Operationalizing Multi-sectoral Coordination and Collaboration for Improved Nutrition

Recommendations from an In-Depth Assessment of Three Countries’ Experiences

Reducing undernutrition requires a commitment from multiple sectors, yet documentation on how to collaborate across sectors to reach global goals is scant. Through a three-country assessment and literature review, SPRING investigated approaches to multi-sectoral collaboration for nutrition. This paper highlights lessons that USAID and its implementing partners learned, and provides a series of recommendations to guide the designing, implementing, and monitoring of future collaboration.

Background

SPRING’s Work in Coordination and Collaboration for Nutrition

In 2013, the USAID-funded SPRING project conducted a landscape analysis of all 19 Feed the Future country portfolios, analyzing the extent to which each country’s agricultural investments might contribute to better nutrition outcomes. This analysis indicated the need for more practical guidance on how to initiate and manage multi-sectoral approaches, which often require coordination and collaboration across a range of stakeholders.

Over the past several years, SPRING has worked to fill this need. SPRING’s experiences in Senegal, Nepal, and Burkina Faso highlighted how cross-sector work occurs in different contexts and suggested some lessons going forward (SPRING 2014a, b, c). Building off this early research, SPRING engaged three Feed the Future USAID Missions and their implementing partners (IPs) in Guatemala, Bangladesh, and Rwanda (see table 1) to strengthen their vision, plans, and approaches for coordination and collaboration around nutrition.

Through document reviews, workshops, and more than 50 interviews, SPRING identified challenges and opportunities the countries face in encouraging stakeholders to work together to improve nutrition. This work resulted in country-specific recommendations, and identified some lessons that can be applied to other countries’ efforts to strengthen multi-sectoral collaboration for nutrition.

The countries used different approaches and were at various stages in the cross-sector collaboration process. Yet they shared similar obstacles in implementing structures, processes, and practices that affected their ability to initiate and sustain their efforts. This report applies lessons from the three countries and proposes several recommendations on how to operationalize multi-sectoral collaboration toward improved nutrition outcomes.

Table 1. USAID Mission-level Coordination and Collaboration for Nutrition in Three Countries

 GuatemalaBangladeshRwanda
Collaboration Project/GroupWestern Highlands Integrated Program (WHIP)Agriculture-Nutrition Linkages GroupCommunity Health and Improved Nutrition (CHAIN) Project
Year Established201120132014
Number of Individual Activities1 Involved~19 activities co-located in 5 departments~12 activities~23 activities
Sectors IncludedAll USAID sectorsAgriculture, nutrition, and food securityNutrition and community health

Importance of Multi-sectoral Approaches for Nutrition

In 2013, The Lancet released a series of papers reviewing progress toward improving nutrition around the globe. The authors stated that a multi-sectoral approach is required to achieve global targets for reducing undernutrition, along with scaling up proven nutrition-specific interventions and strengthening nutrition-sensitive interventions that span a variety of sectors (Ruel, Alderman, and the Maternal and Child Nutrition Study Group 2013). This need for cross-sector collaboration was also expressed in the USAID 2014–2015 Multi-sectoral Nutrition Strategy, which states that “Multi-sectoral coordination along with collaborative planning and programming across sectors at national, regional, and local levels are necessary to accelerate and sustain nutrition improvements (USAID 2014b).” Multi-sectoral programming requires that multiple stakeholders across sectors coordinate and collaborate to design, implement, and monitor joint solutions to address nutrition. Though multisectoral collaboration for nutrition is not a new concept, this renewal of interest has led to many questions about how to do it and whether nutrition outcomes are improved if it is done effectively.

The general consensus is that there are a variety of benefits to working across sectors. Studies have found that collaboration can increase program impact and lower costs (Jennings and Krane 1994; Bardach 1998). Cost decreases may be related to the reduction of redundant activities and multi-sectoral partners’ ability to capitalize on combined strengths—such as access to resources, opportunities, skills, and knowledge—for jointly identifying and solving problems (Garrett and Natalicchio 2011).

