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Multisectoral approaches are central to the global Scaling Up Nutrition (SUN) movement and the Sustainable Development Goals. Nepal joined SUN in 2011 and approved the first 5‐year Multisectoral Nutrition Plan (MSNP) in 2012, covering 2013–2017. This mixed methods study draws on organizational network analysis (ONA) and qualitative interviews with...
Citations
... A key aspect of scaling up is understanding the individuals and organisations that may promote, support, adopt, or implement research [15]. Network analysis provides an opportunity to identify and understand these organisations and aide scaling up efforts [16,17]. ...
Background: One Health focuses on sustainable health for humans, animals, and ecosystems. The approach has been well demonstrated, yet most efforts have not been scaled up. Understanding the organisations involved in scaling up processes is critical to translating research into practice. The Lao People's Democratic Republic has successfully implemented One Health projects for multiple decades; however, the organisational network has not been described and scaling up efforts have been limited.
Methods: Data from organisations involved in One Health projects over the past five years were collected by key-informant interview or workshop. The network was investigated using a mixture of quantitative network analysis and qualitative thematic analysis.
Results: The organisational network was quantitatively described as sparse and centralised. Organisations were required to harness pre-existing relationships to maximise scarce resources and make coordination and alignment of priorities more efficient. A lack of international organisations in the top 10% of resource sharing metrics suggests a potential disconnect between donors. This was reflected in the challenges faced by national organisations and a feeling of being stretched thin over numerous externally funded projects with donor-driven priorities.
Conclusions: It appears that high-level political support for country ownership of development and aid priorities remains unrealised. Developing network capacity and capability may assist scaling up efforts and build resilience in the network and its core organisations. This may allow for the inclusion of more development, education, environment, and water, sanitation, and hygiene organisations that were perceived to be lacking. Future One Health programmes should focus on practical activities that do not overload staff capacity. There is much for One Health to learn about the art of scaling up and organisations are encouraged to include implementation science in their research to inform future scaling up efforts.
... Selain itu, kolaborasi multisektor juga diperlukan untuk meningkatkan status gizi di masyarakat. 20 Berdasarkan penelitian yang dilakukan oleh Tschida et al. (2021), program SUN-Movement seperti pemberian makanan tambahan selain ASI, menyusui, dan memiliki sanitasi dasar dapat mencegah dan menanggulangi kasus stunting pada anak balita. 21 kehamilan (ANC) dan pemberian TTD sudah terlaksana dengan baik. ...
Masih tingginya angka kejadian stunting di Indonesia menurut data SSGI tahun 2021 yaitu 24,4% (Target WHO 20%). Salah satu upaya penanggulangan dan pencegahan yang telah dilakukan pemerintah adalah Scaling Up Nutrition (SUN) movement yaitu gerakan 1000 HPK didasarkan pada Peraturan Presiden nomor 72 tahun 2021 dengan melakukan intervensi spesifik. Artikel ini bertujuan untuk menganalisis pelaksanaan program SUN-Movement dalam penanggulangan kasus stunting. Penelitian ini menggunakan metode literature review yang mengulas 9 artikel. Artikel yang diulas berdasarkan dari hasil skrining dengan membaca semua artikel dan hanya berfokus pada SUN-Movement, Program Penanggulangan Stunting, Stunting Program, dan kata Stunting. Hasil review terhadap 9 artikel di 7 kabupaten/kota di Indonesia bagian barat, bahwa dari 9 intervensi spesifik pada kebijakan SUN-Movement teridentifikasi 6 intervensi telah dilakukan seperti di Aceh Besar dan Subang dilaksanakan pemberian ASI eksklusif. Mengkonsumsi tablet tambah darah pada remaja putri dan ibu hamil, asupan gizi tambahan ibu hamil supaya tidak kekurangan energi kronis sudah dilaksanakan di Palembang, Subang dan Bebes. PMT di Demak sudah dilaksanakan. Bayi di atas 6 bulan diberi MP-ASI sudah dilakukan di Semarang dan Pasaman. Namun intervensi pada balita seperti pelayanan penanganan gizi, tumbuh kembang dipantau, dan imunisasi dasar lengkap belum dilakukan. Terungkap sekitar 3 program intervensi spesifik di 7 kab/kota di Indonesia belum terlaksana.
