Local Experiences of the Uganda Nutrition Action Plan in Lira District: Challenges and Lessons for Policy Implementation

Abstract

Background

In response to high rates of undernutrition, Uganda began rolling out the multisectoral Uganda Nutrition Action Plan (UNAP) in 2011, followed by Phase II (UNAP II) in 2020. Uganda has since progressed toward several nutrition targets; however, limitations in nutrition coordination and financing call for continued strengthening of the UNAP II.

Objectives

Given that monitoring of the UNAP II does not consistently capture district-level outcomes and relies upon quantitative nutrition indicators, this study aims to qualitatively assess nutrition stakeholder and community perspectives at the district level.

Methods

From June to August in 2022, under an umbrella study utilizing community-based participatory research methods to train youth from Lira District in research, in partnership with the University of Southern California (USC) and community organization Children's Chance International-Uganda, these youth helped carry out an explanatory qualitative assessment consisting of 10 key informant interviews. Responses were compiled, transcribed, and analyzed using the Atlas TI software to code responses for thematic insights.

Results

Participants highlighted several challenges with the UNAP II implementation at the local level. Mechanisms intended to promote multisectoral collaboration, such as district nutrition coordination committees, have been on hiatus due to limited funding; local governments experience funding disbursement delays and a lack of nutrition prioritization; and nutrition surveillance is limited by tools, training, and human resources.

Conclusions

Obtaining community perspectives revealed several gaps in local UNAP II implementation and demonstrates the importance of creating mechanisms for communities to continuously provide feedback for national policies like the UNAP II.

Plain Language Summary

Uganda implemented its first multisectoral nutrition strategy, called the Uganda Nutrition Action Plan, in 2011, followed by Phase II in 2020. The Uganda Nutrition Action Plan does not currently have its own mechanism of monitoring and evaluation. Instead, it relies on quantitative data from national health surveys to track levels of undernutrition. These data are not specific to each district and provide a helpful but incomplete picture of nutrition progress in the country. In order to gather local stakeholder perspectives of the Uganda Nutrition Action Plan, our research team facilitated interviews with key nutrition stakeholders in Lira District between June and August, 2022. We sought to understand how the Uganda Nutrition Action Plan's implementation has fared in 3 ways: multisectoral collaboration, funding, and surveillance of nutrition.

Overall, participants described the Uganda Nutrition Action Plan's limited success at the district level. Mechanisms intended to promote multisectoral collaboration, such as district nutrition coordination committees, have been on hiatus due to limited funding. Furthermore, the local government frequently does not have enough nutrition funding due to disbursement delays and the nutrition budget being integrated into the budgets of other sectors. Finally, the district struggles to produce accurate and consistent nutrition monitoring due to inadequate surveillance tools, training, and human resources. Local perspectives in Lira District have uncovered several gaps in the implementation of the Uganda Nutrition Action Plan, and they highlight key recommendations moving forward. This study demonstrates the value of community-level insights on the implementation of national policies like the Uganda Nutrition Action Plan to promote measures that are effective, relevant, and made in partnership with the community.

Introduction

Uganda is heavily impacted by undernutrition, where 29% of children below 5 are stunted, 53% of children are anemic, and only 14% of children meet the Minimum Acceptable Diet guidelines. ¹ Furthermore, one-third of women of reproductive age have anemia. ¹ The consequences of undernutrition are detrimental for children and pregnant women, with lack of access to food being associated with poor cognitive development, reduced immune system function, and increased maternal mortality rates.^2–4 Understanding that proper nutrition is essential for long-term health and well-being, Uganda has set global and regional commitments to address nutrition, the most notable being the Uganda Nutrition Action Plan (UNAP), which relies upon multisectoral efforts to “improve nutrition status among children under 5 years, school-age children, adolescents, pregnant and lactating women and other vulnerable groups by 2025.” ⁵ Phase I took place between 2011 and 2016 and saw improvement in nutrition indicators including stunting, wasting, and breastfeeding practices. ⁵ However, due to slow progress in reducing anemia and low birth weight, poor coordination of nutrition interventions, and financing difficulties, Phase II was launched and is currently running from 2020 to 2025. ⁵

