Challenges and Stakeholders' Views on Achievements of Multi-Sectoral Governance in Improving Child Nutrition in Buhigwe District, Tanzania

Background: In recent years, Tanzania has made good progress in addressing the problem of chronic malnutrition in children, but the levels are still unsatisfactory, at almost three in ten of its children are stunted. The government of Tanzania has taken significant measures to establish and strengthen multi-sectoral governance as part of national efforts to reduce the unacceptably high level of malnutrition. However, few studies have qualitatively documented stakeholder's perspectives at sub-national and community level with regards to performance of multi-sectoral governance in improving nutrition status of children in Tanzania. Objective: This study aimed to explore the achievements, facilitating factors and challenges of multi-sectoral governance in improving child nutrition in Buhigwe District Council. Methods: This was cross-sectional study, which employed qualitative method of data collection whereby semi-structured interviews were used to conduct in-depth interviews with members of the multisectoral steering committee for nutrition in Buhigwe Council and parents/caregivers of under-five children. Results: There is significant improvement in allocating funds for multisectoral governance interventions targeting under five children across sectors, improved inter-sectoral coordination and increased knowledge on feeding practices among parents/caregivers. Strong leadership and political commitment, inter-sectoral linkage and Presence of Non-Governmental Organizations (NGOs) supporting nutrition were identified as factors for improving child nutrition in the context of multisectoral governance. The issue of insufficient funding, inadequate spending of allocated funds, inadequate capacity, lack of cross-sectional financial mechanism and tools to collect nutrition information were raised by stakeholders as factors hindering the implementation of multi-sectoral governance in improving child nutrition. Conclusion: Smooth implementation of multi-sectoral interventions targeting under-five children requires strong multi-sectoral governance, which is supported by adequate spending of the allocated funds, strong leadership and political commitment, presence of NGOs supporting nutrition and inter-sectoral linkage among line sectors. However, key stakeholders including central and local government authorities should address the challenge of insufficient funds, inadequate capacity, lack of cross-sectoral co-financing mechanism and tools to collect nutrition information, which were reported as barriers to the implementation of multi-sectoral governance in improving child nutrition.


BACKGROUND
F or the past one decade, there has been a growing literature highlighting the importance of multisectoral governance for nutrition.The UN's Standing Committee on Nutrition defines "global nutrition governance" as the network of actors whose primary function is to improve nutrition outcomes through processes and mechanisms for convening, agenda setting, decision making (including normsetting), implementation, and accountability. 1Child undernutrition, including stunting, is an important example of a global challenge that spans multiple sectors, including health, agriculture and food systems, water and sanitation, education and gender.Stunting is the impaired growth and development that children experience from poor nutrition, repeated infection, and inadequate psychosocial stimulation.Children are defined as stunted if their height-for-age is more than two standard deviations below the World Health Organization (WHO) Child Growth Standards median. 2 Both strong evidences of the damage caused by undernutrition and the multiple benefits in reducing undernutrition led to the emergence of nutrition governance. 3The strong nutrition governance was associated with lower magnitude of stunting and underweight in low and middle-income countries. 4e Scaling Up Nutrition (SUN) Secretariat is a governance network established in 2010 that leads a global movement across 61 low-and middle-income countries to reduce malnutrition by 2030. 5The Government of Tanzania (GoT) signed up to the SUN movement in 2011 and further issued a 'Presidential call to action for increased accountability in tackling the nutrition situation in the country.The Prime Minister's Office ordered the establishment of multisectoral steering committees for nutrition (MSCN) at each level of government, appointed regional and district nutrition officers and issued nutrition guidelines requiring districts to budget for the implementation of nutrition activities. 6n Tanzania, Council level committees are integral to nutrition governance, playing a key role in ensuring that nutrition policies and programs are implemented in alignment with the National Nutrition Strategy (NNS) of 2011/12-2015/16 which preceded the National Multisectoral Nutrition Action Plan (NMNAP) 2016 -2021.The decentralization of nutrition interventions through council multi-sectoral nutrition steering committees on nutrition (CMSCN) provides Tanzania with a strong system for multi-sectoral nutrition governance. 7The CMSCN meets quarterly with members from key nutrition stakeholders including heads of nutrition sensitive sectors, nutrition focused Civil, Faith based, other non-governmental organizations (CBO,FBO & NGOs), the media, private sector, academic and research institutions depending on the agenda. 8,9Despite the government efforts in strengthening multi-sectoral governance at sub-national level, almost 3 in 10 of its children are still stunted, making the country home to the third highest population of stunted children in Sub Saharan Africa, after Ethiopia and Democratic Republic of Congo. 10 Published studies exploring stakeholder's perceptions on multisectoral governance for nutrition at sub-national and community level remains low both in Tanzania and globally.3][14][15][16] This study was an attempt to explore and analyze the achievements of multi-sectoral governance, facilitating factors and challenges hindering its implementation from the stakeholder's viewpoint to improve the nutrition status of children in Buhigwe District Council.The participants for this study were drawn from the Buhigwe District Council, which has a high number of malnourished children with low height for age which is high compared with that of Kigoma Region. 17The findings from this study also compliment the Joint Multisectoral Nutrition Reviews (JMNRs), an annual event, which brings nutrition stakeholders at National level to review the progress of implementation of nutrition actions in the country for the previous financial year.