Coordinating also allows various partners to see where they fit in a larger system and helps them clarify their own roles and how they can contribute to the problem and its solutions (Garrett and Natalicchio 2011). Case studies documenting multi-sectoral approaches have found value in a convergence approach, combining nutritionspecific and nutrition-sensitive interventions that target vulnerable geographic areas and populations (Levinson 2013).

Definitions
  • Coordination - Exchanging information and altering activities for mutual benefit and to achieve a common purpose.
  • Collaboration - Exchanging information, altering activities, sharing resources, and enhancing one another’s capacity for mutual benefit and to achieve a common purpose.
  • 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.


(Garrett and Natalicchio 2011; the definition for integration comes from the SPRING project)

Coordination, collaboration, and integration are often used interchangeably. However, if the terms are clearly defined, everyone will understand how they can work together to address nutrition. Coordination is an important first step, but collaboration is often crucial to implementing a cross-sector approach to nutrition. To collaborate effectively, people need to already be coordinating with one another. According to our operating definitions, coordination involves exchanging information and adjusting activities for mutual benefit; collaboration adds capacity building to enhance the results. With the understanding that coordination is inherent in collaboration, we use the term “collaboration” throughout the rest of this report.

Feed the Future Leading the Way

A potential testing ground for the contribution of multi-sectoral approaches to nutrition is the U.S. Government’s Feed the Future initiative. The initiative has the dual objectives of inclusive agriculture sector growth and improved nutritional status, which have led to a number of different attempts at strengthening multi-sectoral collaboration within the USAID development portfolios at the country level. Feed the Future Missions have approached the challenge in different ways, but the three Missions highlighted in this report all aim to support IPs, donors, national governments, and other stakeholders to work better with each other, enhance their own work, and improve nutritional outcomes. The varied approaches that these Missions have taken are an opportunity to learn from what has worked across different regions and contexts.

Recommendations along the Collaboration Life Cycle

Lessons gleaned from the three countries suggest how to initiate and manage a multi-sectoral collaboration strategy for nutrition. There are important similarities and differences in how the countries approach this effort, with each employing specific structures, processes, and practices that facilitate or hinder successful collaboration. SPRING identified six commonalities across the countries related to leadership, strategy, communication, accountability, documentation, and reporting that also align with key stages in the program development and implementation cycle. Developing and implementing a strategy for cross-sectoral collaboration requires an understanding of what is happening in each phase, as every stage is crucial for success. SPRING’s assessment seeks to shed light on these enabling factors and proposes how to incorporate them when designing, implementing, or monitoring collaboration efforts for nutrition.

Below is a set of recommendations for multi-sectoral collaboration strategies for nutrition organized along a project life cycle. SPRING based these recommendations on the findings from the three countries and refined them by incorporating lessons from the literature (SPRING 2014a, b, c). While the recommendations are based on work completed with USAID Missions and IP staff, many of them can be applied to other public and private investments for nutrition.

Figure 1. Recommendations along the Collaboration Life Cycle

Figure 1. Recommendations along the Collaboration Life Cycle

#1 Prioritize collaboration to address nutrition

Collaboration should be inclusive, because it involves coordinating action among multiple partners. However, leaders have an important role in prioritizing collaboration for nutrition and overseeing the process to ensure it is initiated and sustained. Leaders at the donor, IP, and government level, who have the respect and authority to work across departments and sectors, are an integral part of an initiative’s success.

All three countries had a champion(s) within the Mission who took the lead in developing the vision for collaboration and initiating the approach. In Guatemala and Bangladesh, USAID and partner staff consistently referred to one person at the Mission as the initial leader of the multi-sectoral collaboration efforts. In Bangladesh, one USAID staff member led the quarterly partner meetings. This initial leader created the working group and has been documenting collaboration efforts to-date. In Guatemala, one person conceptualized and oversaw the formation of the Western Highlands Integrated Program (WHIP) central and department committees, established monthly meetings, and documented processes and challenges. When this person left the Mission, a new leader was selected to continue the work. In fact, many stakeholders felt that, by the summer of 2013, the WHIP was institutionalized and prioritized by enough stakeholders that it was expected to continue with only a small amount of operational guidance from the new point person at USAID. In Rwanda, the directive came from the Mission Director, who made it clear that nutrition was a priority by driving the creation of the Community Health and Improved Nutrition (CHAIN) project,2 so nutrition and community health partners could work together for a greater effect.

