-to-face interviews with key
informants using a semi-open questionnaire. While doing a KII, the interviewer asks questions, listen attentively to participant's
responses, and then ask follow-up questions and probes based on those responses. 

For this study, individuals who provide leadership, coordination, facilitation, and who are in advisory roles at the national,
regional, zonal and woreda levels delivering multisectoral nutrition interventions will be the target groups for the KII. The purpose of
the KIIs is to gather information about the status, opportunities, and challenges of the multisectoral nutrition approach from a
leadership perspective.  The key informant interviewee will be from the NNP II signatory sectors (13 sectors), donors (UNICEF,
WB, USAID, Gates Foundation, and Irish Aid), and implementing partners. We will follow a purposive sampling strategy to select the
interviewee. They will be selected based on their role played (coordination, leadership, membership) and level of knowledge about
the multisectoral coordination (advisory role and subject matter speciality). The sample size of the KII is 16 at the federal level, which
include the 13 signatory sectors of the NNP II (one from each) and 5from partner organizations. At the regional level, 13 individuals
(one from each of the signatory) will be interviewed. However, there are variations in the level of engagement of sectors at the
regional level, and the final decision will be made in consultation with the client. The sample size, therefore, is determined based on
the objective of the research, several key actors involved, and logistics.  

[1] The research team will including as much probing questions as possible  for every question tailored to the Key informants' sectors
and its administrative position (federal, regional and woreda)

3.4.2 Focus group discussion

Focus group discussion (FGD) is a qualitative data collection method effective for capturing information and opinions of groups or
subgroups within a population. The discussions bring together people from similar backgrounds or experiences to discuss a specific
topic. Because focus groups seek to illuminate group opinion, several participants meet as a group (6-8individual per FGD) to discuss

36
a given research topic. Two experienced and trained individuals facilitate each FGD. One person (the moderator) leads the discussion
by asking participants to respond to open-ended questions and a second person (the note-taker) takes detailed notes on the discussion.

For this study, FGDs will be used to collect primary data at Woreda and Kebele levels. The purpose of the FGD is to assess the
implementation aspect of the multisectoral nutrition approach at the lower administrative units. At woreda levels, the FGD participants
will include the coordinators of the multisectoral nutrition and experts working in the line offices of NNP II signatory sectors. Based
on the multisectoral nutrition intervention performance, each region will have two categories of woredas: high and low
performing woredas. The purpose of this categorization is to identify factors which lead to their performance status. Performance
criteria will be developed in consultation with federal, regional, and zonal level coordinators, the client, donors, and
key multisectoral nutrition program implementation sectors. Each region, in turn, will have 2 woredas in each category (4 woredas per
region). These woredas in each group will be randomly selected. In Amhara and Tigray regions, half of the sample will be
SD woredas. There will be one focus group discussion per woreda. The size of the focus group discussion will range from 6 to 8
individuals. The number of participants might be reduced to 5 if the location of the FGD is in the door to follow COVID 19 safety
protocol.  In each woreda, one Kebele will be randomly selected for community-level FGD.

Table 2. Number of FGD per administrative unit covered by the study

Region Woreda level Kebele level Total FGD

Afar 4 4 8
Amhara 4 4 8
Oromia 4 4 8
Tigray 4 4 8
Addis Ababa 4 4 8
Total 20 20 40

37
3.5 Data Analysis

The analysis task will involve secondary and primary data analysis. The secondary data analysis will include searching, sorting, and
analysis of relevant literature. This will help us to captures the status of multisectoral nutrition interventions and identify gaps for
further investigation building on the desk review findings. A wide variety of other documents will be reviewed, including project
documents, local reports, and survey results. In the due process of in-depth desk review, the research team will also conduct a
mapping exercise to identify other partners working in the Woredas which are implementing nutrition-sensitive interventions and the
strength of the multi-sector nutrition coordination. Also, the consulting team will look into the routine monitoring data from the
selected Woredas. This step will help to identify known barriers and bottlenecks and most effective interventions.

The primary data analysis will follow qualitative analysis techniques due to the qualitative nature of the data to be collected (Pope et
al. 2010). More specifically, the framework method will be employed (Gale et al. 2013). This method includes transcription,
familiarization with the interview, coding, developing a working analytical framework, applying the analytical framework, charting
data into the framework matrix, and interpreting the data. 

The first stage in the data analysis process will be transcribing/translating recordings of kids and FGDs into English. Transcribers will
perform transcription by listening to the audio recording and simultaneously writing/typing everything the respondent said on the tape
(verbatim transcription). They will also note nonverbal sounds (such as laughter, coughing, someone knocking on the door) on the
transcript. They will do the transcription/translation of the data using a standard format prepared for this purpose. Using a standard
format will ensure a uniform presentation of information throughout the transcript by different transcribers/translators. Transcribers
will also append handwritten field notes (typed in English) to the transcript. 