The UNAP Phase II has 3 primary objectives: increasing access to and utilization of nutrition-specific services; increasing availability and utilization of nutrition-sensitive services; and strengthening the enabling environment for scaling up nutrition-specific and sensitive interventions. While the first 2 objectives address nutrition services, the final objective involves the practical rollout and sustainability of the nutrition policy itself, which we have summarized into 3 themes found in Chapters 4–6 of the UNAP II:

Enhancing nutrition coordination at the local and national levels

Mobilizing finances and resources

Monitoring progress in meeting the UNAP II objectives

The first, enhancing nutrition coordination, involves the maintenance of multisectoral committees at several levels of government. At the district level, it aims mainly to support District Nutrition Coordination Committees, established under the first UNAP as a focal point for collaboration among public and private sector stakeholders involved in nutrition programming. The second, mobilizing finances and resources, sets out to improve systems for tracking finances for nutrition in the public, private, and civil society sectors. The final monitoring and evaluation of the UNAP II sets out to capture progress in reaching global and program-specific nutrition targets, addressing nutrition-related health conditions, and improving Uganda's political economy and capability.

Notably, the UNAP II relies mainly on quantitative sources of data including the Uganda Demographic and Health Survey, the Health Management Information System, and other surveys to measure the state of nutrition. ⁵ The choice of data sources ties closely in with the UNAP II's monitoring and evaluation targets: 53 nutrition and nutrition-related indicators (ie, proportion of stunted children under 5, proportion of children receiving Vitamin A supplementation) and 8 indicators of progress toward components such as multi-stakeholder platforms and functional information systems, all assessed via objective, quantitative metrics.^5,6 There are several limitations to this current method of evaluation. First, existing surveillance does not capture district and sub-county nutrition outcomes, making it difficult to appropriately allocate resources and target interventions to local-level needs.^5,7 Second, there is increasing consensus on the importance of involving the community and other stakeholders not only in the development and implementation of policies and programs, but also in their evaluation. ⁸ One prominent avenue for gathering community perspectives is through qualitative methodology, which scholars argue can help capture the broader context of why and how nutrition may be improving, worsening, or remaining stagnant—useful for informing public health research, policy, and practice.^9,10

Therefore, the primary objective of this study is to document local perspectives on the downstream implementation of the UNAP II as it relates to the 3 main themes of the UNAP II rollout: multisectoral nutrition coordination, financing, and monitoring and evaluation. While a formal evaluation of the UNAP II is beyond the scope of this article, the study examines district-level implementation challenges, considers how these challenges may illuminate broader issues in Uganda's nutrition policy and programming, and provides useful recommendations to improve rollout moving forward. The analysis draws on the perspectives of subcounty- and district-level stakeholders, supplemented by select national-level perspectives to identify potential gaps between policymakers and local implementers.

Methods

Setting

This study is a continuation of the Youth Public Health Ambassador (YPHA) Program, in which Children's Chance International Uganda (CCI), a community-based organization in Northern Uganda, Energy in Action (formerly Ray United FC), a youth-centered nonprofit organization with nearly a decade of experience working in Uganda, and the University of Southern California (USC), together recruited and trained 30 youth aged 17 to 22 years to serve as public health ambassadors within their northern Ugandan communities in 2021. ¹¹ The youth were trained in public health research, data collection, and data dissemination, and they surveyed 300 households across 3 sub-counties of Lira District on a broad range of public health issues. Of the 3 sub-counties, Ayami sub-county reported lower education levels, lower rates of healthcare access, limited diet diversity, and the greatest difficulty providing food during the pandemic. For this reason, Ayami sub-county was chosen as the setting for this study.

