NUTRITION ADVOCACY IN ZAMBIA - Challenges & Opportunities
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NUTRITION ADVOCACY IN ZAMBIA Challenges & Opportunities
Contents 5 INTRODUCTION TO RESEARCH
IMPORTANCE OF INVESTING IN
6
UNDERNUTRITION
7 ADVOCACY FOR NUTRITION
ZAMBIA: UNDERNUTRITION AND
7
POLITICAL WILL
8
CHALLENGES AND OPPORTUNITIES
FOR NUTRITION ADVOCACY
Limited nutrition advocates in Zambia
Coordination of advocacy
The importance of messaging
Developing champions
The multisectoral nature of nutrition
14 RECOMMENDATIONS
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GLOSSARY ACRONYMNS INTRODUCTION TO RESEARCH
CMAM This report examines the nutrition advocacy space in Zambia
Community-Based Management of Acute Malnutrition - specifically looking at the experience of civil society organisa-
tions (CSOs) working on nutrition advocacy. It provides an over-
view of the types of advocacy Zambian CSOs engage in, and
CSO
1000 days The 1000 days between a woman’s pregnancy and her child’s 2nd birthday offers a unique window identifies some of barriers and challenges to conducting nutrition
Civil Society Organisation
of opportunity to prevent irreversible physical and cognitive damage caused by undernutrition. advocacy, as well as some opportunities to strengthen advocacy
The right nutrition during this 1000 days window can have a profound impact on a child’s ability around nutrition in Zambia. We intend that the report act as a
to grow, learn, and rise out of poverty. GDP catalyst for further discussions around nutrition advocacy.
Gross Domestic Product
Methods
Advocacy The act of actively supporting a certain viewpoint and to persuade governments or other entities GHI
to make policy changes, pledge resources, enshrine rights, or change or create new laws on a Global Hunger Index Findings in this report are based on desk-based research, dis-
particular issue. cussions with Zambian based CSOs during November 2013
GoZ held in Lusaka, Zambia, and a consultation on the research
Government of Zambia findings in March 2014. Staff from RESULTS and CITAM+ in-
Acute Malnutrition Low weight-for-height. Wasting is usually the result of a recent shock such as lack of calories and terviewed 9 individuals from CSOs, from both domestic and
(Wasting) nutrients and/or illness, and is strongly linked to mortality. HANCI international organisations, one elected official, and held focus
Hunger and Nutrition Commitment Index group discussions in which 12 individuals participated. Inter-
views were semi-structured, which allowed for conversations
Chronic Malnutrition Low height-for-age. Stunting is the cumulative effect of long-term deficits in quantity and quality to evolve naturally while ensuring that common themes were
(Stunting)
HIV
food intake, poor caring practices, and illness. discussed with each participant. Interview participants were
Human Immunodeficiency Virus
identified through our local partner, CITAM+, as well as inter-
net searches of CSOs working on nutrition. The purpose of the
Community-Based The management of acute malnutrition through (a) inpatient care of children with severe acute MoCTA consultation day was to verify the findings of the research and
Management of Acute malnutrition with medical complications and infants under six-months of age with visible signs of Ministry of Chiefs and Traditional Affairs
address any gaps in the research. The consultation included 32
Malnutrition severe acute malnutrition; (b) outpatient care for children with severe acute malnutrition; and (c) participants from civil society, academia, Parliament, the media
community outreach. MoF and medical professionals.
Ministry of Finance
Target Audience
Global Hunger Index An index that ranks developing and transitional countries using three indicators to describe the MoH
state of a countries’ hunger situation: (i) the proportion of people who are undernourished; (ii) the Ministry of Health The report is aimed at Zambian CSOs that are currently involved,
prevalence of underweight children under the age of five; and (iii) the under-five mortality rate. or are seeking to become more involved, in nutrition advocacy.
NFNC Some of the lessons may be applicable to other country settings.
National Food and Nutrition Commission
HANCI The Hunger and Nutrition Commitment Index ranks governments on their political commitment
to tackling hunger and undernutrition. The index was created to provide greater transparency and Limitations of the Study
public accountability by measuring what governments achieve, and where they fail, in addressing NFNSP
hunger and undernutrition. National Food and Nutrition Strategic Plan Due to the sample size, the research does not aim to be rep-
resentative; rather it takes a snapshot of the current nutrition
NGO advocacy environment in Zambia.
Hunger A feeling of discomfort, illness, weakness, or pain due to prolonged involuntary lack of food. Un- Non-Governmental Organisation
dernutrition can be one of the manifestations and consequences of hunger.
SUN
Scaling Up Nutrition Movement
Malnutrition Poor nutrition status cased by nutritional deficiency or excess (undernutrition or overnutrition).
TB
Tuberculosis
Undernutrition Poor nutritional status due to nutritional deficiencies. The main three indications of undernutrition
are stunting, wasting, and underweight.
WB
World Bank
WHO
World Health Organisation
ZMW
Zambian Kwacha
4 5THE IMPORTANCE OF INVESTING ADVOCACY FOR NUTRITION
IN UNDERNUTRITION • Job creation, since non-malnourished children do better in to a report by UNICEF undernutrition is likely to be the most
Knowing the problem and the solution is only half of the job.
school, and in adult life, earn 20% more in the labour market Political will is needed from national governments to translate significant factor in child mortality and morbidity, underlying up
Affecting an estimated 2 billion people globally, undernutrition and are 10% more likely to own their own businesses.iv the evidence into policies, and policies into programmes. Politi- to 52% of under-5 deaths in Zambia.xiv
poses the greatest challenge to human health and well-being, cal will cannot just be on paper. It must translate into active and
and to countries’ economic development.i It is directly and • Increased productivity, due to a healthier workforce and lack effective implementation to achieve real nutritional outcomes. A report by the WB estimates that the Zambia economy loses
indirectly responsible for 45% of all child deaths, - 3.1 million a of stunting, as well as improvements in micronutrient status. $186 million annually due to vitamin and mineral deficiencies.