The research team will use NVivo software for managing the qualitative data from KIIs and FGDs. A codebook will be prepared for
qualitative data coding using key themes in line with the study objectives. Before coding starts, two team members will independently
code sample FGD and KII transcripts (using key themes identified based on the study objectives) to identify key themes and points of
interest to produce a basic framework of themes and sub-themes. Then, the research team will compare coding from each team
member and produce the final codebook through a process of deleting, merging, and re-definition, to create a consolidated 'coding
dictionary' of nodes. Once the final codebook is produced, the team will code all English transcripts and field notes line-by-line
against the set of nodes. 

38
After all, transcripts are coded, the research team will conduct the qualitative data analysis based on the study objectives and identified
key themes during coding. They will use the framework method of qualitative data analysis to describe and interpret participant’s
views based on the study objectives and generate emerging themes whose interpretation of interrelation provides insights into the issue
under scrutiny. The analysis will include triangulation of findings across the hierarchy of the administration structure (federal,
regional, zonal, woreda, and kebele level), type of study participants, and study method (KII and FGD). The purpose of triangulation
is to corroborate evidence from various sources and identify and interpret contradictory findings. The team will also interpret findings
from the primary data with existing evidence generated through a review of secondary data sources. Generally, the research team will
analyze the data in a way that the responses are interpreted fully and completely and present the findings clearly to ensure it is easily
understandable for readers.

3.6 Development of Strategic Document

One of the objectives of the operational research is to come up with an innovative and functional strategy that will respond to the
current multisectoral coordination challenges. Considering the complexity of the issues and geographical diversity, no single bullet
will be the remedy. Based on the research findings and consultations with partners, the research firm will come up with an approach or
a list of approaches that will be piloted in the second phase of the research. The lessons learnt will further boost coordination
mechanisms.   

39
4 REFERENCES

1. Addressing Malnutrition Multi-sectorally, Case studies from Peru, Brazil, and Bangladesh,
United Nations, August 2013.
2. Ayana, G., Hailu, T., Kuche, D., Abera, A., Eshetu, S., Petros, A., ... &Dangour, A. D. (2017).
Linkages between health and agriculture sectors in Ethiopia: a formative research study
exploring barriers, facilitators and opportunities for local level coordination to deliver
nutritional programmes and services. BMC Nutrition, 3(1), 69
3. Balbach, D. E. (1999). Using Case Studies to do Program Evaluation. Tufts University.
4. Bennett, S., Glandon, D., &Rasanathan, K. (2018). Governing multisectoral action for health
in low-income and middle-income countries: unpacking the problem and rising to the
challenge. BMJ global health, 3(Suppl 4), e000880.
5. Bhutta, et al, Evidence-based interventions for improvement of maternal and child nutrition:
what can be done and at what cost? The Lancet, Volume 382, Issue 9890, 452-477.
6. Black, R. et al. 2008. “Maternal and Child Undernutrition: Global and Regional Exposures
and Health Consequences.” The Lancet 371 (9608): 243–260.
7. Black, R. et al. 2013. Maternal and Child Undernutrition and Overweight in Low-income and
Middle-income countries. The Lancet 382 (9890): 427–451.
8. Cabaj, M., & Weaver, L. (2016). Collective Impact 3.0: An Evolving Framework for
Community Change. Tamarack Institute: Community Change Series 2016.
9. Chisholm, D. and Evans, D.B. (2010). Improving health system efficiency as a means of
moving towards universal coverage. World Health Report Background Paper, 28.
10. Danaher, A. (2011). Reducing health inequities: enablers and barriers to inter-sectoral
collaboration. Toronto: Wellesley Institute, 20.
11. Danton, H., Clark, S., Klein, A., Lidan, D., & Titus, S. (2017). Operationalizing Multi-
Sectoral Coordination and Collaboration Strategies for Improved Nutrition.
12. Demographic and Health Survey 2016, Central Statistical Agency, Addis Ababa, Ethiopia,
July 2017.
13. Deniston, O. L., Rosenstock, I. M., & Getting, V. A. (1968). Evaluation of program
effectiveness. Public health reports, 83(4), 323.
14. Deniston, O. L., Rosenstock, I. M., Welch, W., & Getting, V. A. (1968). Evaluation of
program efficiency. Public Health Reports, 83(7), 603.
15. Durrans, S., Jones, D., Pando, N. and Wilson-Jones, M. (2017). The recipe for success: how
policymakers can integrate water, sanitation and hygiene into actions to end malnutrition.
WaterAid, SHARE, and Action Against Hunger.
16. Evolution of Nutrition Policy in Senegal, Andrea L. Spray, 2018.
17. FAO, IFAD and WFP. (2014). The State of Food Insecurity in the World 2014.
Strengthening the enabling environment for food security and nutrition. Rome, FAO.