Overwhelmingly, IPs across countries welcomed USAID’s lead in coordinating activities and partners. This is primarily because USAID can mandate participation and recognizes where and how partners relate to one another within the donor portfolio. Implementers explained that while USAID sees the big picture, the implementing partners do not always understand where they fit and, instead, focus on their separate work plans. USAID is, therefore, in a unique position to help the partners see where they fit and how they can better connect to other activities.

#2 Develop a practical strategy

While creating a practical joint agenda might seem straightforward, SPRING found that all three countries were struggling to develop a strategy that defined roles and responsibilities across participants, including a system for monitoring and feedback.

Observations across the countries suggest that a collaboration strategy for nutrition should be inclusive, understandable, measurable, and responsive. Each of these characteristics is discussed in more detail in figure 2 and below.

Figure 2. Characteristics of a Practical Strategy

Figure 2. Characteristics of a Practical Strategy

  • A strategy should be inclusive, encouraging participation from all stakeholders to generate consensus from the beginning and foster meaningful engagement. In Guatemala, the WHIP held a workshop to finalize a two-year action plan and generate feedback from all partners. During this workshop, stakeholders agreed on common language to include in the strategy, vision, and objectives of the WHIP, and defined the roles and responsibilities of the various stakeholders. Convening people at the outset helped them devise a common vision and, at the same time, generated support for the design and implementation of collaboration across and among activities. The WHIP also gave autonomy to partners in the field. In addition to a central-level technical working group in Guatemala City, there are WHIP coordinating bodies in the five departments3 that the IPs manage. Each departmental committee has the authority to institute its own plans to achieve WHIP’s overall goal, identify leadership, and create a strategy to collaborate in its department. This has produced interesting early results as these committees have felt empowered to try various ways of working together.
  • A strategy should define terminology and expectations. This includes outlining key terms—colocation, coordination, collaboration, integration, etc.—or selecting an existing framework that includes definitions. In Guatemala, the WHIP previously used the terms coordination, collaboration, cooperation, and integration interchangeably, without clearly defining the expectations or anticipated outcomes related to each. Confusion over terminology was reflected in differing perceptions of how various activities were working together, and what they believed they were expected to do.
  • A strategy should impose a time limit and result in a realistic outcome(s). While long-term goals for improving nutrition may underpin collaboration, one or more short-term, attainable goal(s) will motivate partners and allow people to see concrete results from their efforts. Ideally, a collaboration strategy includes a combination of easy wins to sustain momentum early in the collaboration, as well as more ambitious, long-term outcomes that may not be attainable for several years. Defining these short-term goals helps set priorities for types and levels of action partners can work on together, and helps clarify where time and resources should be spent. See the box on this page for examples: Short- Term Goals Identified by CHAIN Partners.
  • A strategy should include learning objectives and an understanding of the context in which collaboration is being promoted to guide current and future approaches. Collaboration strategies for nutrition are not static and should be viewed as “working hypotheses” of how the participants collectively believe they can accomplish their goals (Hanleybrown, Kania, and Kramer 2012). Emphasizing learning in a strategy can ensure that implementation is successful and responsive to lessons learned and shifts in the local context. Many Mission staff in Rwanda believe that CHAIN has the potential to be a prototype of multi-sectoral program design and management. Learning from this effort could inform the management of future projects and collaboration efforts between USAID IPs. However, there isn’t a formal structure in place to capture and share this learning. The baseline for learning could be strengthened by incorporating context assessment and evidence from past evaluations in order to capitalize on partners’ combined strengths to enhance nutrition outcomes.
    To purposefully capture what is and is not working and document lessons for future efforts, a strategy should note specific learning objectives and have a baseline understanding of the context in which collaboration is being promoted. Multi-sectoral collaboration for nutrition is not a new concept, and earlier attempts had been made by USAID, IPs, and government stakeholders in the three countries. Designing new individual activities or projects requires an adequate analysis to identify factors like those that may contribute to food insecurity and malnutrition in the defined target area communities. Collaboration strategies, which encompass a variety of stakeholders, should also be informed by context assessments and the existing evaluations to better illustrate how all partners relate to one another to make the greatest impact. Interviewees across the countries stated that they felt as though new activities had been designed separately from existing portfolios, and without a sound assessment of where the gaps were and how the new partners would best fit. One IP said that they were unclear whether they were a “flower, a tree, or a house” and wanted to have the strategy articulated to them so they would understand where they fit into the landscape. Another partner suggested the concept of being only one piece of a puzzle. By incorporating context assessment and evidence from past evaluations, USAID and other designers may develop collaboration strategies that capitalize on partners’ combined strengths to enhance nutrition outcomes.
Short-Term Goals Identified by CHAIN Partners
As part of the March 4 CHAIN partners meeting in Rwanda, attendees brainstormed and prioritized anticipated outcomes from CHAIN’s collaboration efforts. Below are some of the prioritized outcomes:
  • Increased adaptation and use of each other’s materials and messages. Several implementing mechanisms see CHAIN as an opportunity to revise existing materials to fit their own activity needs and avoid duplication of effort.
  • Increased complementarity of interventions. CHAIN could help partners gain a better idea of USAID’s overall approach to community health and nutrition, which will help them understand where they fit and how to connect to other activities.
  • CHAIN partners have a common voice. Many partners believed that CHAIN would enhance their credibility with the local government by uniting them and establishing a common goal.