year – making it the leading cause of death among children under “The issue is how to translate policy into actual imple- Yet, scaling up core micronutrient interventions would cost less
five.ii As well as increasing the risk of death, chronic undernu- • Saving of resources currently directed to healthcare, than $7 million a year.xv The economic cost of undernutrition
mentation and integrate nutrition into programmes that
trition (stunting) can irreversibly impair a child’s physical and disease treatment and other problems associated with to Zambia over the last 10 years (2004-2013) is estimated to
have tangible impacts.”
cognitive development, impacting their education and earning undernutrition.v be as high as $775 million.10 According to the National Food
potential in adult life, and locking them in a cycle of poor health and Nutrition Commission (NFNC) the elimination of iodine de-
Commitment alone is not enough for the millions of nutritionally
and poverty. Currently 165 million children worldwide suffer from • Acceleration of fertility declines, which is driven by a decline ficiency, reduction in stunting by 1% point per year and reduc-
vulnerable women and children around the world. Political will
stunted growth due to undernutrition, with Sub-Saharan Africa in infant mortality, since children suffering from stunting are tion of maternal anaemia by one third would increase Zambia’s
is crucial in the fight against undernutrition, but it rarely emerges
accounting for 38% of the total burden. two times more likely to die, and children who are wasted are productivity by $1.5 billion over the next 10 years.11 Despite
by chance. Deliberate action is required to build and sustain
up to 9 times more likely to die than well-nourished children. the potential gains there has been no significant improvement
political will. If we hope to see governments implementing the
The economic costs of undernutrition, in terms of lost national in levels of undernutrition in the last 10 years.
right mix of interventions and programmes then civil society
productivity and economic growth, are also high. It is estimated The global community has the knowledge, tools and strategies
must marshal the political will to build and sustain an enabling
that countries can lose up to 3% of their potential Gross Domes- that could improve the lives of millions of women and children The Government of Zambia (GoZ) has taken some steps that
environment.
tic Product (GDP) each year..iii around the world and boost national economies. The 2013 Lan- demonstrate an increase in political commitment to nutrition.
cet Series on Maternal and Child Undernutrition defined, and It was among the early risers in the Scaling Up Nutrition (SUN)
Advocacy is key to achieving this since it can accord impor-
Despite the devastating consequences, undernutrition is costed, a set of 10 nutrition specific interventions that could Movement, having joined in December 2010. Since then it
tance to issues that might not figure in national priorities due
largely preventable. There are huge short-term and long-term save millions of lives and contribute to long-term health and has developed the National Food and Nutrition Strategic Plan
to their controversial nature or because other issues are being
benefits to investing in nutrition, especially in regards to eco- development. The 2012 Copenhagen Consensus estimated (NFNSP) 2011-2015, a process which was coordinated and led
given higher importance by decision-makers. Through advocacy
nomic growth: that every $1 invested in nutrition could generate as much as by the NFNC - a convening body under the Ministry of Health
CSOs can give a voice to some of the most marginalised and
$138 (748 ZMW) in benefits – from better health to increased (MoH) to coordinate action on nutrition in Zambia. At the 2013
disadvantaged communities, and demand that their rights as
productivity.vi A lack of evidence and solutions are no longer Nutrition for Growth event, Zambia made some ambitious pledg-
citizens - that governments and services can overlook - are met.
viable excuses for inaction. es over the next 10 years, including:
In the absence of effective nutrition advocacy governments may
Despite the overwhelming evidence inaction perseveres, and • To reduce stunting by 50%,
be less likely to ensure that nutrition-related goods and services
nutrition remains chronically underfunded and under-prioritised.
are provided to their citizens, especially where there is a lack of
Inaction from governments points to a lack of political will. • To progressively match additional cooperating partners’
political momentum and demand for action.
resources through new and existing nutrition budget lines,
and aim to increase its financial contributions by at least
CSOs have a key role in building and sustaining political will to
20% annually,
effectively implement actions to reduce undernutrition. CSOs
What about financial capacity? influence and shape nutrition policies, and have the mandate to
• To increase government expenditure on nutrition to an es-
hold government agencies accountable for providing nutrition-
While a lack of resources can exacerbate a governments inaction, addressing undernutrition is not solely contingent on financial capac- timated $30 per child under five as recommended by the
related services for their citizens.
ity. Zambia displays significantly higher prevalence of child stunting than other African nations with similar or lower per capita income, World Bank.xvi
including Kenya (35%) and Mauritania (22%). This suggests that it is possible to achieve better nutrition outcomes despite low income.
The GoZ has made some ambitious targets over the next dec-
ade, but much progress need to be made if these targets are to
ZAMBIA: UNDERNUTRITION
Source: Stunting rates were obtained from the WHO Global Database on Child Growth and
be achieved. For instance, it is estimated that the 2013 budget
Malnutrition. GNI data were obtained from the World Bank’s Development Indicators
allocated between 11–33 ZMW ($2-$6) per child to addressing
AND POLITICAL WILL undernutrition.12 This is a large, but not unachievable, gap to
fill over the next 10 years if they are to reach their $30 per child
Zambia has experienced steady economic growth over the past target. While part of this funding gap will need to be reached
decade. By the end of 2013 Zambia’s GDP growth had risen to through a combination of bilateral and multilateral donors, strong
6% - higher than the 4.7% average for Sub-Saharan Africa – CSO advocacy is needed to ensure that the GoZ increases the
and is expected to improve with GDP growth forecast to rise to domestic resources available for nutrition programmes. CSOs
6.5% in 2014.viii Thanks to its steady economic growth it was have a key role in ensuring the government fulfils its commit-
officially reclassified as a lower-middle-income country by the ments.