40
18. Fawcett, S., Schultz, J., Watson-Thompson, J., Fox, M., &Bremby, R. (2010). Building
multisectoral partnerships for population health and health equity. Preventing chronic
disease, 7(6).
19. Gaihre, S., Kyle, J., Semple, S., Smith, J., Marais, D., Subedi, M., & Morgan, H. (2019).
Bridging barriers to advance multisector approaches to improve food security, nutrition and
population health in Nepal: transdisciplinary perspectives. BMC public health, 19(1), 961.
20. Gale, N. K., Heath, G., Cameron, E., Rashid, S., & Redwood, S. (2013). Using the
framework method for the analysis of qualitative data in multi-disciplinary health
research. BMC medical research methodology, 13(1), 117.
21. Garrett, J. L., &Natalicchio, M. (Eds.). (2011). Working multisectorally in nutrition:
principles, practices, and case studies. International Food Policy Research Institute
22. Garrett, J., S. Kadiyala, and N. Kohli. (2014). Working Multisectorally to Improve Nutrition:
Global Lessons and Current Status in India. POSHAN Policy Note #1. New Delhi, India:
International Food Policy Research Institute.
23. Glandon, D., Mondal, S., Okeyo, I., Zaidi, S., Khan, M. S., Dar, O., & Bennett, S. (2019).
Methodological gaps and opportunities for studying multisectoral collaboration for health in
low-and middle-income countries. Health policy and planning, 34(Supplement_2), ii7-ii17.
24. Government of the Federal Democratic Republic of Ethiopia (FDRE) (2008), National
Nutrition Program I, 2008-2015. Addis Ababa, Ethiopia.
25. Government of the Federal Democratic Republic of Ethiopia (FDRE) (2016), National
Nutrition Program II, 2016-20. Addis Ababa, Ethiopia.
26. Government of the Federal Democratic Republic of Ethiopia (FDRE). (2018). Food and
Nutrition Policy. Addis Ababa, Ethiopia.
27. Hanleybrown, F., Kania, J., & Kramer, M. (2012). Channeling Change: Making Collective
Impact Work. Stanford Social Innovation Review, Winter.
28. Hawkes, C., Brazil, B. G., Castro, I. R. R. D., & Jaime, P. C. (2016). How to engage across
sectors: lessons from agriculture and nutrition in the Brazilian School Feeding
Program. Revista de saude publica, 50, 47.
29. HLPE. 2018. Multi-stakeholder partnerships to finance and improve food security and
nutrition in the framework of the 2030 Agenda. A report by the High- Level Panel of Experts
on Food Security and Nutrition of the Committee on World Food Security, Rome.
30. Institute of Development Studies (IDS) (2017), Brazil’s Food and Nutritional Governance
Plan, July 2017.
31. Institute of Development Studies (IDS) (2020), Multi-Sectoral Nutrition Policy and
Programme Design, Coordination and Implementation in Ethiopia, March 2020.
32. Kania, J. & Kramer, M. (2011). Collective Impact. Stanford Social Innovation Review,
Winter.
33. Keefe, M. (2016). Nutrition and equality: Brazil’s success in reducing stunting among the
poorest. Nourishing millions: Stories of change in nutrition, 99-105.