#3 Communicate the strategy’s goals and expectations at all levels

Communication has a crucial role in translating strategy into action. The overall goal and expectations of a collaboration strategy should be communicated consistently and frequently to remind partners of their roles, whether at the central or field level. If collaboration strategies extend to the districts and communities, partners will be more likely to reduce communication gaps between and within organizations and to build on existing mechanisms at the level of implementation.

Communication at the national level between chiefs of party and Mission staff in the three countries was strong and regular meetings were well attended. While collaboration among stakeholders at the central level is important, all three countries would like the majority of collaboration (joint trainings, joint site visits, etc.) to take place in the communities where they work. District-level interviews in Bangladesh and Rwanda revealed that several stakeholders had not heard about initiatives to collaborate, despite the fact that there were structured meetings between senior staff at the central level. Many interviewees across all the countries noted that they are often unaware of the collaboration challenges that staff in other locations face. This suggests that communication between the central and district levels related to collaboration was weak, and there were no formal structures for communicating the purpose of Bangladesh’s Agriculture-Nutrition Linkages Group and Rwanda’s CHAIN objectives. If field staff are expected to work together locally, they need to better understand how the overarching collaboration strategy relates to and benefits their work. At the same time, SPRING found that ad-hoc coordination at the district and community levels was strong. This was especially the case with staff who knew each other well and had worked in close proximity over many years. There may be opportunities to augment collaboration platforms that are already in place at the district levels, and the first step is to reduce communication gaps.

In contrast to Bangladesh and Rwanda, the monthly departmental meetings in Guatemala are a venue for decentralized collaboration. Department-level staff indicated a high level of understanding about what the other activities were doing, where they were doing it, and how they were working together. IPs said that communication from the department-level committees has been valuable and many feel they can problem-solve and work more efficiently at the department level than at the central level.

#4 Hold all stakeholders accountable for achieving the strategy

One of the most critical learning points from SPRING’s assessment is that all participants should be held accountable for working together. All stakeholders need clear, documented roles and responsibilities to facilitate commitment and promote effective collaboration. This may entail hiring a full-time staff member dedicated to collaboration, including discrete responsibilities in job descriptions, and empowering partners to prioritize collaboration.