World Bank (WB) in 2011.ix
Political will needs to be strengthened if these commitments are
Despite its economic growth Zambia’s hunger and nutrition to be achieved. In terms of commitments for hunger and nutri-
situation is classified as ‘alarming’ on the Global Hunger Index tion, the 2012 Hunger and Commitment Index (HANCI) ranked
(GHI). Zambia has one of the highest rates of stunting among Zambia 17th out of 45 counties. The HANCI Index found that,
children under five in the world. It is one of 20 countries where in both policies and expenditure for nutrition, there is scope for
the prevalence of stunting is higher than 40% - ‘very high’ improvement – with the GoZ as public expenditure for nutrition is
according to WHO classifications.xi With prevalence at 45% much weaker than expenditure for hunger.13 Although the total
stunting rates in Zambia remain higher than the vast earmarked fund for nutrition through the NFNC was $1.2 million
majority of its neighbouring countries.xii The rates of micronutrient for the year of 2012, actual disbursements fell short by around
deficiencies are also high, with 53% vitamin A deficiency and 50%.xvii Overall, HANCI found that Zambia shows a ‘moderate
4% of school age children suffering from iodine deficiency commitment’ to the reduction of hunger and undernutrition.
disorders while 46% have iron deficiency anaemia.xiii According
Figure 1: Stunting rates compared to GNIvii
7CHALLENGES AND
OPPORTUNITIES FOR
organisations are not experts at policy analysis, coalition While participants were enthusiastic about the opportunity to do
NUTRITION ADVOCACY IN ZAMBIA Nutrition is critical for the progress of numerous health and building, lobbying, media engagement and grassroots joint advocacy, they felt that a coordinating body was needed to
developmental issues – it is a foundation for their attainment. organising. Usually organisations, especially smaller ones, bring CSOs together and be able to speak with one voice. Coor-
Therefore, integrated messaging can play an important role for only have expertise in a few of these areas. dinating bodies do exist in Zambia; however, they are relatively
1. Limited nutrition advocates in Zambia raising the profile of undernutrition and can offer a good entry new, which may explain why they were not known to most par-
point for further nutrition engagement. However, efforts must • Working in partnership can enhance the credibility and ticipants. The perceived absence of an effective nutrition coali-
While Zambia is not short of organisations doing advocacy, be made to ensure that undernutrition is not perceived as ‘be- influence of an alliance, as well as that of individual tion was viewed as a key constraint on delivering strong nutrition
participants felt that nutrition was not a priority for many, and ing part of the normal order things.’ To build political will within coalition members. advocacy to build national commitment to tackle undernutrition.
that the majority of advocacy efforts were focused on ‘more the GoZ, discussions around undernutrition should generate
popular’ and established issues like HIV. Participants reported a perception of crisis that requires significant, urgent and high • Decision makers may be more inclined to meet with a 3. The Importance of Messaging
being relatively unaware of other organisations working on nu- profile action. coalition that represents the views and objectives of
trition. Overall, there was a general sense that there was a very group of organisations, than meet with 20 organisations Being able to package advocacy messages and to speak
small pool of organisations that worked on nutrition advocacy. Programmes and service delivery projects are much more individually. From the perspective of the decision powerfully about an issue is one the most important skills for
common than advocacy projects. There were very few makers, coalitions provide an opportunity to engage with a any advocate.
While a few participants’ highlighted nutrition as a key organisations that were solely or primarily advocacy focused. coordinated ‘CSO voice’, rather than dealing with multiple
advocacy priority within their organisation, for the majority nutri- This may be due to the lack of funding available for advocacy and disparate CSOs. They simply do not have the time to • By developing a common language between policy
tion was a small component of their work. It was perceived as a in Zambia. Participants reported struggling to securing funding meet with 20 individual organisations. makers, politicians, and the general public, a complex and
complementary issue to their current advocacy work., with for the advocacy components of their work, which has curtailed seemingly insurmountable issue can be transformed into a
most orgaisations focused on issues such as HIV/AIDS or their ability to conduct advocacy for nutrition. This raised a It was apparent in both one-on-one and focus group interviews coherent and achievable goal.
education, where nutrition relevant but rarely pivotal. As such, number of problems and concerns: that there was a serious lack of awareness of other organisa-
some participants admitted to having a limited knowledge of tions working on nutrition. During the focus group discussions it • Packaging messages can be vital when meeting with busy
undernutrition, with discussions restricted to areas where nutrition • While organisations would like to scale up their advocacy was clear that many participants were meeting for the first time, decision makers. Often advocates will only have a couple
impacted or was interlinked with other priority issues. For these work, a chronic lack of funding had either compelled or despite all working on nutrition – to some extent or another - and of minutes to get their message across and convince them
participants it was perceived as a means to achieving another end, could compel some to scale back their nutrition advoca- most being based in Lusaka. Nevertheless, participants shared to take an action.
such as improved health for people living with HIV or improved cy work in favour of programmes or other more popular many of the same goals and priorities, which indicates a clear
educational outcomes for school children. Improved nutrition advocacy issues. opportunity to do some joint and coordinated advocacy. Some • It can build the credibility of organisations and individuals
was generally not viewed as an end in itself. shared goals included: by having decision makers see them as a source of both
• Participants highlighted that the current lack of funding information and inspiration for their efforts to help end
“We have had meetings with policy makers about could discourage other organisations from becoming • The need to elevate the NFNC out of the MoH and into the poverty in Parliament.
education and how nutrition is related to enrolment in involved in nutrition advocacy. Organisations are more Vice Presidents office.
schools and how it affects educational outcomes.” likely to get funding to tackle hunger than undernutrition, On the other hand, if it is difficult to understand a complex
and when funding is available for nutrition it is more likely • The need for other key line Ministries to take responsibil- position, political leaders and decision makers are less likely to
“We engage with the Ministry of Health about nutrition to be for programmes and service delivery projects. ity for undernutrition and increase their budget lines for champion the cause and it is less likely that concerned citizens
nutrition. will choose to contact their elected representatives (or become
when it is to do with HIV.”