41
34. Kennedy, E., Tessema, M., Hailu, T., Zerfu, D., Belay, A., Ayana, G., ... &Kassaye, T.
(2015). Multisector nutrition program governance and implementation in Ethiopia:
opportunities and challenges. Food and nutrition bulletin, 36(4), 534-548.
35. Klint, M. B., &Sjöberg, U. (2003). Towards a comprehensive SCP‐model for analysing
strategic networks/alliances. Int. Journal of Physical Distribution & Logistics Management.
36. Kuruvilla, S., &Dorstewitz, P. (2010). There is no “point” in decision-making: a model of
transactive rationality for public policy and administration. Policy Sciences, 43(3), 263-287.
37. Kuruvilla, S., Hinton, R., Boerma, T., Bunney, R., Casamitjana, N., Cortez, R., ... & Papp, S.
(2018). Business not as usual: how multisectoral collaboration can promote transformative
change for health and sustainable development. bmj, 363.
38. Kuruvilla, S., Hinton, R., Boerma, T., Bunney, R., Casamitjana, N., Cortez, R., ... & Papp, S.
(2018). Business not as usual: how multisectoral collaboration can promote transformative
change for health and sustainable development. bmj, 363.
39. McAfee, M., Blackwell, A. G., and Bell, J. (2015). Equity: The Soul of Collective Impact.
PolicyLink.
40. Michaud‐Létourneau, I., Gayard, M., Mathisen, R., Phan, L. T. H., Weissman, A., &
Pelletier, D. L. (2019). Enhancing governance and strengthening advocacy for policy change
of large Collective Impact initiatives. Maternal & child nutrition, 15, e12728.
41. Ministry of Health (MoH), Federal Democratic Republic of Ethiopia. (2008). National
Nutrition Strategy. Addis Ababa, Ethiopia: MoH.
42. Moss, C., Bekele, T. H., Salasibew, M. M., Sturgess, J., Ayana, G., Kuche, D., ... &Dangour,
A. D. (2018). Sustainable Undernutrition Reduction in Ethiopia (SURE) evaluation study: a
protocol to evaluate impact, process and context of a large-scale integrated health and
agriculture programme to improve complementary feeding in Ethiopia. BMJ open, 8(7),
e022028.
43. National Nutrition Program Performance Assessment. Final Draft Report. Addis Ababa,
Ethiopia: EPHI, 2019  
44. National Multi-Sector Nutrition Policy 2018 – 2022, Government of Malawi, DNHA, April
2018.
45. One WASH National Program, a Multi-sectoral SWAp, Phase II program document, FDRE,
November 2018.
46. Oshaug, A. (1997). Evaluation of nutrition education programmes: Implications for
programme planners and evaluators. FAO FOOD AND NUTRITION PAPER, 151-178.
47. Pelletier, D., Gervais, S., Hafeez‐ur‐Rehman, H., Sanou, D., &Tumwine, J. (2018).
Boundary‐spanning actors in complex adaptive governance systems: The case of
multisectoral nutrition. The International journal of health planning and management, 33(1),
e293-e319.
48. Pope, C., Ziebland, S., & Mays, N. (2000). Qualitative research in health care: Analyzing
qualitative data. BMJ: British Medical Journal, 320(7227), 114.
49. Preskill, H., Parkhurst, M., Juster, J. S. (2014). Guide to Evaluating Collective Impact, FSG.

42
50. Reinke, W. A. (1994). Program evaluation: Considerations of effectiveness, efficiency and
equity. Journal of family & community medicine, 1(1), 61.
51. Ruducha, J., Mann, C., Singh, N. S., Gemebo, T. D., Tessema, N. S., Baschieri, A., ... &
Berman, P. (2017). How Ethiopia achieved Millennium Development Goal 4 through
multisectoral interventions: a Countdown to 2015 case study. The Lancet Global
Health, 5(11), e1142-e1151.
52. Ruel, M. T., Alderman, H., & Maternal and Child Nutrition Study Group. (2013). Nutrition-
sensitive interventions and programmes: how can they help to accelerate progress in
improving maternal and child nutrition? The lancet, 382(9891), 536-551.
53. Scaling up nutrition (SUN). (2011). Scaling up nutrition: a framework for action. 
54. SPRING. 2016. Operationalizing Multi-sectoral Coordination and Collaboration for
Improved Nutrition: Recommendations from an in-depth assessment of three countries’
experiences. Arlington VA: Strengthening Partnerships, Results, and Innovations in Nutrition
Globally.
55. Turner, S., Merchant, K., Kania, J. & Martin, E. (2012). Understanding the Value of
Backbone Organizations in Collective Impact. Stanford Social Innovation Review, Summer.
56. U.S. Agency for International Development (USAID). (2014). Multi-Sectoral Nutrition
Strategy 2014-2025. Washington, DC: USAID.
57. UN. 2016. United Nations Decade of Action on Nutrition (2016–2025) [online].
www.un.org/en/ga/search/view_doc.asp?symbol=A/RES/70/259
58. United Nations Children’s Fund (UNICEF). (2013). Improving Child Nutrition: The
achievable imperative for global progress. New York: UNICEF.
59. United Nations Children’s Fund. (2015). UNICEF’s approach to scaling up nutrition for
mothers and their children. Discussion paper. Programme Division, UNICEF, New York.
60. USAID. (2013). Technical Note on Evaluative Case Studies. Monitoring and Evaluation
Series
61. Warren, A. (2016). Agriculture, WASH and safety nets. Ethiopia’s multisector
story. Nourishing millions: Stories of change in nutrition, 139-147.
62. Weaver, L. (2014). The promise and peril of collective impact. The Philanthropist, 26(1).
63. WHO. (2010). Intersectoral Action to Tackle the Social Determinants of Health and the Role
of Evaluation. Report of the first Meeting of the WHO Policy Maker Resource Group on
Social Determinants of Health, Viña del Mar, Chile, 27-29 January.
64. Wolff, T. (2016). Ten Places Where Collective Impact Gets It Wrong. Global Journal of
Community Psychology Practice, 7(1)
65. Wood DJ, Gray B. Toward a comprehensive theory of collaboration. J Appl Behav Sci.
1991;27:139–162.
66. World Bank. (2014). Learning from World Bank history: Agriculture and food-based
approaches for addressing malnutrition. World Bank report number 88740-GLB.
67. World Bank. 2013. Improving nutrition through multisectoral approaches. Washington, DC:
The World Bank.