Ensure that collaboration responsibilities are central to everyone’s work

USAID Rwanda has initiated structures to manage the implementation of CHAIN, which has a project manager who oversees the coordination of the project management team (PMT) and all the activities. Originally, participation in the PMT was not obligatory. The CHAIN project manager was the only Mission staff member who had specific tasks related to the functioning of CHAIN included in his/her job description. And, just as PMT participation was not included in the Mission staff’s job descriptions, collaboration efforts were not written into the majority of CHAIN IP’s work plans. Because they were not accountable, some CHAIN IPs and Mission staff considered collaboration secondary to their work, resulting in related efforts not being prioritized. In an attempt to address this issue, USAID Rwanda recently included discrete responsibilities in job descriptions and incorporated collaboration requirements in newly awarded activities.

In Bangladesh, IPs faced a similar obstacle. Numerous interviewees mentioned that quarterly meetings are the primary mechanism for sharing information about what they are doing and where they are working, and for discussing activities that would mutually benefit the partners involved. However, because no one is held directly responsible for initiating or reporting on collaborative activities, few IPs are motivated to invest the time necessary to conduct the work.

Collaboration requires resources, time, and committed staff to initiate and maintain efforts over time. One department in Guatemala wanted a paid staff member to manage collaboration. Since none of the activities had budgets to pay for one, the department committee applied for and won a grant to hire someone to lead and document the collaborative work within that department. It is not always possible to dedicate full-time staff members to oversee collaboration, but all partners should be held accountable if collaboration is to be sustained. If donors would like their IPs to prioritize and conduct collaboration efforts, they can encourage partners to hire or appoint a focal person, or include collaboration responsibilities in the job descriptions of activity staff to ensure commitment to the time and effort required for collaboration. Additionally, donor staff who manage activities should have collaboration responsibilities as part of their work to ensure that all stakeholders share the commitment and goals related to collaboration.

Provide autonomy

In Guatemala, each departmental WHIP committee has the power to institute its own plans to contribute to WHIP’s overall goal. This has inspired partners to be accountable for their collaboration obligations, and has empowered some committees to take the initiative. In one department, the committee selected a pilot community where a number of partners work and they contacted the local mayor. With his support, the IPs created a joint one-year work plan for that community and worked closely to collaboratively implement all the project interventions. The other departments have also selected pilot communities to try this approach. They recognize that, given the current activity timelines and funding levels, the model cannot be expanded broadly, but they want to see and learn what they might achieve from intensive multi-sectoral collaboration in a small area.

#5 Share learning and adjust during implementation

Successful collaboration relies on formal structures (online platforms, regular meetings, etc.) during implementation to foster communication. Jointly analyzing monitoring data and establishing structures to disseminate information can encourage information sharing among partners. Most important, this information can inform decisions, facilitate needed changes in real time, and guide future efforts.

All three USAID Missions have made an effort to systematically bring all the partners together to provide updates and share resources and lessons. One common finding from Bangladesh, Guatemala, and Rwanda is that partners are working on similar activities simultaneously (e.g., duplicative evaluations, separate social and behavior change materials for nutrition, repeated or overlapping mapping exercises and tools). In other words, Mission investments are often duplicating efforts and aren’t working in a cost-effective way. In Rwanda, many partners provided examples of sharing training and other activity materials so that others can reuse or adapt them to their own contexts in order to promote operating efficiencies and avoid duplication of effort. During a recent meeting, the partners created a platform to share tools that could be adjusted to serve others. At the end of the meeting, they decided to form a technical working group to continue sharing these resources. Similarly, the Guatemala Mission held a meeting at which IPs identified numerous operational challenges for the WHIP and formed working groups to address the top priorities. These types of initiatives can help identify issues that might not be captured otherwise and allow lessons to be shared for future use.