Design

Drawing on the strengths outlined by Bush, Singh, and Kooienga, ¹² we utilized both community-based participatory research (CBPR) methodology and thematic analysis. Building upon important principles of CBPR, which identify research participants as active and equal partners in the research process, ¹³ we partnered with the YPHAs from Ayami sub-county in planning and recruiting participants. Thematic analysis provided the necessary framework to identify key themes across nutrition stakeholder perspectives of UNAP multisectoral nutrition coordination, financing, and M&E at the local and national levels.

Our research team included Research Coordinators at USC and Makerere University, the Director and staff of CCI, the Principal Investigator, and the Youth Public Health Ambassadors. All protocol, interview guides, and consent forms were reviewed and approved by the USC Institutional Review Board (UP-21-00478-AM001), Gulu University Research and Ethics Committee (GUREC-2022-275), and the Uganda National Council for Science and Technology (SS1385ES).

Selection of Participants

Purposeful sampling ¹⁴ was used to identify key informants (KIs) who bring expertise from a diverse array of sectors contributing to nutrition in Ayami sub-county, as well as at the larger district and national levels. A total of 10 KIs were intentionally selected from the district government, national government, NGO, private sector, and academic spheres (Table 1).

Table 1.

Key Informant Sample Collection Strategy.

Key Informant Stakeholder Type	Number of Key Informants
National-level government	2
District-level government	2
District and sub-county health sector	3
District-level community-based organizations	1
District-level private sector	1
Academia/Research	1

Interview Guide

A semi-structured interview guide was developed for the KIs by the research team and reviewed by a nutrition expert. We elicited KI perspectives on the current state of nutrition and asked them to recount ongoing nutrition interventions, discuss the challenges of implementing nutrition programs and improving broader nutrition outcomes, and suggest improvements. Furthermore, we probed KIs on their perceptions regarding the implementation of the Uganda Nutrition Action Plan. In alignment with the 3 key elements highlighted in the UNAP II, we solicited KI perspectives on multisectoral nutrition coordination, financing, and M&E.

Data Collection and Analysis

Data collection was completed between July and August 2022. KI interviews were conducted in private locations convenient for the participants, namely their offices and the CCI office premises. All KI interviews, barring 1 interview on Zoom, were conducted in-person. All KI interviews were conducted in English. The Research Coordinators served as interview moderators.

KI participants provided written informed consent, in both their local language and in English, to participate in the study and to be audio-recorded. For remuneration, KI participants were provided an amount of cash in UGX deemed appropriate by the partner community-based organization CCI and the Gulu University IRB.

KI interviews were between 40 min and 1 h and were audio recorded on a password-protected mobile device. Audio recordings were transcribed and imported into the Atlas TI analytical software to be analyzed. Two coders developed a codebook, then independently and systematically coded all transcripts. Throughout the process, they met to discuss similarities and discrepancies and to ultimately develop a final consensus on the code.

Results

Sample Characteristics

Among the 10 KIs, ages ranged from 29 to 50, and 9 KIs (90%) had postsecondary education. 60% of KIs were female and 40% male (Table 2).

Table 2.

Characteristics of Key Informant Participants.

Key Informants
Total (n)	10
Age (yrs)	29-50
Male	4 (40%)
Female	6 (60%)
Education level
None	0 (0%)
Some primary	0 (0%)
Some secondary	1 (10%)
Vocational/Diploma	3 (30%)
Bachelor's degree	1 (10%)
Master's degree	3 (30%)
Some doctoral	2 (20%)

Adhering to the key components outlined in the UNAP II, interview responses are organized into participant perspectives on multisectoral nutrition coordination, financing, and M&E. Participants primarily discussed nutrition efforts at the sub-county and district levels; however, several participants working in a nutrition-related sector at the national level also added their perspectives. These 3 concepts are further outlined below.