43
68. Gaihre, S., Kyle, J., Semple, S., Smith, J., Marais, D., Subedi, M., & Morgan, H. (2019).
Bridging barriers to advance multisector approaches to improve food security, nutrition and
population health in Nepal: transdisciplinary perspectives. BMC public health, 19(1), 961.
69. Theis, T., &Tomkin, J. (2015). Sustainability: A comprehensive foundation.
70. Acosta, A. M. (2011). Analysing success in the fight against malnutrition in Peru. IDS
Working Papers, 2011(367), 2-49.
71. Nyumba, T., Wilson, K., Derrick, C. J., & Mukherjee, N. (2018). The use of focus group
discussion methodology: Insights from two decades of application in conservation. Methods
in Ecology and evolution, 9(1), 20-32.
72. World Health Organization(WHO), (2013) Expanding Capacity for Operations Research in
Reproductive Health: Summary Report of a Consultative Meeting, WHO, Geneva,
Switzerland, December 10–12, 2001,

5 ANNEXES

44
 Annex 2: Data Collection Tools/ Instruments

Key Informant Interview Checklist

for
OPERATIONAL RESEARCH ON ETHIOPIAN MULTI-SECTORAL APPROACH FOR
NUTRITION – 2020
UNICEF Ethiopia
AND

DAB Development Research and Training PLC

Good morning /afternoon. This is _______ from DAB Development Research & Training PLC.
UNICEF Ethiopia commissioned DAB – DRT to conduct operational research on Ethiopian
multisectoral approach for nutrition. The objective of this research is to assess the facilitators,
implementation barriers and test the proposed changes to improve the multisectoral coordination in
selected regions of Ethiopia. The results of this operational research will be useful for the Government of
Ethiopia (GOE) and key partners (UNICEF, World Bank) in strengthening the multisectoral coordination
to strengthen the National Nutrition Program (NNP) implementation.
The discussion will take about one hour. All the information we obtain will remain strictly confidential,
and your answers will never be shared with anyone other than our project team.

[Federal, Regional, Zonal, Woreda Sector offices; Donor and Partner leaders]
Identification particulars
Questions Response
Name of Institution:
Position in the Organization
Years in the current position
Membership (tick one): NNCB member:
NNTC member:
Other (specify):
Interviewee training/ qualification:
Current role in the membership:
Years in the current membership role :
Name :____________________________ E-Mail:________________
Mobile:________________

Part I. Common Agenda

45
 1. To start our discussion, can you please explain to me how nutrition is aligned with your
organization’s vision and mission? How relevant is nutrition to your organization in
terms of priority? 
2. Which of your organization’s vision is shared by other sectors collaborating in the MSC?
What kind of nutrition-specific and/or sensitive nutrition activities have you been
implementing?
3. How do you explain your organization’s leadership commitment to MSC, sense of
urgency for nutrition, and resource allocation (financial and human) to nutrition
interventions through MSC?
4. What are the challenges you face related to setting nutrition as a priority agenda in your
organization if any? What can be done differently to fix the problem? By who?     

Part II. Reinforcing Activities

1. Can you please explain to me how you went through the planning and implementation
process of your organization’s nutrition-specific and/or sensitive nutrition activities? 
2. Can you further elaborate about the level of collaboration with other members of the
MSC in planning and coordination nutrition-specific and/or nutrition-sensitive activities? 
3. Is a joint multisectoral nutrition implementation plan developed in advance, by whom,
and what is included in this plan? What is quality assurance in place during planning
Who is leading the planning process? Who is approving the final plan?
4. What are the incentives in place to your organization which enables it to plan and
implement nutrition-specific and/or sensitive nutrition activities through MSC? 
5. To what extent does the delivery of the MSC meet your organization’s needs - facilitating
the coordination of activities to avoid redundancy and allow for specialization?
6. How is the contribution of your institution been recognized and appreciated in the
partnership?
7. What are the challenges of the MSC related to executing reinforcing activities? What
needs to be done differently to improve the multi-sectoral coordination further?