After incorporating learning objectives into a collaboration strategy, related tasks may also be included in projectand activity-level monitoring and evaluation plans and work plans. In Guatemala, the Mission made deliberate efforts to coordinate the monitoring and evaluation processes across partners. One activity had an explicit objective to facilitate learning and information sharing. It was tasked with working with the other partners to ensure that data were shared, a single mapping system used, and evaluations coordinated across the portfolio. Similarly, in Bangladesh, one activity is responsible for organizing indicators across the activities, and a number of IP staff noted that this activity is well positioned to help the partners share information related to their collaboration efforts, and measuring their progress and outcomes.

#6 Report on collaboration efforts

Monitoring collaboration is important to recognize participants’ efforts and to demonstrate that the time, energy, and money invested contribute to objectives. However, measuring collaboration is challenging due to a lack of well accepted indicators and, consequentially, collaboration is infrequently measured. One solution is to incorporate qualitative and quantitative methods to understand the varied effects of collaboration approaches for nutrition. Reporting on collaboration will help participants implement the efforts (what is measured is prioritized), know if activities are on track, and determine if implementation approaches need to be revised. Importantly, measuring collaboration will also help the participants direct resources to collaborative efforts and ensure that these efforts do not detract from other activity goals.

Many of the partners in all three countries did not have specific deliverables, objectives, or metrics related to collaboration. As a result, partners perceived a conflict between their contracts and the request from their donor to collaborate. In some instances, partners pushed to allocate resources for collaboration and faced resistance from their headquarters because these activities fell outside the current contracts and indicators. The discrepancy between mandatory activity targets and a request for collaboration leaves implementers reluctant to allocate time and resources to collaboration.

The Missions agreed that it was important to recognize stakeholders’ work on collaboration and requested assistance in monitoring their efforts. Many of the IPs also believed that including measurable goals to report to USAID regularly would provide them information that would ensure they achieve their collaboration goals. Contextualized qualitative methods involving different perspectives are encouraged to better understand and monitor collaboration (Hardy, Hudson, and Waddington 2003). For example, joint trainings are common across all countries. The trainings themselves (number of trainings and people trained) are sometimes measured, but rarely are attempts made to measure additional outcomes of the trainings. This leaves little incentive to follow up trainings or ensure that goals are being met, because only the initial joint training is counted toward activity goals. Several IPs noted that they would be more willing to conduct joint trainings, and the trainings themselves might be more meaningful, if they knew that the information was used by those who were trained. Qualitative methods can answer important questions on what happened as a result of the trainings and to obtain details missed in traditional reporting: “Was the training useful to the participants’ jobs/how much of their total work time requires the knowledge and skills presented in the training? How has the information been applied? What else do participants need to use the information more effectively?” Certain benefits of collaboration, like participant satisfaction, are infrequently captured in traditional monitoring systems that focus on quantitative outputs or outcomes (FHI 360 2016). Combining qualitative and quantitative methods may more effectively capture the dynamic nature of collaboration and indicate the need to revise approaches in real time.

Conclusion

The justification for multi-sector approaches to nutrition is grounded in evidence demonstrating strong connections between the underlying determinants of nutrition and a range of other sectors. Systematic reviews indicate that cross-sector approaches requiring collaboration among and across a range of stakeholders can lead to better nutrition and health outcomes (FHI 360 2014; Yavinsky et al. 2015). While collaboration strategies, goals, and models vary, they often follow a similar life cycle that can be systematically designed, implemented, and monitored. Understanding the intricacies in each of these phases can help standardize approaches and inform future strategies. Incorporating the recommendations highlighted by this assessment may lead to more successful and sustained collaboration for nutrition. At the same time, well-designed indicators measuring the process and outcomes of collaboration still need to be developed, adopted, studied, and documented to demonstrate the level of impact that is possible through multi-sectoral collaboration for nutrition. Collaboration for improved nutrition is still in its formative years. At activity, organization, and Mission levels, it is an ongoing learning process that will expand and improve as stakeholders test and share approaches and results.