• Given the limited resources, and that CSOs are frequently concerned in the first place). Participants recognised that nutrition
compete for the same sources of funding, CSOs find that Despite sharing common advocacy goals, participants was a complex issue, and that more effort was needed to create
This presents a set of challenges in raising awareness and the
they struggle to plan and implement long-term strategic reported that they rarely carried out any joint advocacy activities a solid understanding of the issue to boosts both confidence and
profile of undernutrition – which participants reported as being
objectives. to achieve these goals. This may be due to: conviction among citizens and decision makers. They reported
low across the board – when it is viewed and discussed as a
secondary issue. This risks perpetuating the view that when it a widespread misconception among all stakeholders – from
Since there is a greater abundance of nutrition programmes than • The lack of awareness of other organisations working on political leaders to citizens to civil society – that nutrition is
comes to nutrition it is ‘business as usual.’
advocacy programmes, and that participants reported finding nutrition. synonymous with hunger.
it “very difficult to find statistics from rural areas”, working in
That said, given the limited organisations doing nutrition advoca-
partnership with programmatic organisations would provide • The lack of funding available, which means that rather the “There is a strong link between hunger and undernutrition,
cy in Zambia, participants felt that it may offer an entry point for
an opportunity to strengthen their nutrition advocacy, and build coordinating CSOs are frequently competing for the same but they are not the same.”
other CSO organisations to engage in nutrition advocacy. It may
credibility, by developing a stronger evidence base, for example. sources of funding
also provide an opportunity to push for nutrition to be integrated
into broader health and development issues, and raise its profile Participant were concerned this misconception could act as
within and through other issue arenas. For instance example:
“Advocacy is strengthened when organisations work “CSOs have a history of being competitive. We need to a barrier to nutrition advocacy, particularly for pushing for the
with service delivery, as this helps build the evidence on compliment each other and work together in order to implementation of nutrition interventions, if both citizens and
• Zambia’s HIV epidemic significantly overlaps with popula- the ground.” have a bigger voice.” decision makers perceive the GoZ as addressing undernutrition
tions experiencing low diet quality and quantity, leading to by addressing hunger. They recognised the need for create clear
worsened undernutrition for people living with HIV, weak- Some participants expressed concerns that nutrition advocates and accessible messaging to raise awareness of undernutrition.
ened immune systems and increased risk of opportunistic 2. Limited coordination on advocacy appeared uncoordinated, which may be impacting their cred-
infections and mortality. ibility among decision makers, and that if they continued to ‘go
Given the limited number of CSOs prioritising nutrition as an at it alone’ this could impede the effectiveness of their advocacy
• Zambia has one of the highest incidences of tuberculosis advocacy objective, coordination becomes even more and could even end up undermining each others efforts. That
(TB) in Africa. Efforts to address the TB epidemic in Zambia important. Working in coordination with members of civil society said, all participants felt that there was appetite to coordinate
are seriously hampered by undernutrition, which is associ- and other key stakeholders enhances the reach of advocacy on advocacy.
ated with an increased risk of early death among people efforts and makes for much stronger advocacy:
living with TB.xviii “The better the coordination the better our chances of
• It can enlarge the base of support, and pressure, for a success.”
• Poor educational outcomes are a major challenge in Zambia, particular policy change.
with 25% of youth still not fully literate.xix Undernutrition, can “You can create that energy and a larger voice that one
significantly impact the children’s ability to learn in schools. • It is a good way to leverage the comparative advantage of NGO, on their own, is not able to provide.”
Stunted children are 19% less likely to be able to read by other organisations or individuals, since no organisation
age 8 compared to their well-nourished counterparts.xx can be the expert in everything. In other words – most
8 9meeting with a parliamentarian, the parliamentarian got frus- • Inform the public and decision makers about the facts Discussions with journalists revealed that a lack of reporting on
Hunger and Undernutrition trated and asked multiple times “what do you expect me to do?” around undernutrition. nutrition did not necessarily reflect a disinterest or unwillingness
from the journalists themselves.
Hunger is the body’s response to prolonged lack of food – often Other participants reported that parliamentarians were • Reframe the way that undernutrition is viewed. The media
experienced through a feeling of discomfort, illness, weakness, resistant to pushing for investment in nutrition because it can can help frame the issue as a public health concern that • Some media participants admitted having limited knowledge
or pain. The feeling of hunger can be quenched if people have take years to see impact. Stunting can be generational, so it impacts the whole country, not just individuals. of nutrition, which discouraged them from reporting on the
access to good quantity of food. can takes years to break the cycle. One participant suggested issue. Given the tight deadlines many felt that they had
that some “MPs prefer quick fixes” and were more likely to push • Encourage the public, other CSOs and decision makers neither the time nor the capacity to ‘get up to scratch’
That does not mean to say they are not at risk of undernutrition. for investments in structural projects, such as the construction to find out more about undernutrition, and to get involved. with the issue. Participants felt there was scope for
People can become malnourished if they don’t have access to of buildings or wells, where outcomes are almost immediate. journalists and CSOs to work together to relieve some of
good quantity and quality food and/or suffer from illness. Participants reorganised that if parliamentarians want to be Where the public can be difficult to mobilise, due to a lack of these constraints that have discouraged journalists from
re-elected they need to be seen to be “doing something” in their awareness or empowerment the media can provide another pursing stories on nutrition. Some media journalists were
Therefore, someone may have access to three meals a day, but constituencies. form of pressure. Mass media reporting on an issue can create enthusiastic about the idea of taking part in nutrition trainings.
if it is primarily made up of one type of food – such as maize – an illusion of public opinion on numerous political and social
then they are not accessing good quality food, balanced with Participants who had offered solutions in meetings reported that issues, where there is, in fact, still a lack of awareness. “Nutrition itself is technical and we can’t expect journalists
vitamins and minerals, needed for a healthy diet. In Zambia the ‘1000 days message’ was well received by decision makers, to understand right away. We must build capacities of
many families eat maize porridge three times a day. as it provided a clear and tangible timeline to intervene. Participants recognised that media could be a powerful means media to deal with the issue well.”
of raising awareness of, and the agenda on, nutrition.