... Several NCDs (such as tobacco-induced NCDs) and injuryinduced morbidities and mortalities (e.g., road traffic accidents, trauma) can be prevented through MSAs and incorporating the HiAP approach and strengthening PHC systems [15,32,46]. Nepal's Multisectoral Nutrition Plan (MSNP) is an example of HiAP where MSAs occurred in policy dialogue, strategic planning and implementation [57]. Similarly, not only in NCDs and nutritional issues, but macro-level also MSAs were effective in responding to the pandemic. ...
... In addition, micro-level MSAs can potentially address the downstream SDoH of individuals by adopting a healthy lifestyle and implementing interventions outside the health sector [51,54]. Moreover, health literacy empowers individuals and citizens to optimize their health, linking community and health system to prevent and control NCDs and malnutrition [43,57]. ...
... The interest of stakeholders, with shared ideas and institutions, could work for joint planning and produce policy and strategic documents. There are case studies of the macro-level intersectoral actions, including led agency actions to reduce road traffic accidents in Iran [63], tobacco control policies and actions in India [58], and MSNP for improving nutritional outcomes in Nepal [57]. In Indonesia, there was irrational use of antimicrobial resistance in formal health care facilities, communities, and beyond health sector such as the livestock and fishery sectors, and farms; but lacked multisectoral coordination between sectors [64]. ...
Background:
Multisectoral actions (MSAs) on health are key to implementation of primary health care (PHC) and achieving the targets of the Sustainable Development Goal 3. However, there is limited understanding and interpretation of how MSAs on health articulate and mediate health outcomes. This realist review explored how MSAs influence on implementing PHC towards universal health coverage (UHC) in the context of multilevel health systems.
Methods:
We reviewed published evidence that reported the MSAs, PHC and UHC. The keywords used in the search strategy were built on these three key concepts. We employed Pawson and Tilley's realist review approach to synthesize data following Realist and Meta-narrative Evidence Syntheses: Evolving Standards publication standards for realist synthesis. We explained findings using a multilevel lens: MSAs at the strategic level (macro-level), coordination and partnerships at the operational level (meso-level) and MSAs employing to modify behaviours and provide services at the local level (micro-level).
Results:
A total of 40 studies were included in the final review. The analysis identified six themes of MSAs contributing to the implementation of PHC towards UHC. At the macro-level, themes included influence on the policy rules and regulations for governance, and health in all policies for collaborative decision makings. The meso-level themes were spillover effects of the non-health sector, and the role of community health organizations on health. Finally, the micro-level themes were community engagement for health services/activities of health promotion and addressing individuals' social determinants of health.
Conclusion:
Multisectoral actions enable policy and actions of other sectors in health involving multiple stakeholders and processes. Multisectoral actions at the macro-level provide strategic policy directions; and operationalise non-health sector policies to mitigate their spillover effects on health at the meso-level. At micro-level, MSAs support service provision and utilisation, and lifestyle and behaviour modification of people leading to equity and universality of health outcomes. Proper functional institutional mechanisms are warranted at all levels of health systems to implement MSAs on health.
... For instance, Nepal's MSNP aims to improve nutrition through an intersectoral approach. While the MSNP has strengthened the nutrition system and increased investments in nutrition in Nepal [35], there is lower nutrition expertise and weaker implementation at the district level [36] and little ownership in any sector but health, limiting collaboration within districts [37,38]. This means that intersectoral approach in Nepal would require strengthening administrative capabilities and political will at a provincial and local level. ...