Part III. Shared Measurement 

1. How do you measure your organization’s success in terms of accomplishing nutrition-

specific and/or nutrition-sensitive activities within the MSC context? 
Does 
1. Had supervision and monitoring been done jointly or by your sector alone? How
frequently is it done?
2. What shared indicators and measurements your organization has adopted to measure
success in terms of achieving desired outcomes for nutrition through the MSC?  

46
 3. Can you explain your organization’s data collection and reporting system put in place
about nutrition-specific and/or sensitive-nutrition activities in the context of MSC? 
4. Can you also explain about accountability and learning mechanisms put in place about
nutrition-specific and/or nutrition-sensitive activities in the context of MSC?
5. What are the challenges you face related to implementing a shared measurement
approach? What can be done to fix the problem? By whom?     

Part IV. Continuous Communication

1. Can you explain your organization’s internal and external communication strategy that
you adopted about awareness creation, cascading, reporting,
2. To what extent Is the multi-sectoral nature of malnutrition well understood by staffs in
your sector? What are the steps undertaken to ensure the teams understood the multi-
sectoral nature of malnutrition?
3. Can you specify the national/regional guidance? 
4. Exist and shared for effective implementation of Multisectoral Nutrition Coordination
5. How do you evaluate the performance of your organization's communication strategy in
terms of:
a. Cascading activities to your line offices in the next administrative level?
b. Building trust and revealing common motivation among members of MSC?
c. Allowing continuous learning
d. Assuring mutual objectives
What are the challenges of the MSC related to ensuring continuous communication? What
needs to be done differently to improve it further?

 
Part V. Backbone support 

1. Can you explain how the MSC is being governed/coordinated at                 

(Federal/Regional/Zone/Woreda/Kebel) level?
2. Is there any independent entity assigned for this purpose with dedicated staff? 
3. What sectoral policies /strategies and /or enabling environment are available in (for) your
organization to effectively implement nutrition interventions through MSC? 
4. Are there adequate human resources available to implement the nutrition-sensitive/
specific intervention? 
5. Do Nutrition focal and managers have sufficient knowledge, skills and abilities to deliver
and monitor the nutrition-sensitive/specific intervention?
6. Are relevant skills upgraded regularly, via training courses, access to on-line material,
other means?

47
 7. Are staff willing to fully engage in the implementation of the nutrition-specific/ sensitive
intervention and what factors motivate staff to work on nutrition?
8. How do you evaluate the performance of the MSC governing body in terms of:

a. Guiding the vision and strategy

b. Supporting aligned activities
c. Establishing shared measurement practices
d. Building public will
e. Advancing policy
f. Mobilizing funding
g. Are you facilitating continuous communication? 

What are the challenges of the MSC related to ensuring backbone support? What needs to be
done differently to improve it further?

Part VI. MSC Effectiveness

H-Form Guideline
H-Form Guideline
H form is a participatory monitoring and evaluation tool developed by Andy Lenglis, in 1997.
Since then, it has been used in evaluation exercise around the globe. H- Form is a user-friendly
tool and can help to assess or evaluate and extract lessons from programs, projects and or
initiatives. DAB Development Research &Training PLC modifies the H Form to evaluate the
performance of the MSC. 
Participants: 
All key staffs who have been participated in the MSC Project 
Facilitator: DAB DRT consultant 

Step One: Dear facilitator, please Prepare the following Materials 

- Flip chart paper 
- Enough Markers with different colours 
- Post It notes with different colours 

Step Two: Dear facilitator; Please fold the flip chart paper as follows;
- Fold it in half lengthwise and half again width-wise 
- Unfold the paper 
- Draw a large “H” using the folds 
- Write 0 (Not at all well) at the left end of the horizontal centre line of the “H”
- Write 10 (Extremely Well) at the right end of the horizontal centre line of the “H”

48
Step Three: Dear facilitator, Please write the questions being discussed in the top centre area of
the H- Form (please do question by question)

Step Four: Dear facilitator, please give each participant a marker and ask them to place their
score along the line between 0 and 10

Step Five: Dear facilitator, please give each participant three different colours post it and ask
them to write the negative reasons for their score ( why did they not give it the maximum
possible score). One reason one Post it. 
NB: it is possible to add post its 

Step Six: Dear facilitator, while the participants are recording their reason, please make a
heading at the top left-hand side of the “H” form: ‘Negative Reasons for your score.’
- Once everyone has written down their reasons, ask them to stick the post its on the left-hand
side of the “H” form

Step Seven: dear facilitator, please give to each of the participants three post its and ask them to
record their positive reasons for their score
 While the participants are recording their reason, please make a heading at the top right-
hand side of the “H” form: ‘Positive Reasons for your score.’
 Once everyone has written down their reasons, ask them to stick the post its on the right-
hand side of the “H” form.