Someone may even have access to good quantity and quality • Media participants reported a lack of power over what
food, but may not have access to clean water and sanitation The 1000 days window of opportunity “Everyone is affected by the media, especially politicians.” they report. They recounted feeling pressure from editors
and become susceptible to illness, such as diarrhoeal disease, and media houses to ‘find stories that would sell papers.’
which means their body cannot absorb the vital nutrients. The 1000 days between a woman’s pregnancy and her child’s However, participants felt that Zambian media rarely report Generally, for editors, who have final say on whether a story
2nd birthday offers a crucial window of opportunity to prevent on nutrition. The media was more likely to report on hunger, runs, nutrition was not a nutrition as a ‘money making story.’
While some people may not be hungry, they may still be irreversible physical and cognitive damage caused by under- particularly during a emergencies or electoral cycles, since
malnourished. nutrition. The right nutrition during this 1000 days window can hunger is considered to be a political issue, while nutrition is not. • Media participants felt that there wasn’t much incentive
have a profound impact on a child’s ability to grow, learn, Participants identified a need to reframe nutrition as a political for journalists to report on nutrition. Participants felt that
and rise out of poverty. issue. introducing some sort of non-financial incentive, such as a
nutrition media award, could be useful in encouraging more
When meeting with decision-makers participants reported By focusing on improving nutrition for mothers and children in While all participants identified media as a powerful advocacy journalists to report on nutrition.
having very little time to fully engage them on undernutri- the 1000 day window, we can help ensure a child can live a ally, only half had worked with the media around nutrition. Some
tion, and sometimes left meetings having delivered only half healthy and productive life. things that discouraged CSOs from engaging with media were:
b. Citizen mobilisation
of their intended messages. They identified the need to have
well-packaged messages – presenting the problem, the solution • A lack of confidence about giving statements or quotes.
and making a clear call to action. One participant referred to a past experiences where a Empowering citizens - from ordinary members of the public
Even fewer participants reported making a ‘call to action’ during statement they had given had not been accurately reflected. to those affected by undernutrition - to speak up and call for
Participants felt comfortable presenting the problem of meetings with decision makers. Those who had reported not change can be a powerful advocacy strategy. It demonstrates
undernutrition, and reported using facts and figures to always following up to find out the outcome of the action, and • Limited financial capacity. to decision makers and those in power that its citizens people
illustrate how widespread the issue is. Many were able to link the whether it was taken. A call to action should be specific. Specific care about an issue, and that they are taking action to create
importance of nutrition to other key issues, such as and clear calls to action, which are relatively simple to follow • Not knowing how to effectively pitch undernutrition as an change. The more people that actively champion nutrition,
economic growth and educational outcomes. They recognised that through, can leave decision makers with a sense of empower- issue journalists should care about. Participants reported the more influence advocates will have on decision-makers to
presenting the problem, with evidence, can be useful if creating ment and achievement. They also enable CSOs to follow up to that journalists felt that there were simply too many devel- deliver on their commitments.
a sense of urgency to intervene. learn if they’ve taken this action. opment issues to report on - that there was “no room for
a new issue.” Participants felt there was a lot to learn a lot about from the HIV
After presenting the problem, it is important to inform people Strong and well-packaged messages, that can transform com- movement, particularly around citizen mobilisations. However,
about the solution. Knowing that something can be done about plex positions into coherent and achievable goals, are especially Some efforts have been made by some CSOs to cultivate nutri- many felt that it could be challenging to mobilise grassroots
an issue, that may have first appeared insurmountable, is a good useful for developing champions for nutrition. tion champions. Some successful examples include: around nutrition. One reason why the HIV movement was so
way to inspire decision makers. There are a number of ways to powerful was because millions of people living with HIV mo-
illustrate the solution by examples of: • Conducting nutrition trainings for a small group of journal- bilised to demand their right to treatment and care from their
4. Developing champions political leaders. While there are millions of people suffering from
ists. Participants found this useful in getting more factually
• How and where it has worked accurate media reports on nutrition, and for overcoming undernutrition, who could speak up and call for change, the
The success of any advocacy initiative depends on majority of those affected are children. As Dr Robert Mwadime,
misconceptions that hunger and nutrition are synonymous.
strong champions to build the political and public support of Uganda Action for Nutrition, put it at the 2010 African Union
• How it is proven and cost-effective
necessary to sustain these initiatives and ensure that they have the meeting: “children don’t vote.” As such, children are politically
• Taking journalists to visit programmes implementing nu-
power to transform government policies. Champions can be any weak, given their lack of political voice and participation in pub-
• How it has benefited the poorest trition interventions, such as clinics for the community
authority figure - from journalists to influential leaders - who lic debate. What’s more, beneficiaries of nutritional programmes
management of acute malnutrition (CMAM). Participants
is able to use their expertise and clout to mobilise change. tend to be poor who are often the politically marginal. If political
• Recent studies or reports found these strategies were most successful in getting
Cultivating champions from different spheres can help to leaders feel that their citizens, particularly those most affected,
journalists passionate about the issue, and were more
facilitate change at multiple levels. are not going to hold them to account they can get away with
• A first-person account of how the solution has impacted likely to result in them reporting on nutrition. Howev-
someone in the community. er, there were financial costs associated with site visits. paying little attention to the millions of children who die every
a. Media year of malnutrition-related causes.
