Understanding the Role of Political Commitment and Coherence

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Understanding the Role of Political Commitment and Coherence University of South Carolina Scholar Commons Theses and Dissertations Summer 2020 Understanding the Role of Political Commitment and Coherence Across Sectors and Across National and Sub-National Levels in Enabling Improvements in Nutrition in Rwanda Elyse Iruhiriye Follow this and additional works at: https://scholarcommons.sc.edu/etd Part of the Public Health Education and Promotion Commons Recommended Citation Iruhiriye, E.(2020). Understanding the Role of Political Commitment and Coherence Across Sectors and Across National and Sub-National Levels in Enabling Improvements in Nutrition in Rwanda. (Doctoral dissertation). Retrieved from https://scholarcommons.sc.edu/etd/6031 This Open Access Dissertation is brought to you by Scholar Commons. It has been accepted for inclusion in Theses and Dissertations by an authorized administrator of Scholar Commons. For more information, please contact [email protected]. UNDERSTANDING THE ROLE OF POLITICAL COMMITMENT AND COHERENCE ACROSS SECTORS AND ACROSS NATIONAL AND SUB-NATIONAL LEVELS IN ENABLING IMPROVEMENTS IN NUTRITION IN RWANDA by Elyse Iruhiriye Bachelor of Arts Boston University, 2011 _________________________________________________ Submitted in Partial Fulfillment of the Requirements For the Degree of Doctor of Philosophy in Health Promotion, Education, and Behavior The Norman J. Arnold School of Public Health University of South Carolina 2020 Accepted by: Edward A. Frongillo, Major Professor Christine E. Blake, Committee member Simeon Nanama, Committee Member Deanna K. Olney, Committee Member Cheryl L. Addy, Vice Provost and Dean of the Graduate School © Copyright by Elyse Iruhiriye, 2020 All Rights Reserved ii Dedication To my father’s parents, Marcel Makoresho and Emma Ndabacekure and my mother’s parents, Jean Ntibanga and Anna Ntibikwinge iii Acknowledgments For funding this research: I gratefully acknowledge funding from the Dutch Government through SNV and the Voice for Change Partnership Programme and the CGIAR Research Program on Agriculture for Nutrition and Health led by the International Food Policy Research Institute. I would like to thank all the people who have been with me along this journey, some in large parts and others just for passing moments, but that nonetheless made an impact on me. I would like to thank my dissertation committee members, Dr. Christine Blake, Dr. Edward Frongillo, Dr. Simeon Nanama, and Dr. Deanna Olney, for volunteering their time and efforts to help guide me through the dissertation process and to provide me with helpful advice. I thank my advisor Dr. Edward Frongillo for being a great mentor and encouraging me to value the questions that I may sometimes think are small. I would like thank Dr. Deanna Olney, who not only gave me my first job after college but also opened this world of research in international nutrition to me that I never thought of being a part of my journey. Thank you also for your mentorship over the last nine years. I would like to acknowledge and thank all the people who supported this study, including the data collection team and especially the interview and focus group respondents who took time out of their busy schedules to share their experiences and views with me for this study. I would like to also thank my family based in Burundi and iv Rwanda who provided me with much love, support, and laughter, even when at times things seemed to be falling apart. Thank you for always reminding me to look on the bright side of things. I thank my friends for their unwavering support and love, my friends and colleagues in the HPEB department for the advice, laughter, and sometimes for the space to just vent. I couldn’t have done any of this without my family. To my brothers, sister, and sisters-in-love, thank you for always encouraging me, for keeping the Happy Mondays going, and for just being you. To Donald, thanks for being on this dissertation journey with me and experiencing all the ups and the downs of this process with me. Last but not least, I thank my mom and dad for everything. I admire you. Thank you for always reminding us where we come from and to always use our gifts to do better for not just ourselves but also others. I acknowledge and thank God for his blessings, the people he has put in my life, and giving me the strength to push through. v Abstract Reducing undernutrition is on the political agendas of many low- and middle-income countries. There is general consensus that to improve nutritional outcomes involves actions across the different sectors that influence both the immediate and underlying determinants of optimal nutrition and an enabling environment to support the political and policy processes. Despite renewed attention over the last 15 years, addressing nutrition in a multisectoral way was previously promoted in the 1970’s but failed to have sustained political commitment due to its organizational complexities to plan and implement strategies across sectors. We conducted an in-depth retrospective case study to understand how Rwanda, a low-income country with high burdens of undernutrition, achieved progress reducing undernutrition and how the country addressed the challenges presented by multisectoral nutrition strategies. We conducted a document review of nutrition and nutrition-related policies and programs since 2000, in-depth interviews with nutrition stakeholders at national (n=32), district (n=38), and community (n=20) levels, and community focus group discussions (n=40) in 10 purposefully selected districts in Rwanda’s five provinces. In each province, we selected one district with decreased stunting (reduced districts) and one where no change or an increase occurred vi (non-reduced districts) between the two last Rwanda Demographic and Health Surveys (2010 and 2014/15). After 2008, reducing undernutrition became a national priority in rhetoric, policy, and institutionally. Nutrition goals were gradually integrated into different sectoral policies and in national economic development strategies. Political commitment to nutrition was generated across sectors at national level and translated to sub-national levels where, because of the country’s decentralized governance system, mid-level leaders had increasing responsibilities for coordinating and implementing nutrition strategies. Institutional bodies were established to facilitate collaboration across sectors and actors at both the national and sub-national levels. At the sub-national context, we find that capacity in nutrition, nutrition monitoring and evaluation, and the implementation of coherence were reported to be more optimally implemented in the districts that improved stunting compared to the non-reduced districts. The results from this study provide a narrative on how improvements occurred in Rwanda, a better understanding of implementing multisectoral nutrition strategies at the sub-national context, and the perspectives of the mid-level leaders and frontline workers coordinating and implementing multisectoral nutrition programs and services. vii Table of Contents Dedication ........................................................................................................................... iii Acknowledgments............................................................................................................... iv Abstract ............................................................................................................................... vi List of Tables ....................................................................................................................... ix List of Figures ....................................................................................................................... x Chapter 1: Introduction ...................................................................................................... 1 Chapter 2: Background and Significance ............................................................................ 8 Chapter 3: Methods .......................................................................................................... 34 Chapter 4: Document Review ........................................................................................... 47 Chapter 5: Manuscript 1 Translating national political commitment and coherence in nutrition to sub-national levels is a pathway of change in the reduction of undernutrition in Rwanda .................................................. 69 Chapter 6: Manuscript 2 Coherence among sectors and stakeholders and community perspectives on contributors to change differentiate districts in Rwanda that did and did not improve child stunting ................................. 119 Chapter 7: Conclusion ..................................................................................................... 158 References ...................................................................................................................... 169 Appendix A: Topics covered in semi-structured interviews and FGDs ........................... 185 Appendix B: Sectoral roles in nutrition ........................................................................... 186 Appendix C: Nutrition programs in Rwanda ................................................................... 187 viii List of Tables Table 2.1: Forms of political commitment to nutrition .................................................... 29 Table 2.2: Administrative structure in Rwanda before and after 2006 ............................ 30 Table 3.1: Study district
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