Multisectoral Nutrition Coordination

Key Informant Perspectives on the Extent of Existing Collaboration

Key informants were asked whether they observed multisectoral collaboration to improve nutrition within their sub-county, region, or country at large. While KIs agreed that collaboration exists, their perspectives on the extent of this collaboration differed. One of the sub-county level KIs stated that their only active stakeholder partnerships were between community members, community-run groups, and local governments. Another KI working with a community-based organization (CBO) in the district described partnerships primarily between community members and NGOs, with limited district government involvement. Of note, while one KI working with the district government stated there were multisectoral district and sub-county coordination committees meeting quarterly to coordinate nutrition efforts in each region, another sub-county level KI explained these committees had not been meeting for at least 3 years due to a lack of funding.

Key Informant Recommendations on Strengthening Multisectoral Collaboration

KIs had many ideas on how to strengthen multisectoral collaboration moving forward. Several discussed the need for both government and NGOs to consider the importance of involving communities in addressing nutrition, stating:

The government has tried, other NGOs have tried, but sometimes they impose things on the farmers. Maybe they say, “We are bringing you cassava cuttings. We are bringing you ABCD,” and yet that may not be what the farmers want. They have to go on the ground and first […] find out, “What do you really need?” and how will this help them?

Additionally, a KI who works in the private agriculture sector emphasized the importance of engaging the private sector and research institutions to fill in the gaps where the government is unable to. He suggested following the example of a project by the International Fertilizer Development Center, which partners with the private sector and research institutions to bring improved potato agricultural technology and training to the community.

KIs also emphasized the need to create clearer links between different stakeholders in the community. Different government departments—including environment, agriculture, and transportation—and nongovernmental entities need a space to meet together to establish priorities, budgets, and plans. One sub-county level KI resolutely stated, “To improve nutrition issues, we need to strengthen the structures right from the district up to the lowest level. We need to reactivate the [nutrition] coordination committees.” To support such coordination and help link patients to proper follow-up care, a KI working in the health sector recommended creating an active stakeholder map with all the nutrition partners in the region.

Financing Nutrition

Funding Disbursement Delays

Key informants attested to various challenges in funding nutrition activities. At the time of the interview, funding had not been received at 1 sub-county health center for 2 fiscal quarters, and the KI was concerned that when it did disburse, most of the funding would be diverted away from nutrition. Another KI described how the national government is supposed to return 65% of local revenue collected in the sub-county; however, the sub-county local government had not received this money for 4 quarters. Without this money, they would be unable to fund nutrition capacity-building activities for their sub-county.

Differing Perspectives on Funding Allocations

There were also differing perspectives on how the government should finance nutrition activities. A national-level KI explained the importance of distributing funding across different ministries and of moving away from donor and development partner financing to government financing. They stated:

Currently, the government [is using a] […] program-based approach to planning, implementation and coordination, so sectors right now all work together to achieve certain known outcomes. The business of […] moving in silos […] has [come] to an end.

According to a KI who coordinates nutrition in the healthcare system, however, this strategy leaves limited funding for nutrition-specific interventions. In her words:

One of the challenges we have is there has been no specific budget allocated for nutrition. And when you look at the […] current approach, it expects us to integrate nutrition within the existing systems […] It becomes hard because there are things that are specific for nutrition.

She went on to list how nutrition-specific interventions, such as treating undernutrition, educating mothers, and transporting patients, are not covered. The KI pointed out that not only is there insufficient funding to sustain established nutrition centers, but there are also only a few districts with in-patient nutrition services in the northern region. Sub-county and national-level KIs added that with no nutrition-specific budget to meet these needs, they often have to rely on outside partnerships. However, many are unreliable, and as one KI says, “[the] moment that organization goes, you’ll find issues of nutrition […] also go with them.” For those that have remained, like UNICEF and USAID, they support a few health centers and have specific targets—namely, people with HIV and children under 5.

Key Informant Recommendations on Improving Nutrition Funding

To address these shortcomings, 4 sub-county-level KIs advocated for the government to give nutrition greater priority and a specific budget through which funding is distributed in a timely manner. A national-level KI, however, attributed the current financing strategy to the ongoing constraints of the government's budget, stating, “It would be very good that nutrition as a whole is financed, but you know us being a developing country, having constraints with budget and also having been affected by COVID-19. So we keep prioritizing all the time.”