Despite most being able to reference key interventions for “We invite them to the field to see nutrition projects so they
preventing or treating undernutrition, few participants report- The media can be a powerful advocacy tool. The manner in can get an accurate reflection of undernutrition.” Participants felt there were a number of opportunities for CSOs
ed offering any tangible solutions or interventions during their which policy makers and the public understand and resolve the to engage with Zambian citizens around undernutrition, by:
meetings with decision makers. On reflection some challenges faced by communities, is guided by the quality of • Using local media. Some smaller organisations, and those
participants felt that by presenting the scale of the problem, without information available to them. The media, as a primary source of based outside of Lusaka, found using local radio stations a • Raising awareness of undernutrition among the public, par-
demonstrating a solution, had left some decision makers with information, can play a very powerful role in shaping public and useful means of raising awareness of undernutrition among ticularly around the prevalence and consequences. There
a sense of hopelessness. One respondent reported that in a political dialogue. Mass media can be a useful tool for CSOs to: the community. Participants found these more easy to was a sense that Zambian citizens are aware that there is
access than national media outlets. hunger crisis in Zambia, but people are less aware of there
10 11being a nutrition issue, which are often hidden. Participants and the elected official were of the view that MPs should not Ministries have their own particular sectoral mandate where particularly around the budget. Some participants suggested
identified some barriers around languages. Zambia has request a ‘sitting allowance’ when meeting with civil society, they nutrition does not often fit neatly, and in the absence of nutri- that there were opportunities for CSOs to input into budget
eight recognised regional languages and numerous other felt that it would be difficult to encourage MPs to change this tional indicators nutrition becomes a secondary priority, whereby submissions.
dialects, many of which do not have specific terms to practice. Participants felt that they needed to come up with new Ministries can effectively ignore it and still satisfactorily meet
describe ‘nutrition.’ Terms used to describe nutrition are incentives to encourage MPs to engage with them on nutrition, it’s primary mandate. From discussions with participants, on “All Ministries are quite difficult to access at the begin-
often synonymous with hunger. however, none were able to offer any suggestions on what these their experiences pushing shared responsibility, it was apparent ning. We need to begin by setting up a relationship.”
incentives could be. that there is a clear perception that undernutrition was a MoH
• Ensuring that citizens voices are represented in the politics issue and could be sufficiently addressed by the efforts of one Participants recognised some potential difficulties in not only
that govern their futures. CSOs that work on programmes Participants who were based outside of Lusaka, found it more ministry. When broached on the subject, one decision maker getting Ministries to take joint responsibility for nutrition, but
and with grassroots have the opportunity to incorporate difficult to engage with parliamentarians, given the amount of reportedly said: to also get them to work in a coordinated manner. Especially
the experiences of those most at risk within their advocacy time spent in the Capital. since Ministries have their own priorities and are competing
messages. Participants felt that this could enhance the le- “Nutrition is simple. Why are you talking about all these for the same, relatively small, sources of funding.
gitimacy of advocacy efforts in the eyes of decision makers. Participants highlighted the importance of relationship building. other sectors?”
Those who reported success in engaging with parliamentarians The NFNC is meant to be responsible for the coordinating
• Empowering citizens to speak up and call for change. were those who had built good relationships with them over time. Some participants reported meeting with the Ministry of Finance efforts of key ministries to tackle undernutrition in Zambia.
Participants were concerned that citizens did not view a (MoF), who echoed their concerns about the lack of shared re- However, despite its efforts, participants felt the NFNC has
high prevalence of undernutrition as indicative of the failure sponsibility and funding for nutrition, but expressed that demand limited powers and capacities to convene and coordinate
d. Traditional Leaders
of the government to fulfil its duties to its citizens, and as needed to coming from within the Ministries themselves before among the different Ministries needed to work together to
such there was little demand. the MoF could consider further financing nutrition. Participants ensure adequate progress in tackling undernutrition. This is,
While no participants reported cultivating traditional leaders
reported that there was little internal demand for Ministries to in- in large part, due to it being housed in, and funded by, the
This was evident from the one-to-one interview with the elected as champions for nutrition, they did identify this as a future
creases their nutrition budgets. Unless other Ministries increase, MoH which diminishes its autonomy as an independent agent.
official, who reported experiencing very little demand around opportunity to expand their influence. The elected official
on introduce, budget lines for nutrition, it will be very difficult for
nutrition from his constituents. believed that if the Ministry of Chiefs adopted nutrition
the GoZ to reach its commitment of a 20% increase annually in “It’s hard for the National Food and Nutrition Commis-
within their mandate that it would have the potential elevate the
financial commitments to nutrition budget lines, which currently sion to take a coordinating role when it is viewed as
“There is demand from constituencies around hunger. Nu- issue and have impact both at the grassroots community and
only make up an estimated 3% of the national budget. being part of the Ministry of Health.”
decision-maker level.
trition requires more support because it is a silent issue.
MPs will do more if they feel there is demand.” All CSO participants identified building internal demand within Participants felt that the NFNC would have great power if it
“When chiefs say something people listen.” Ministries, for nutrition, as a key advocacy priority. Until all key were taken out of the MoH and rehoused. Participants report-
c. Political leaders Ministries take joint responsibility for undernutrition, and it steps ed that efforts are being made to have the NFNC’s mandate
Traditional leaders are well respected within the community. out of the silo of the MoH, undernutrition is unlikely to get the revised, specifically to for the NFNC to be move from the MoH
They could be a means of raising awareness of undernutrition attention is deserves and will continue to suffer from a chronic
Participants felt that nutrition was not being championed strong- to the office of the Vice President, from where it would have
to communities that were not aware of the current crisis and the lack of funding.
ly within Parliament. Many CSOs, including the elected official, the authority and capacity to ensure adequate coordination
risk it poses to their health.
felt that this was due to lack of knowledge and awareness of amongst all these stakeholders, and to ensure that each is
While many participants found it to difficult to engage with playing its role as outlined in the strategic plan for 2011-2015.
undernutrition among most parliamentarians. Given that chiefs are highly respected, even among the high- Ministries, some did feel that there were opportunities to engage,
est levels of government, participants felt that that cultivating
Participants reported that, in meetings with parliamentarians, traditional leaders as champions for nutrition could open up
some would often confuse ‘nutrition‘ with ‘hunger’ and insist doors to parliamentarians and other key line Ministries that many
that the GoZ was adequately tackling undernutrition through participants found elusive and difficult to access.
food relief interventions.