Community-based primary care settings are a potential entry point for delivering Early Childhood Development (ECD) interventions in Nepal. Past studies have suggested that integrating stimulation with nutrition interventions is an effective way to deliver multiple benefits for children, but there is limited knowledge of how to do this in Nepal. We conducted a qualitative study in Nepal's Dhanusha district to explore how stimulation interventions for early learning could be integrated into existing health and nutrition programmes within the public health system. Between March and April 2021, we completed semi-structured interviews with caregivers (n = 18), health service providers (n = 4), district (n = 1) and national stake-holders (n = 4), as well as policymakers (n = 3). We also carried out focus group discussions with Female Community Health Volunteers (FCHVs) (n = 2) and health facility operation and management committee members (n = 2). We analysed data using the framework method. Respondents were positive about introducing stimulation interventions into maternal and child health and nutrition services. They thought that using health system structures would help in the implementation of integrated interventions. Respondents also highlighted that local governments play a lead role in decision-making but must be supported by provincial and national governments and external agencies. Key factors impeding the integration of stimulation into national programmes included a lack of intersectoral collaboration, poor health worker competency, increased workload for FCHVs, financial constraints, a lack of prioritisation of ECD and inadequate capacity in local governments. Key barriers influencing the uptake of intervention by community members included lack of knowledge about stimulation , caregivers' limited time, lack of paternal engagement, poverty, religious or caste discrimination , and social restrictions for newlywed women and young mothers. There is an urgent need for an effective coordination mechanism between ministries and within all three tiers of government to support the integration and implementation of scalable ECD interventions in rural Nepal. PLOS GLOBAL PUBLIC HEALTH PLOS Global Public Health | https://doi.org/10.1371/journal.pgph.
... A high-level, national nutrition committee was formed in 1977, followed by the endorsement of a national nutrition strategy in 1978. After participating in the Scaling Up Nutrition movement in 2010, 18 Nepal endorsed a multisector nutrition plan, which has been a main guiding document for nutrition strategies and programs. Before and after the implementation of the multisector nutrition plan, various food and nutritional policies and strategies have been implemented. ...
... Recently, the multisector nutrition plan has tried to fill this gap by integrating nutrition-sensitive and nutrition-specific interventions through the network of stakeholders; however, several implementation-level challenges exist, 49 including disparities in access to adequate nutrition and health care, limited technical capabilities, weak coordination between different levels of government, lack of ownership, inadequate data, insufficient budget, and weak institutional structure. 18,50,51 Most nutritional policies have emphasized the reduction of conditions associated with childhood undernutrition, such as stunting, wasting, underweight, and specific micronutrient deficiency. 11 Childhood malnutrition has been reduced significantly over the past decades. ...
In the past few decades, the Nepali government has endorsed several nutritional policies, strategies, and guidelines. Given the lack of a comprehensive review of such policy documents, this review aims to describe the nutrition and food security policies and understand the existing policy gaps in Nepal. Findings from this study can be used to develop policies and programs to address Nepal's current and future nutritional needs. Policies relevant to nutrition and food security were identified by searching government websites and directly approaching relevant government ministries. Thematic analysis was conducted using framework methods under 8 predetermined themes: nutrition intervention, food security, food system, capacity building of human resources, nutrition education, nutrition governance, research, and monitoring and evaluation. The contents of each document reviewed were manually extracted in a spreadsheet stratified by the themes, and the findings were summarized for the respective themes. A total of 30 policy documents were reviewed. Most policies have focused on undernutrition; only a few have addressed overnutrition and diet-related noncommunicable diseases. Food security through a sustainable food system has been considered a key policy area in Nepal. Other areas in the food and nutrition policy landscape are capacity building for human resources, behavior change practices, nutrition governance, monitoring, and evaluation. Policy gaps have been identified in the quality and sustainability of nutrition programs; access to health care services; competent human resources for nutrition; intersectoral coordination and commitment; and support for monitoring, evaluation, and research activities. Most policies have tried to address a wide range of components of food and nutrition security; however, strategies focused on overnutrition and diet-related noncommunicable diseases are lacking. Several gaps are identified in this policy review; the findings can guide the policymakers to address these gaps via further policy development.
... ONA examines how the strength, frequency and nature of interactions between organizations influences the dynamics and performance of the overall network. ONA has been used previously to study relationships within multisectoral and multi-stakeholder networks, including on health and nutrition in South Asia Keywords: Organizational network analysis, Qualitative research, Regional networks, Social networks, South Asia, Undernutrition [12][13][14]. The semi-structured interviews explored the organizations' perspectives and experiences on working relationships between organizations at regional level to provide further context and possible explanations for the ONA findings. ...
... First, organizations of the same type tended to cluster together, a pattern known as the homophily principle of networks, in which there is a tendency for organizations with similar characteristics to be connected [26]. This may mean they tend to engage with like-minded organizations, which could limit the opportunities to build connections across different organizational types and explore new ideas and novel approaches [13]. ...