Step Eight: Dear facilitator, please allow each person to reads out her/his negative and positive
reasons for their score. Encourage people to read what they have written (or drawn) on their own
‘sticky-notes without going into a lengthy discussion, with any clarification if necessary. The
group does not have to agree or disagree with any of the reasons people have recorded. This is
simply an opportunity for each person’s views to be heard and understood.
Step Nine: Once everyone has read out their negative and positive reasons for their score, please
ask them to give or develop a group score. This group score is based on the negative and positive
reasons participants recorded on the ‘sticky notes’.
 
Note: This is often a quick process because the group will have heard a wide range of reasons
behind the individual scores and can therefore usually agree on the group score.
 
 Once the group has decided upon a score between 0 and 10 then that score can be marked
as a large number at the top centre section of the H-form.
 

49
Step Ten: Dear facilitator: Please ask the participants to list ways in which the current situation
as represented by all the positive and negative reasons could be improved. This is carried out by
asking someone from the group to record everyone’s ideas in the bottom centre half of the H-
form.
 
Dear facilitator, this step can also be done individually by giving each person 3 ‘sticky notes’,
and the group will agree later.
 
Step Eleven: Dear facilitator, please appreciate the participants' participation and conclude the
discussion
Step Twelve: Dear Facilitator, please record the outputs of this tool and transfer into a report
without losing any detail or changing any words or symbols people have used to record their
views and ideas.
Note: This can be done by creating one H form and marking on it all the individual marks from
all the H-forms on the horizontal line and listing all the negative and positive reasons as well
as all the ideas for improvement.

Questions to be asked for discussion

Please help us understand the effectiveness level of the MSC for nutrition in terms of ensuring to
achieve the five pillars of the CI. Please circle the level, 0 refers to none, and 10 refers to the
max that can be achieved.  
1. Level of the effectiveness of the MSC in terms of enabling nutrition as a common agenda
among collaborating sectors. To make sure we are in the same page, our working
definition for Common Agenda refers to “All participants share a vision for change that
includes a common understanding of the problem and a joint approach to solving the
problem through agreed-upon actions.”  
2. Level of the effectiveness of the MSC in terms of guiding collaborating sectors to execute
reinforcing nutrition-specific and nutrition-sensitive interventions. To make sure we are
in the same page, our working definition for Mutually Reinforcing Activities refers to
“diverse set of stakeholders, typically across sectors, coordinate a set of differentiated,
mutually reinforcing set of activities”.
3. Level of the effectiveness of the MSC in terms of developing a shared measurement
system of success in terms of accomplishing nutrition-specific and/or sensitive nutrition
activities? To make sure we are in the same page, our working definition for
shared Measurement refers to “All participants agree on how to measure and report on
progress, with a shortlist of common indicators identified to drive learning and
improvement.”

50
 4. Level of the effectiveness of the MSC in terms of adopting continuous internal and
external communications pertinent to achieving its goal? To make sure we are in the
same page, our working definition for Continuous communication refers to “All players
engage in frequent, structured communication to build trust, assure mutual objectives,
and create common motivation”.
5. Level of the effectiveness of the MSC in terms of establishing backbone support adopting
continuous internal and external communications pertinent to achieving its goal? To
make sure we are in the same page, our working definition for Backbone support refers
to “An independent, dedicated staff provides support and key functions for the sustained
operation of the collective impact initiative”.

Is there anything that you would like to share with me related to this topic? 
Thank you!

51
Woreda Level Focus Group Discussions Checklist
for
OPERATIONAL RESEARCH ON ETHIOPIAN MULTI-SECTORAL APPROACH FOR
NUTRITION – 2020
UNICEF Ethiopia
AND

DAB Development Research and Training PLC

Good morning /afternoon. I am _______ from DAB Development Research and Training PLC.
UNICEF Ethiopia commissioned DAB – DRT to conduct an Operational research on Ethiopian
multisectoral approach for nutrition. The objective of this research is to assess the facilitators,
implementation barriers and test the proposed changes to improve the multisectoral coordination
in selected regions of Ethiopia. The results of this operational research will be useful for the
government of Ethiopia (GOE) and key partners (UNICEF, World Bank) in strengthening the
multisectoral coordination to strengthen the National Nutrition Program (NNP) implementation.
The discussion will take about one hour. All the information we obtain will remain strictly
confidential and your answers will never be shared with anyone other than our project team.