Design
This was a cross-sectional study, which employed qualitative method of data collection whereby semi structured interviews were used to collect data on the achievements, facilitating factors and challenges of multisectoral governance in improving child nutrition in Buhigwe District Council.

Setting
This study was conducted in Buhigwe District, Tanzania, which is bordered to the north by Burundi, to the east by Kasulu Rural District and Kasulu Urban District, and to the west by Kigoma Rural District.According to the 2012 Tanzania National Census, the population of Buhigwe District was 254,342 and the population of under-five children was 62,208 in 2019.Buhigwe is one of the districts in Tanzania implementing the NMNAP for the period of 2015/16-2020/2021.

Sampling and Sample Size
A sample size of 25 key informants were purposely drawn from a specific population of interest to the study-that is members forming the CMSCN and parents/caregivers who received significant multi-sectoral nutrition interventions for more than six months at community level.17 CMSCN members were selected based on their occupational and professional experience and their involvement in multisectoral steering committee for nutrition, these were  (8)  parents/caregivers were conveniently selected from the list of 76 parents/caregivers who were reached with messages to improve child nutrition and multi-sectoral interventions for more than six months.The selection of 8 parents/caregivers were based on their accessibility particularly geographical proximity.However, it is important to note that the final sample size for this study was determined after reaching saturation point. 18

Data Collection
The principal investigator (PI), conducted in depth interview with assistance from one research assistant who took notes and all non-verbal responses that emerged during the interview.A semi structured interview guide was used for conducting in-depth interviews with each study participant involved under the study.The focus of questions in the interview guide was divided into three thematic areas, namely achievements, facilitating factors and challenges of multi-sectoral governance in improving the nutrition status of children.

Data Analysis
The qualitative data analysis employed a thematic approach which involved reading through the transcribed texts of each interview to identify responses relevant to the specific research questions of the study.Transcripts were read line by line to generate initial codes through data reduction.Recurrent themes were organized into subcategories then coherent categories to make meaning in the text.Themes were defined and named by refining the specifics of each theme and the overall story that the analysis tells to generate clear definitions and names for each theme basing on the study objectives.

Ethical Considerations
Ethical approval for this study was obtained from Muhimbili University of Health and Allied Sciences Ethical Review Board with Ref.No.DA282/298/01.C/.The permission to conduct research was also approved by the District Executive Director for Buhigwe District Council.Before consenting, the moderator told the participants that their participation was purely voluntary.Furthermore, they were informed that no names were required and data would be treated with high level of confidentiality.All participants were informed about the purpose of the study and gave a written consent for their participation, audio recording and the anonymized publication of quotes for research purposes was assured.All measures to maintain the rights of human subjects in social research, including the right to privacy, confidentiality and prevent from any harm were considered.

Trustworthiness
Several criteria were used in this study to evaluate the trustworthiness of the qualitative data.First, credibility was enhanced through spending a long period of time in the field to become familiar with the setting.Second, different perspectives of researchers in the study with different degrees of familiarity with the setting was included.Third, transferability is how applicable the findings are to other contexts. 19Here, the transcripts were translated from English to Kiswahili to increase the free expression of participants, and discussion of emerging themes among researchers enriched the interpretation of the data through the balance of perspectives representing different backgrounds and qualitative expertise.These measures enhanced the credibility of the representation of participants' views that is presented in our findings.Lastly, the detailed description of the study context, selection criteria, data collection and analytical process was complemented by quotations to allow readers to judge the dependability of the analysis and transferability of the findings.