Background
Many national and international organizations are working to improve maternal and child nutrition in countries with high malnutrition prevalence and burdens. While there has been progress in strengthening multi-organizational networks on nutrition at country and global levels, the regional level has received much less attention. We conducted a study to 1) determine the existing relationships and levels of engagement between international organizations working to improve nutrition at the regional level or in at least two countries in South Asia; and 2) examine the experiences and perspectives of international organizations on regional-level communication, coordination or collaboration on nutrition in South Asia.
Methods
A mixed methods approach involving organizational network analysis (ONA) and semi-structured interviews was used to develop an understanding of the existing network and relationships between international organizations working on nutrition in South Asia. ONA data from 43 international organizations was analysed using a social network analysis software (UCINET) to systematically quantify and visualize the patterns of relationships between organizations.
Results
We found a high degree of connectivity between most of the international organizations in South Asia, but there were gaps between the many organizations that knew each other and the work they did together regionally on nutrition. Most organizations worked together only ‘rarely’ or ‘sometimes’ on nutrition at the regional level and high-intensity (collaborative) working relationships were uncommon. Organizations of the same type tended to cluster together, and a small number of UN agencies and multilateral organizations were central brokers in the nutrition working relationships. Perceived constraints to the nutrition working relationships included organizations’ agenda and mandate, threats to visibility and branding, human and financial resources, history, trust and power relations with other organizations, absence of a regional network for cooperation, and donor expectations. There was high demand to remedy this situation and to put network mechanisms in place to strengthen communication, coordination and collaboration on nutrition.
Conclusions
Opportunities are being missed for organizations to work together on nutrition at the regional level in South Asia. The effectiveness of regional nutrition networks in influencing policy or programme decisions and resources for nutrition at country level should be explored.
... 23 More recently, its application has been tested to understand levels of engagement and network dynamics among participating sectors and organisations in the planning of multisectoral nutrition programmes. 24 Thus, SNA provides distinctive methods to map, measure and analyse how social relationships within a network are established and evolve. 25 26 This study focuses on multisectoral policy implementation and governance, using the case of tobacco control policy at the district (local) level in Karnataka, a southern Indian state. ...
Introduction
Interest in multisectoral policies has increased, particularly in the context of low-income and middle-income countries and efforts towards Sustainable Development Goals, with greater attention to understand effective strategies for implementation and governance. The study aimed to explore and map the composition and structure of a multisectoral initiative in tobacco control, identifying key factors engaged in policy implementation and their patterns of relationships in local-level networks in two districts in the state of Karnataka, India.
Methods
Social network analysis (SNA) was used to examine the structure of two district tobacco control networks with differences in compliance with the India’s national tobacco control law. The survey was administered to 108 respondents (n=51 and 57) in two districts, producing three distinct network maps about interaction, information-seeking and decision-making patterns within each district. The network measures of centrality, density, reciprocity, centralisation and E-I index were used to understand and compare across the two districts.
Results
Members from the department of health, especially those in the District Tobacco Control Cell, were the most frequently consulted actors for information as they led district-level networks. The most common departments engaged beyond health were education, police and municipal. District 1’s network displayed high centralisation, with a district nodal officer who exercised a central role with the highest in-degree centrality. The district also exhibited greater density and reciprocity. District 2 showed a more dispersed pattern, where subdistrict health managers had higher betweenness centrality and acted as brokers in the network.
Conclusion
Collaboration and cooperation among sectors and departments are essential components of multisectoral policy. SNA provides a mechanism to uncover the nature of relationships and key actors in collaborative dynamics. It can be used as a visual learning tool for policy planners and implementers to understand the structure of actual implementation and concentrate their efforts to improve and enhance collaboration.
... 11 Early application of organisational network analysis demonstrated the potential benefits of cooperation between entities in a network structure, including the pooling of resources (eg, financial or physical capital, technical skills, information, etc.), increased efficiency or effectiveness in achieving a shared objective or bringing together diverse stakeholders that may not have otherwise come together in a planned or coordinated manner. 12 13 Organisational network analysis has also been used to assess network structure and/or coordination of services, 14 15 to identify opportunities for integration of services, 16 17 to refine internetwork and intranetwork resource exchange 18 19 and planning in multisectoral environments, 20 to monitor and evaluate capacity building 21 22 and to study policy advocacy. 23 Despite the encouraging findings from this research, the application of network analysis to organisational networks seems to be lagging behind that for networks of individuals. ...