Monitoring Nutrition

Participants discussed the current pathway for reporting cases of poor nutrition, summarized in Figure 1.

Figure 1.

Reporting Pathway as Described by Key Informants.

Challenges in the Reporting Pathway

KIs working in the district health sector described how Village Health Team members (VHTs) and healthcare workers collect primary data, but they do not have enough primary tools (ie, hard copy surveys), training, or manpower to adequately track and follow up with malnutrition cases. Furthermore, there is only one data clerk entering all health data for several sub-counties. All of these compromise data quality and result in both instances of underreported and overreported statistics. Without proper surveillance, KIs worried that funding and district plans to target nutrition would not be prepared or distributed well.

Key Informant Recommendations on Improving Nutrition M&E

Across sub-county, district, and regional levels, KIs recommended that local-level nutrition assessment and sharing be improved. One KI reasoned:

We need to advocate for [nutrition] to be assessed, because if we advocate for it to be assessed, […] it's going to be a must for the lower local governments and the local governments to really plan for it.

Moreover, they recommended clarifying and updating surveillance tools created by the national government with participation and input from local governments. To improve data quality and address M&E personnel shortages, a KI working with the regional health sector recommended installing computers at individual health centers and training healthcare workers to do their own data entry.

Summary of Key Informant Recommendations

Based on the responses received, recommendations to improve UNAP II implementation in the 3 primary categories studied were compiled (see Figure 2).

Figure 2.

Recommendations to Improve UNAP II Implementation.

Discussion

This study provides timely insights into the local implementation of the UNAP II, with opportunities to strengthen community-level implementation of future nutrition strategies across Uganda after the plan's conclusion in 2025. The compiled key informant recommendations provide very clear next steps for policymakers to refine the existing nutrition coordination, financing, and monitoring structures—suggestions that may prove useful to the successful rollout of other multisectoral strategies in health and development in Uganda and other countries.

At least 1 previous study has established the need for district-level monitoring of nutrition indicators, including rates of stunting and wasting, in order to assess local progress toward UNAP targets. ⁷ The current study builds on these findings by highlighting the additional need for district-level monitoring of the UNAP structure itself, particularly the local level implementation of multisectoral collaboration, funding, and surveillance mechanisms. Both cohesive and conflicting perspectives were gathered from a variety of sub-county, district, and national nutrition stakeholders in order to provide a nuanced and informative understanding of the current UNAP implementation and targeted recommendations moving forward.

The results suggest that multisectoral coordination between stakeholders is currently very limited. Although KIs generally had an understanding of their own role in addressing nutrition, they expressed the need for strengthened partnerships with other government sectors and implementing partners, including community members, the private sector, research institutions, and NGOs. It is important to note that district and sub-county nutrition coordination committees (DNCCs and SNCCs) were established during the first UNAP to facilitate these very partnerships. Their role includes M&E, providing technical assistance to lower government levels, and coordinating nutrition activities. ¹⁵ And while several district and national government KIs affirmed the existence of such committees in our interviews, representatives from sub-county government and CBOs explained how they had not been meeting for the last few years in Lira District and its sub-counties due to lack of funding and momentum.

The discrepancy between these KI responses is notably linked to each KI's proximity to the community in question—KIs working more closely with the community had more up-to-date information, including, for example, when the DNCCs and SNCCs had last convened. This suggests a greater need for local government and stakeholders to provide continuous and updated input on their communities’ specific nutrition landscape. Furthermore, in alignment with previous research demonstrating the correlation between active DNCCs and improved nutrition outcomes in Kisoro District, ⁷ reestablishing Lira's DNCCs and SNCCs could likewise help to improve nutrition outcomes. These committees would be ideal agents to spearhead KI recommendations, including stakeholder mapping, collaborative nutrition initiatives, and improved resource distribution across the district.