Demographic characteristics
Table 1 provides a summary of the demographic information of participants who were involved in the study.A total of 25 key informants involved in the implementation of the multisectoral nutrition governance both at the council and community level participated in an in-depth interview.The actors at the council included implementers in the 6 public sectors including health, agriculture, education, water, livestock and fisheries and community development.Of the CMSCN who participated, 82% attended college and university education while 12% had A level education and 6% had primary education level.The majority of parents/ caregivers who participated in the study had attained primary education (50%) while 13% never attended school.
Nine themes emerged from the stakeholder's perspectives regarding the multi-sectoral governance in improving child nutrition in Buhigwe District Council.These were further condensed to form three main categories basing on study objectives.These were achievements, facilitating factors and challenges of multi-sectoral governance in improving child nutrition in Buhigwe District Council.

Achievements of Multi-Sectoral Governance in Improving
Nutrition Status Among Children.Allocation of specific budget for supporting nutrition interventions for under-five children.Participants from health sector reported that they have allocated a budget for supporting nutrition intervention to under-five children in the council.The initiative is due to the establishment of the National Nutrition Compact between central government and regions which ensures allocation of nutrition funding per child (TZS 1000 per under-five child).Moreover, the continuous engagement of other sectors through the CMSCN and the annual multi-sectoral planning and budgeting meetings ensured proper allocation of nutrition funds across line sectors.However, the findings revealed that the disbursed budget from the council is inadequate to support planned activities as expressed by one of the participants: "  Parents/caregivers reported that that their ideas and perceptions of child feeding practices had significantly changed after receiving counselling sessions on feeding practices through monthly support groups' meetings aimed at improving child nutrition.The synergies between various multi-sectoral governance interventions and Tanzania Social Action Fund (TASAF) have contributed to over 40% TASAF beneficiaries been enrolled and regularly participate to monthly group counselling on optimal caregiving practices to improve maternal and child nutrition. 40An observational study on childhood stunting after exposure to multi-sectoral interventions (agriculture, income generation, improved water and sanitation, education, infrastructure) in 9 sub-Saharan African countries found a significant reduction in stunting prevalence in 5 of them. 26Despite an increased knowledge of parents/caregivers in the area of infant and young child feeding practices, the multi-sectoral team needs to combine a comprehensive package of services to parents/caregivers, including early stimulation, social and child protection, to support families providing nurturing care of children.
This study critically analysed potential facilitators for effective multi-sectoral nutrition governance towards improving child nutrition.Participants reported strong leadership and political commitment, presence of partner NGOs and inter-sectoral linkage as factors for improving child nutrition in the context of multi sectoral governance.In this study, the council's authority was mentioned as among the potential actors in driving political commitment to address the malnutrition burden including ensuring allocation of budget for supporting