As health systems practitioners and researchers increasingly turn towards systems thinking approaches and work on building interorganisational networks, they have demonstrated increasing interest in network analysis for investigating relationships and interactions between system actors, both at the individual and organisational levels. Despite the potential of network-based approaches to improve health system efficiency, effectiveness and responsiveness, both the theoretical and practical guidance on designing and evaluating network-building strategies is underdeveloped within the field. While there are multiple tools and resources to help users collect, manage and analyse network data, there is much less guidance on the practical applications of this information. One apparent gap is the limited application of longitudinal organisational network analysis, in which data are collected from the same organisational actors repeatedly over multiple time points. This yields insights into the dynamic nature of networks, including how the network structure and interactions change over time. Given that networks are rarely static, the addition of the time dimension has the potential to substantially enhance the analytical value of network analysis and contribute to more nuanced guidance for interested practitioners and policymakers. In this article, the authors draw on their experiences in conducting longitudinal network analysis of interorganisational relationships in the USA and India to comment on the opportunities and challenges of the methodology within the field of health systems research. We also provide suggestions as to how some of these challenges may be addressed or mitigated.
Community-based primary care settings are a potential entry point for delivering Early Childhood Development (ECD) interventions in Nepal. Past studies have suggested that integrating stimulation with nutrition interventions is an effective way to deliver multiple benefits for children, but there is limited knowledge of how to do this in Nepal. We conducted a qualitative study in Nepal’s Dhanusha district to explore how stimulation interventions for early learning could be integrated into existing health and nutrition programmes within the public health system. Between March and April 2021, we completed semi-structured interviews with caregivers (n=18), health service providers (n=4), district (n=1) and national stakeholders (n=4), as well as policymakers (n=3). We also carried out focus group discussions with Female Community Health Volunteers (FCHVs) (n=2) and health facility operation and management committee members (n=2). We analysed data using the framework method. Respondents were positive about introducing stimulation interventions into maternal and child health and nutrition services. They thought that using health system structures would help in the implementation of integrated interventions. Respondents also highlighted that local governments play a lead role in decision-making but must be supported by provincial and national governments and external agencies. Key factors impeding the integration of stimulation into national programmes included a lack of intersectoral collaboration, poor health worker competency, increased workload for FCHVs, financial constraints, a lack of prioritisation of ECD and inadequate capacity in local governments. Key barriers influencing the uptake of intervention by community members included lack of knowledge about stimulation, caregivers’ limited time, lack of paternal engagement, poverty, religious or caste discrimination, and social restrictions for newlywed women and young mothers. There is an urgent need for an effective coordination mechanism between ministries and within all three tiers of government to support the integration and implementation of scalable ECD interventions in rural Nepal.
South Asia has made significant progress in reducing child undernutrition. The prevalence of stunting declined by one third between 2000 and 2019; as a result, in 2019, there were 34 million fewer stunted children than in 2000, indicating that progress for child nutrition is possible and is happening at scale. However, no country in South Asia is on track for all nutrition targets of Sustainable Development Goal 2, and the region has the highest prevalence of stunting (33.2%) and wasting (14.8%) in the world. Nepal, the best performing country in the region, narrowly missed the Millennium Development Goal (MDG) target to half the prevalence of child underweight between 1990 and 2015 and achieved the fastest recorded reduction in stunting prevalence in the world between 2001 and 2011. In 2019, UNICEF Nepal completed a series of papers to examine Nepal's progress on maternal and child nutrition during the MDG era. The series explores the trends, distribution and disparities in stunting, micronutrient deficiencies and feeding practices in children under 5 years and anaemia in adolescents and women. Besides, it reviews national micronutrient programmes (vitamin A supplementation, iron and folic acid supplementation and universal salt iodization) and Nepal's first Multi‐Sector Nutrition Plan, to illuminate the success factors and enduring challenges in the policy and programme landscape for nutrition. This overview paper summarizes the evidence from these analyses and examines the implications for the direction of future advocacy, policy and programme actions to improve maternal and child nutrition in Nepal and other similar contexts.