5. Ministries and the multisectoral nature of nutrition
Both CSOs and the elected official respondent identified CSOs
as playing a key role in overcoming the lack of awareness and The conceptual framework on the determinants of a child’s
misconceptions about nutrition among political leaders nutritional status [Figure 2] emphasises the multisectoral na-
ture undernutrition and the need for a comprehensive effort to
Source: UNICEF, Improving Child Nutrition: The achievable impera-
“CSOs are acting as a think-tank for MPs. They are coming improve the nutritional status of a population. If the potential
tive for global progress, 2013 – adapted from UNICEF 1990
around to the issue thank to advocacy efforts of CSOs.” impact of one set of interventions delivered by one sector is
undermined by the lack of interventions in other sectors, the
“CSOs need to give MPs more information. This is critical progress towards improved nutrition will be slow at best. For
to be able to have informed debates in Parliament.” example, reductions in undernutrition are unlikely if children
are repeatedly treated for diarrhoeal diseases, or dewormed,
The elected official recommended that CSOs engage with without adequately addressing the lack of sanitation and
parliamentarians more around nutrition, as he attributeD his hygiene responsible for continuous reinfection.
becoming a ‘nutrition champion’ down to the CSO engagement.
CSOs also reported a need to engage with political leaders The multisectoral nature of undernutrition poses a number of
more regularly. However, some participants - particularly those challenges, particularly for Ministries. First, it raises the notion
belonging to smaller organisations - reported finding it difficult that nutrition is “everyone’s problem, but no one’s responsi-
to engage with parliamentarians on a regular basis. bility.” No one Ministry can be expected to shoulder all the
responsibility for improving the nutritional status of the
Some cited financial constraints as barriers to regular population. All Ministries are responsible for some elements
engagement with parliamentarians. While not enshrined in that impact nutritional status, irrespective of whether improved
law, there are cultural expectations, and codified conditions of nutrition is used as a performance indicator. Despite the
service, that MPs are paid for their time. This is known as a multisectoral nature of undernutrition, and the GoZ pledging
‘sitting allowance.’ Participants reported this seriously limit- to resolve the human and financial resource gaps in five key
ing their ability to engage with parliamentarians on a regular line Ministries,xxii nutrition remains closeted within the MoH.
basis. If they could not afford to pay an MPs sitting fee and Participants felt that “Ministries [would not] come together to
travel costs then they would simply not be able to engage. work on nutrition.”
Participants reported this having cost them between 700 and
900 ZMW ($120-$155) for just one meeting. While both CSOs
Figure 2: Conceptual framework on the determinants of nutritional status
12 13REFERENCES
RECOMMENDATIONS
i FAO, 2010, The state of food insecurity in the world: addressing the food insecurity crisis
Recommendations for CSOs
ii Black et al, (2013), Maternal and child undernutrition and overweight in low-income and middle-income, countries, The Lancet. http://
CSOs should take steps to improve their coordination around nutrition advocacy to avoid duplication and build a www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2960937-X/abstract
united voice. They should actively seek to include all CSOs working on nutrition. CSOs should work together to identify
iii Horton, Shekar, McDonald, Mahal & Books, (2010), Scaling up nutrition: what will it cost?
common goals and opportunities to collaborate on joint advocacy activities. CSOs working on nutrition, and other key
http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/Peer-Reviewed-Publications/ScalingUpNutrition.pdf
stakeholders, can become members of the Zambia Civil Society Scaling Up Nutrition Alliance (CSO-SUN), whose role is
to coordinate and support nutrition advocacy in Zambia. CSO-SUN should conduct an analysis of the needs of nutrition iv IDS, (2013), “Delivering Demographic Dividend in Africa: Investing in Nutrition is the First Step”
CSOs – members and inquiring members – to inform the kind support they can provide.
v DFID, (2009),The neglected crisis of undernutrition: Evidence for action.
CSOs need to develop strong coherent messages that are tailored for different audiences – from Zambian citizens to http://reliefweb.int/sites/reliefweb.int/files/resources/1CA1358F7C7E873A49257656001C1E72-nutrition-evidence-paper.pdf
journalists to decision makers - and clearly explain undernutrition. All stakeholders should collaborate to break down
common misconceptions, such as the belief that hunger is synonymous with nutrition. vi Hoddinott, Rosegrant & Torero, (2012) Copenhagen Consensus Challenge Paper.
http://www.copenhagenconsensus.com/sites/default/files/Hunger+and+Malnutrition.pdf
CSOs should conduct a media analysis to fully understand why reporting on nutrition is given low priority in Zambia.
vii World Bank, Nutrition at a Glance: Zambia http://siteresources.worldbank.org/NUTRITION/Resources/281846-1271963823772/
CSOs should conduct a nutrition budget analysis of all key Ministries and identify key opportunities to engage in budget Zambia.pdf
processes, and where possible take part in formal budget submissions.
viii World Bank,Global Economic Prospects.
http://www.worldbank.org/en/publication/global-economic-prospects/regional-outlooks/ssa
CSOs should make efforts to build strong relationship with influential authority figures from all spheres – from political
leaders to the media – to facilitate change at multiple levels. ix World Bank. Zambia Overview.
http://www.worldbank.org/en/country/zambia/overview
Recommendations for Donors x IFPRI, (2013) Global hunger Index.
http://www.ifpri.org/sites/default/files/publications/ghi13.pdf. - The Global Hunger Index is a tool, developed by International Food
Policy Research Institute (IFPRI), which is designed to comprehensively measure and track hunger globally and by region and country.
