The challenge of local implementation in Uganda's new nutrition policy

GULU, Uganda — Since she had Tracy 18 months ago, Angee Welsy has not missed any of her daughter’s immunization appointments. Three times, Welsy took Tracy to the health center near her small farm in rural northern Uganda and then waited in line to see a health worker.

As they administered the immunizations, none of those health workers ever mentioned that Tracy seemed small for her age or asked if she was keeping up with her developmental milestones. Because Tracy had been born a few months premature, Welsy assumed that was why her daughter remained persistently smaller than other children born around the same time. By the start of 2020, when her daughter was still unable to walk, though, Welsy took her to the closest referral hospital.

Tracy was diagnosed as stunted, and because she’s not yet even 2 years old, she is almost certain to have some problems with cognition and to struggle in school. Work will be harder and she’ll probably earn less than her peers. And she will be at greater risk than them of acquiring chronic diseases as she gets older.

“A stunted child will never be healthy again,” said Susan Awino, Uganda program coordinator at Feed the Children. Her NGO has now enrolled Tracy in a supplemental feeding program to prevent the condition from worsening, while preparing Welsy for the fact that her daughter will never fully recover. “That’s really a life lost.”

Despite presidentially endorsed, multisectoral strategies to end malnutrition, including a new national plan set for approval in a matter of weeks, stunting remains pervasive among children across Uganda, affecting almost a third of all children under 5 years old — an estimated 2.2 million, according to the U.S. Agency for International Development.

That rate has dropped gradually over the years, from 44% in 2010, and it is actually slightly ahead of the regional rate of 35.6 % and neighbors like Rwanda which is at 38% and mainland Tanzania at 35%, which also have large rural populations. But it is not falling fast enough for children like Tracy, who is also more likely to have stunted children herself, perpetuating a cycle of hunger and poverty.

According to experts, Uganda’s shortcomings underscore, not a policy gap, but a failure to translate those policies into more resources, better services or even higher awareness of the problem in some communities.

International agencies and NGOs have taken some of the slack, but Uganda’s struggles reflect a broader concern with a global target approaching to reduce stunting by 40% by 2025 rapidly: Doing so requires coordination across sectors and a willingness to push national policies to a local level that only a government can provide. What happens if that commitment, whether for political or economic reasons, never makes it past the planning stage?

Need for government oversight

The persistence of high rates of stunting suggests several systems aren’t working.

There is a nutritional failure, but stunting is often more than just not getting enough to eat. The chronic infections that come from poor water and sanitation services contribute, worsened by an absence of affordable treatment. And stunting reflects social, agricultural, and trade policies that do not facilitate easy access to a variety of nutritious foods.

Because it exists at all of these intersections, it demands government attention and oversight — and spending. Spending on implementing preventive programs within the agriculture and health sectors and also training and equipping health system volunteers embedded within the communities and health workers stationed at low-level clinics to identify the signs of chronic undernutrition.

“The government doesn’t have enough resources allocated to nutrition,” said Cecilia De Bustos, nutrition manager at UNICEF Uganda. “When you talk with government counterparts, they tell you that there is government commitment and the only issue is the lack of resources.” Officials from the ministries of health and agriculture and Uganda’s executive office did not respond to requests for comment.

Uganda has not historically consolidated what it budgets for nutrition, though a USAID-funded project estimated government spending in both 2013-14 and 2014-2015 was only 1% the national level government budget. Making more resources available, particularly with the imminent approval of the new nutrition plan — Uganda Nutrition Action Plan II, or UNAP II, — would do more to signal a commitment to addressing stunting and other forms of malnutrition than an updated policy.

“Nutrition interventions should have taken the biggest budget,” Awino said. “Once the population is healthy, then any other thing will fall into place.”

The problem is not only one of funding. Nutrition policies necessarily cut across ministries, but that multisectorality makes oversight difficult. The lack of indicators to guide ministries has created an additional challenge of accountability. Then, at the local level, district officials face the same complications, with the additional difficulty of matching the policies to their specific settings and implementing them.

Within communities, there is also a sense that national policies lag behind evolving local needs. Northern Uganda has seen a boom in agribusiness, according to Duncan Ongeng, faculty dean of agriculture and environment at Gulu University, a flagship institution in the region. Subsistence farmers, who would normally have grown a variety of produce, are being recruited to turn their land over to a few high-profit products — often crops, such as soybeans or sunflowers, that do not offer enough nutritional value to sustain their families.

They should be able to use their earnings to buy supplementary food to round out their diets, but the markets in northern Uganda have not yet caught up. With the shift in crop production, Ongeng said other food items have become scarce and too expensive even for farmers who have been selling to the agribusinesses.

“The challenges seem to be increasing,” he said. “It’s a surprise, because development should bring positive changes. But in this case it’s quite negative.”

Though he has raised the issue, there has been little interest from government officials in studying the impact of agribusiness, let alone introducing policies that might solve the immediate need of making a diversity of food available.

Policies and political will

Within communities, there is not much political or civic pressure around reducing stunting. It occurs gradually and has too many causes. What is also missed, said Vivian Jacky Aciro, food and nutrition officer at Feed the Children, is how stunting helps lock communities into a cycle of poverty that can be nearly impossible to escape, especially since stunted women are more likely to have stunted children. She sees the work of fighting stunting as “trying to save the next generation.”

Nutrition advocates are looking to the Ugandan government to more seriously join in that effort. The national government was meant to oversee the implementation of the previous UNAP on the district level by a combination of government health workers and NGOs, but the work often fell exclusively to NGOs — if there were any active in those areas.

The World Food Programme is looking to introduce a program before the end of the year that would help shore up some of the gaps left in the UNAP implementation, including coaching health workers and educating communities about what stunting actually is, according to Robert Ackatia-Armah, the program’s head of nutrition.

The pending introduction of UNAP II could be more significant — particularly in the way it corrects for some of its predecessor’s problems. UNAP II features a multisectoral approach, but De Bustos said officials have learned from their previous experience and assigned indicators to the various ministries.

There is also a greater consideration of trade and industry, said Jacob Korir, the Technical Assistance for Nutrition project adviser for Africa at Nutrition International. Under the DFID-funded TAN, Nutritional International managed a consultant who oversaw the creation of UNAP II. There was also an effort to prepare local officials and partners for the release, to ensure it would be adopted and implemented quickly.

At the same time, the ministry of finance introduced a new requirement at the end of last year that all ministries highlight their nutrition spending in future budgets, which should make it easier to spotlight the shortcoming.

The policies are once again in place. It will soon become clear if the political will is, as well.

This focus area, powered by DSM, is exploring innovative solutions to improve nutrition, tackle malnutrition, and influence policies and funding. Visit the Focus on: Improving Nutrition page for more.