DISCUSSION
This study has shown a number of achievements resulting from use of multi-sectoral governance in the implementation of nutrition activities in Tanzania.Such achievements include an increasing amount of funds allocated by the council to implement nutrition-related activities across different sectors, improved Inter-sectoral coordination and improved knowledge on child feeding and practices among community members.Furthermore, this study revealed that actors from all sectors can sit as one team and work together on nutritional activities through a functional multi-sectoral steering committee for nutrition which represents all sectors.These achievements were made possible because the senior officials at the council were held accountable by the compact agreement which was signed between them and the minister responsible for Regional Administration and Local Government Authorities on scaling up implementation of nutrition indicators especially the minimum mandatory nutrition funding allocation per child, (TZS 1000 per under-five child). 9nzania has made efforts to fuel action predominantly in the area of enabling environment within the NMNAP which aims to improve effectiveness and efficiency of nutrition governance (including coordination and leadership) and response across all sectors and actors. 8owever less consideration has been given to explore the achievements, facilitating factors and challenges encountered by multi-sectoral governance for nutrition in Tanzania.A study of Nepal's nutrition governance capacity found improvement across all levels of administration in cross-sector engagement. 21However, it is also reported that the disbursed budget from the councils is still inadequate to implement all nutritional activities for under-five children.Despite the fact that the Minimum Nutrition Package is part of the recommended high impact intervention (HII), it has been noted that the interventions aiming at reducing malnutrition.From this perspective, achieving political commitment is more than generating attention to malnutrition or getting it onto a government agenda.It further involves the mobilization of political systems and institutions, enabling policies, guideline, allocating resources and coordinating responses for as long as necessary to ensure positive results. 35Cascading multi-sectoral nutrition structures from central to local levels will depend on improved awareness, leadership and continued political commitment. 3 Similarly, the participation of highlevel politicians was seen as one of the key indications of political will and determination. 35,39The existence of inter-sectoral linkage was reported as important factor to implement a multi-sectoral governance which will facilitate the reduction of high levels of malnutrition especially to children.Establishing governance structures and policies to manage coordination across sectors is crucial to implementing a national Multi-Sectoral Nutrition (MSN) plan.The presence of development partners in nutrition such as NGOs were also reported as a facilitator which strengthens the multisectoral governance in improving nutrition outcomes.Effective engagement of development partners for nutrition in the MSN coordination structures have been found in Ethiopia to be useful in implementation of nutrition activities. 25r findings confirm that key challenges to effective multisectoral governance is insufficient financial resources.Studies conducted in Ethiopia and Burkina Faso have also documented the insufficient financial resources as the main challenges of the implementation of activities involving multisectoral collaboration. 16,25,37Furthermore, participants reported lack of a cross-sectoral co-financing mechanism.This could be explained with the fact that different sectors have different priorities and are allocating their budget based on their own sectoral priority.Thus, tracking funding contributions and performance of sector actors in implementing nutrition sensitive interventions in the councils is a challenge.Consequently, the sectors, in carrying out programs to fulfill their particular mandates, inevitably situate themselves as competitors for resources rather than as partners in action. 3Multisectoral approaches can suffer due to differing cultures, mandates, and incentives characteristic of different sectors.These factors are barriers to coordination and cooperation, and turf battles further interfere with integrated action. 28The major nutrition indicators such as wasting and stunting indicators are not collected due to lack of anthropometric tools to collect the required indicators.Moreover, it is reported that CMSCN's members lack training, knowledge and skills in integrating nutrition within sectoral departments.Participants identified significant gaps in capacity for nutrition and emphasizes the urgent need for capacity-strengthening in the coordination structures for effective multi-sector governance implementation.A district director of health services in Uganda noted that local political leaders first ask for the construction of health units in seeking to find a solution to the health problems their constituents face.However, she noted that, they rarely go a step further to consider what are the causes of those health problems, including malnutrition.A knowledge gap must be bridged if nutrition is to become a more significant part of the content of local government debate, planning, and action. 3Lack of knowledge or commitment to nutrition, lack of resources and presence of competing priorities within individual sectors were identified as barriers to effective coordination between health and agriculture sectors. 37There is a general need for nutrition awareness in the area, as relates to basic nutrition-sensitive roles and responsibilities of the members in the CMSCN.This is similar to a recent analysis conducted of the African Nutrition Security Partnership, which identified a broad range of governance challenges encountered by African countries, including human resource constraints for overall MSN implementation and coordination, lack of dedicated implementation staff for subnational efforts, and failure to engage high-level decision-makers. 32udy Limitation and Mitigation: The main limitation of this study is the selection of only one district for the study, which may have limited the information generated about the implementation of multi-sectoral governance in improving child nutrition.However, the researchers used triangulation methods to collect data and they have ensured that data collected from this district reached saturation point, thus provided adequate and detailed information to answer the research questions.

CONCLUSION AND RECOMMENDATIONS
Smooth implementation of nutrition interventions targeting undernourished under-five children require strong multi-sectoral governance, which is supported by adequate spending of the allocated funds, political commitment, operationalized policies and guidelines for nutrition.However, key stakeholders including central and local government authorities should address the challenge of inadequate capacity, lack of a cross-sectoral co-financing mechanism and lack of necessary tools to collect nutrition information, which were reported as barriers to the implementation of multi-sectoral governance in improving child nutrition.Strengthening sector participation and mobilizing financial resources have the potential to significantly reduce barriers and improve the quality of implementation of multi-sectoral governance in improving child nutrition.Further research that focuses on multi-sectoral governance at the ward and village level, as the lowest administrative levels of the Tanzania Local Government System, is also recommended.

TABLE 1 :
Summary of Socio-Demographic Characteristics of Study Participants