Community Level
Dear facilitator and raporter,

 For the facilitator, please start by introducing yourselves, and explaining the purpose of
the research
 For rapporteur, please make sure all participants are registered (circulate the registration
form)
 To guide the discussion, you can start by explaining the conceptual and analytical
frameworks
 Please present the discussion topics to participants and guide them with the participator
tools 
 Use Annex 4 for FGDs Participant Profile Registration

1. What are the basic assumptions that NNP implementing sectors have about the value of
the coordination in improving nutrition outcomes? 
2. To what extent does the multisectoral nutrition coordination meet users’ needs?
3. How well-aligned is the multisectoral nutrition coordination within implementing
sectors?

52
4. Are there any constraints faced in the implementation of multisectoral nutrition
coordination? 
5. Can multisectoral coordination activities be feasibly implemented within the budget that
can be allocated by the government in the long run?
6. Do sectors include nutrition activities with other sectoral planned activities? How? Who
is responsible for supporting these actions? 
7. To what extent is leadership, commitment and readiness for nutrition coordination in
place? 
8. What measures have been tried (put in place) to create awareness of sectoral office heads
on nutrition and have these measures been successful?
9. Are there effective accountability mechanisms in place and is there capacity to build and
improve?
10. Is sectoral nutrition activities executed according to plans and progress routinely
assessed?

53
Community Level Focus Group Discussions Checklist
for
OPERATIONAL RESEARCH ON ETHIOPIAN MULTI-SECTORAL APPROACH FOR
NUTRITION – 2020
UNICEF Ethiopia
AND

DAB Development Research & Training PLC

Good morning /afternoon. This is _______ from DAB Development Research & Training PLC.
UNICEF Ethiopia commissioned DAB – DRT to conduct operational research on Ethiopian
multisectoral approach for nutrition.

The objective of this research is to assess the facilitators, implementation barriers and test the
proposed changes to improve the multisectoral coordination in selected regions of Ethiopia. The
results of this operational research will be useful for the Government of Ethiopia (GOE) and key
partners (UNICEF and World Bank) in strengthening the multisectoral coordination to reinforce
the National Nutrition Program (NNP) implementation.

The discussion will take about one hour. All the information we obtain will remain strictly
confidential, and your answers will never be shared with anyone other than our project team.

Community Level
Dear facilitator and rapporteur, 
               
 For the facilitator, please start the interview by introducing yourselves and then explain
the purpose of the research
 For rapporteur, Please make sure all participants are registered (circulate the registration
form)
 To guide the discussion, you can start by explaining the conceptual and analytical
frameworks 
 Please present the discussion topics to participants and guide them with the participator
tools
 Use Annex 4 for FGDs Participant Profile Registration

1. Have you heard anything about nutrition in the past 6 months? If yes, from whom did you
hear that? [probe: HEWs, HDAs, schoolteachers, DAs, other frontline workers]

54
[List all the actors who pass on the nutrition messages]

2. For which community groups do these workers provide information about nutrition?
/Which community members are targeted?

[List the target groups for each of the frontline workers]

3. Can you please tell me what kind of information about nutrition you get from each one
of frontline workers?

[List what they have been told by each of the frontline workers]

4. How frequent have you been visited by each of the frontline workers?

[Record the frequency of visit, on average, for each of the frontline workers]

5. Was the visit made in a group or by individual? If were visited by a group of people,
please explain who were included in the group?
6. Did the information you hear from the frontline workers conflicting or in harmony with
your earlier information?

[Give examples for your response]

7. What is your suggestion for these frontline workers to deliver nutrition messages

effectively and efficiently in your community?
8. Do you have any other thoughts to improve the nutrition work in your community?

55
 Annex 3: Summary sheet - Challenges, suggested solutions and responsible bodies

Mitigation Limitations on Suggested How it should

Analysis Domain Constraint measures taken the measures solutions Responsible body be done?
External – Enabling Environment
Policy & strategy
Coord.
Mechanism
Capacity
Internal – Structure, Conduct, and Performance
Structure
Governing body
Representation
Complementarity
Conduct
Planning
Implementation
Monitoring
Evaluation
Performance
Effectiveness \
Efficiency
Sustainability

56
 Annex 4: KIIs and FGDs Participant Profile Registration

Data collection method: 1. KII 2. FGD 3. WBD (please circle one)

Date of the event (DD/MM/2020):
Location Profile:Federal:_____________Region: Zone: Woreda: Kebele: Place:

Facilitator Profile: Name Signature: Phone: Email:

Participant Profile

Name of Role played Years served

Organization she/he Responsibility within within the MSC within the MSC
S/N Participant’s Full Name represents the organization body body
1
2
3
4
5
6
7
8
9
10
11
12

57