Findings regarding the current status and challenges of nutrition funding echo previous observations in the “Pathways to Better Nutrition” study which evaluated UNAP I funding from 2013 to 2015. ¹⁶ This study found that only half of the allocated government funding was spent due to delays in funding disbursement to local governments. Furthermore, the study revealed that with only 7% of Lira District's budget allocated to nutrition-related activities and no specific budget line for nutrition, much of the nutrition budget came from external donor sources. ¹⁶ Likewise, KIs interviewed discussed the ongoing challenges of funding disbursement delays and obtaining enough funding to meet the current need. Of note, the stakeholders interviewed offered varying perspectives on the efficacy of the current financing strategy, which embeds nutrition funding into existing budgets, as opposed to having a specific nutrition budget line. This strategy of integrating nutrition objectives into the programs of nonhealth sectors (ie, agriculture) is aligned with the goals of many key stakeholders including the World Bank, which published a report on how doing so leads to a faster, more cohesive, and sustainable response to undernutrition.^17,18 Lamstein et al adds, however, that this multisectoral strategy of embedding nutrition into different sectors often poses the challenge of nutrition efforts having to compete with other sector priorities for funding. ¹⁸ Key informants at the district level were running into this very issue and finding that in the end, without sectors prioritizing nutrition and with budgeting authority often remaining in the hands of district officials with no nutrition expertise, very little resources remained for nutrition efforts.

In response to this challenge, Lamstein et al poses that “countries cannot manage or improve what they do not measure” and advocate for governments and their partners to strengthen nutrition budget and expenditure tracking systems. ¹⁸ Both past and current findings call for reevaluating national funding disbursement mechanisms while also strengthening funding allocation, tracking, and sustainability at the local level.

Finally, KI testimonies were consistent with previous data demonstrating how district-level nutrition surveillance in Uganda is often limited in consistency, scope, and quality. ⁷ KIs provided concrete recommendations for improving local nutrition monitoring systems—particularly, updating surveillance tools with input from the local government and increasing local health centers’ bandwidth to accurately record and transfer data. Furthermore, KIs highlighted the close relationship between M&E and the ability to adequately plan and fund nutrition interventions. Given Uganda's current utilization of the Program-Based Budgeting System, which relies on quarterly and annual performance reports to inform budgeting of different items, including nutrition, ¹⁹ addressing the KIs’ concerns regarding the availability and quality of data remains a top priority.

This study was limited in its scope to 1 sub-county and district and thus unable to robustly evaluate the UNAP II on a national scale; however, the gathered insights reveal local challenges with coordination committees, budgeting priorities, and surveillance resources that are likely not unique to Lira District. Future studies should build on these findings by engaging stakeholders from additional sectors and extending their scope beyond the Lira District.

One constant critique of qualitative methodology is the potential for participant response bias^20,21; however, capturing interviewees’ full perspectives, while inevitably subjective, adds much-needed complexity and depth to the understanding of a field that has historically largely been evaluated using quantitative indicators. Qualitative methods are increasingly being utilized to provide context and triangulation of multiple perspectives ²² important for policy design and implementation. For example, comparing perspectives of stakeholders at different levels of government revealed how proximity to the local communities impacted their views of multisectoral collaboration, funding, and M&E. Those more removed from local communities (ie, national level) focused predominantly on the stated or ideal implementation of UNAP II, and those in closer proximity (ie, sub-county level) offered greater insight on the extent to which such strategies were actually executed in the community. While both perspectives are necessary, greater efforts must be made to amplify local community voices.

Conclusion

This study highlights several gaps in the implementation of Uganda's UNAP II at the community level. Key challenges of inactive multisectoral collaboration, limited and delayed funding, and weak local monitoring underscore the importance of incorporating local perspectives—often overlooked at national levels—into informing policy. As UNAP II concludes in 2025, these insights offer cost-effective and timely recommendations to inform nutrition progress and policies that are effective, relevant, and made in partnership with the community in individual sub-counties, districts, and nationally.^10,23