Donors should allocate more funding for nutrition advocacy projects in Zambia, with an understanding that policy ad-
vocacy needs long-term engagement and rarely shows immediate results. xi WHO, Cut off points and summary statistics.
http://www.who.int/nutgrowthdb/about/introduction/en/index5.html
Donors should provide technical assistance to CSOs engaging in nutrition advocacy – both established and smaller
organisations – to help build their advocacy capacity. xii The average rate for Africa is 42%
xiii UNICEF, (2008), Vulnerability context for children and woman.
http://www.unicef.org/zambia/UNICEF_GRZ_Situation_Analysis_2008-part2.pdf
Recommendations for Government and Government Bodies
xiv UNICEF, (2008), Vulnerability context for children and woman.
The GoZ should move the National Food and Nutrition Commission out of the Ministry of Health into the office of the Vice http://www.unicef.org/zambia/UNICEF_GRZ_Situation_Analysis_2008-part2.pdf
President. Here it can greater co-ordinating power over all Ministries that have a role to play in tackling undernutrition.
xv World Bank, Nutrition at a Glance: Zambia
Ministries that have existing budget lines on nutrition should take steps to allocate more funding for nutrition. Other http://siteresources.worldbank.org/NUTRITION/Resources/281846-1271963823772/Zambia.pdf
key Ministries, that do not currently have budget lines for nutrition, should work with CSOs to develop budgets and
activities for nutrition that will be complementary to their existing mandate. All Ministries should make formal requests xvi DFID, (2013), Nutrition for Growth Commitments: Executive Summary.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/207274/nutrition-for-growth-commitments.pdf
of the MoF to increase their nutrition budgets.
xvii IDS, (2013), Hunger and Nutrition Commitment Index 2012.
Steps should be taken to enhance the collaboration of responsible Ministries to ensure that nutrition-related interven- http://www.ids.ac.uk/files/dmfile/HANCI_2012_reportv2.pdf
tions complement each other.
xviii Zachariah & Spielmann, (2002), Moderate to severe malnutrition in patients with tuberculosis is a risk factor associated with early death.
Decision makers should engage more openly with CSOs and, where possible, alleviate financial barriers that limit the http://fieldresearch.msf.org/msf/bitstream/10144/17718/1/trans%20spielmann%20harries%20malnutrition%5B1%5D.pdf?origin=publication_detail
ability for CSOs to work with them. Decision makers should use civil society and academia as sources of information
and support in a joint collaborative effort to eliminate poverty and undernutrition. xix UNESCO, (2012), Zambia EFA Profile.
http://www.unesco.org/new/fileadmin/MULTIMEDIA/FIELD/Dakar/pdf/ZambiaEFAprofileoct2012.pdf
xx Save the Children, (2013), Food for Thought.
http://www.savethechildren.org.uk/sites/default/files/docs/Food_for_Thought_UK.pdf
xxi Bemba, Tonga, Lozi, Lunda, Luvale, Kaonde, Nyanja, Chewa
xxii Health; Community Development, Mother and Child Health; Local Government and Housing; Agriculture and Livestock; Education,
Science, Vocational Training and Early Education.
14 15AUTHORS
Sabrina de Souza, Nutrition Advocacy Assistant, RESULTS UK
Katherine Pittore, Nutrition Advocacy Officer, RESULTS UK
Lloyd Handongwe, Nutrition Manager, CITAM+
RESULTS UK
The research project was lead by RESULTS UK, a non‐profit advocacy organisation that aims to generate the public and po-
litical will to end hunger and poverty. RESULTS’s focus is on educating and empowering people – be they ordinary citizens or
key decision-makers – to bring about policy changes that will improve the lives of the world’s poorest people. Our advocacy
focuses on areas we believe have the most potential to make a difference. We have a track record of expertise in education,
microfinance, and global health and nutrition issues.
As well as our collaboration with MPs and other high level ‘champions’ RESULTS also has a network of volunteers around the
UK: grassroots advocates who work together in local groups to become effective advocates for change. We support people to
build their understanding of the issues and what they can do about them. Our approach has proven to be effective and pow-
erful, yielding significant results which have brought an end to poverty closer. RESULTS also carries out strategic advocacy,
media and public awareness‐raising campaigns at national and international levels. RESULTS UK collaborates with RESULTS
organisations in the USA, Japan, Canada, Mexico and Australia to achieve our advocacy objectives, and we work closely with
NGOs such as CITAM+ through the ACTION Global Health Partnership.
CITAM+
The research project was supported by CITAM+ - the Community Initiative for Tuberculosis, HIV/AIDS and Malaria plus related
diseases - a Zambian NGO that was established in June 2005 to help disseminate information on TB/HIV and AIDS co-infection
through community engagement. The organization is made up of passionate TB/HIV co-infection reduction and treatment ad-
vocates, many of whom have had TB and are now cured and some of whom are living with HIV/AIDS and have suffered from
TB in the past. CITAM+ has expanded it’s advocacy efforts to now include work on undernutrition.
ACTION
RESULTS UK and CITAM+ are both members of ACTION – a global partnership of advocacy organizations working to
influence policy and mobilize resources to fight diseases of poverty and improve equitable access to health services. Founded
in 2004, ACTION partners work across five continents in both donor and high burden countries. ACTION’s priorities are ending
the tuberculosis epidemic and ending preventable child deaths.
Photo credits: Steve Lewis, cover.
www.results.org.uk www.citamzambia.webs.com www.action.org
RESULTS UK
31-33 Bondway
London
SW8 1SJ
+44 20 7499 8238
© RESULTS UK, March 2014.
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