Measuring Governance: Developing a Novel Metric for Assessing Whether Policy Environments are Conducive for the Development and Implementation of Nutrition Interventions in Nepal

Document Type : Original Article


1 Friedman School of Nutrition Science and Policy, Tufts University, Boston MA, USA

2 Department of Community Health Sciences, Patan Academy of Health Sciences, Lalitpur, Nepal

3 Helen Keller International, Patan, Nepal


The Nutrition Governance Index (NGI) defines a first standardized approach to quantifying the ‘quality of governance’ in relation to national plans of action to accelerate improvements in nutrition. It was created in response to growing demand for evidence-based measures that reveal opportunities and challenges as nutrition-related policies on paper are translated into outcomes on the ground. Numerous past efforts to measure ‘governance,’ most notably World Health Organization’s (WHO’s) NGI and the separate Hunger and Nutrition Commitment Index (HANCI), both of which lack granularity below the national level and each of which fails to capture pinch points related to necessary crosssectoral actions. This paper addresses such caveats by introducing an innovative metric to assess self-reported practices of, and perceptions held by, administration officials tasked with implementing government policy at the sub-national level. The paper discusses the development of this metric, its methodology, and explores its application in the context of Nepal.
Conducted as part of a nationally representative longitudinal survey across 21 of Nepal’s 75 districts, the substudy on which this paper is based used data from 520 government and non government officials at different geographic and administrative tiers of authority. Using robust statistical techniques, structured questionnaire data were condensed into a score using a scale from 0 to 100.
Six domains were identified through the analysis: Understanding Nutrition and related responsibilities; Collaboration; Financial Resources; Nutrition Leadership, Capacity, and Support. About half of all health sector representatives achieved a high score (>3 on 5-point scale) compared to representatives in other sectors of government activity (such as agriculture or education) (χ2= 12.99, P < .003). The health sector also showed the most improvement in mean NGI score over a two-year follow-up period.

This paper shows that self-reported perceptions and behaviors of those responsible for policy implementation can be usefully quantified. The NGI can be used to assess countries’ readiness for the application of nutrition policies.



Supplementary file 1. Nepal PoSHAN Policy Process Research R4 (2016).



  1. World Health Organization (WHO). UNICEF-WHO-The World Bank: Joint Child Malnutrition Estimates - Levels and Trends.  Accessed May 16, 2018.
  2. Development Initiatives Poverty Research Ltd. Global Nutrition Report 2017: Nourishing the SDGs. Bristol, UK: Development Initiatives; 2017.
  3. World Health Organization (WHO). The UN Decade of Action on Nutrition: Working Together to Implement the Outcomes of the Second International Conference on Nutrition.  Accessed May 16, 2018. Published 2016.
  4. World Health Organization (WHO). Global Nutrition Targets 2025: Policy Brief Series.  Accessed March 16, 2020. Published 2014.
  5. World Health Assembly. Infant and Young Child Feeding. Published 2018.
  6. Gillespie S, Haddad L, Mannar V, Menon P, Nisbett N. The politics of reducing malnutrition: building commitment and accelerating progress. Lancet. 2013;382(9891):552-569. doi:10.1016/s0140-6736(13)60842-9
  7. Heaver R. Strengthening Country Commitment to Human Development: Lessons from Nutrition. Washington, DC: World Bank; 2005.
  8. 9. Mejía Acosta       A, Fanzo J. Fighting Maternal and Child Malnutrition: Analysing the Political and Institutional Determinants of Delivering a National Multisectoral Response in Six Countries. Brighton, UK: Institute of Development Studies; 2012:39.
  9. van den Bold M, Kohli N, Gillespie S, Zuberi S, Rajeesh S, Chakraborty B. Is there an enabling environment for nutrition-sensitive agriculture in South Asia? Stakeholder perspectives from India, Bangladesh, and Pakistan. Food Nutr Bull. 2015;36(2):231-247. doi:10.1177/0379572115587494
  10. Sunguya BF, Ong KI, Dhakal S, et al. Strong nutrition governance is a key to addressing nutrition transition in low and middle-income countries: review of countries' nutrition policies. Nutr J. 2014;13:65. doi:10.1186/1475-2891-13-65
  11. Baker P, Hawkes C, Wingrove K, et al. What drives political commitment for nutrition? A review and framework synthesis to inform the United Nations Decade of Action on Nutrition. BMJ Glob Health. 2018;3(1):e000485. doi:10.1136/bmjgh-2017-000485
  12. FANTA III U. Strengthening Nutrition in Mozambique: A Report on FANTA Activities from 2012 to 2018. FANTA III; 2012.
  13. Garrett J, Natalicchio M. Working Multisectorally in Nutrition: Principles, Practices, and Case Studies. Washington, DC: International Food Policy Research Institute (IFPRI); 2011. doi:10.2499/9780896291812
  14. Exworthy M. Policy to tackle the social determinants of health: using conceptual models to understand the policy process. Health Policy Plan. 2008;23(5):318-327. doi:10.1093/heapol/czn022
  15. Pelletier DL, Frongillo EA, Gervais S, et al. Nutrition agenda setting, policy formulation and implementation: lessons from the Mainstreaming Nutrition Initiative. Health Policy Plan. 2012;27(1):19-31. doi:10.1093/heapol/czr011
  16. Chisholm N. Multi-sectoral collaboration for improved nutrition: the problems and prospects of implementation in Ethiopia. Dev Policy Rev. 2019;37(2):274-292. doi:10.1111/dpr.12347
  17. Webb P, Ghosh S, Shrestha R, et al. Measuring nutrition governance: an analysis of commitment, capability, and collaboration in Nepal. Food Nutr Bull. 2016;37(4 Suppl):S170-S182. doi:10.1177/0379572116674856
  18. Walt G, Shiffman J, Schneider H, Murray SF, Brugha R, Gilson L. 'Doing' health policy analysis: methodological and conceptual reflections and challenges. Health Policy Plan. 2008;23(5):308-317. doi:10.1093/heapol/czn024
  19. World Health Organization (WHO). Landscape Analysis on Countries’ Readiness to Accelerate Action in Nutrition Country Assessment Tools. WHO; 2012.
  20. te Lintelo D, Haddard L, Lakshman R, Gatellier K. The Hunger and Nutrition Commitment Index (HANCI 2014): Measuring the Political Commitment to Reduce Hunger and Undernutrition in Developing Countries. Institute of Development Studies; 2014. doi:10.1163/2210-7975_HRD-0148-2015067
  21. Fox AM, Balarajan Y, Cheng C, Reich MR. Measuring political commitment and opportunities to advance food and nutrition security: piloting a rapid assessment tool. Health Policy Plan. 2015;30(5):566-578. doi:10.1093/heapol/czu035
  22. World Health Organization (WHO). Global Nutrition Policy Review: What Does it Take to Scale Up Nutrition Action? Geneva: WHO; 2013.
  23. Engesveen K, Nishida C, Prudhon C, Shrimpton R. Assessing countries' commitment to accelerate nutrition action demonstrated in PRSPs, UNDAFs and through nutrition governance. SCN News. 2009;(No.37):10-16.
  24. IDS. HANCI Global -- Hunger and Nutrition Commitment Index.  Published 2020. Accessed March 16, 2020.
  25. Harris J. Advocacy coalitions and the transfer of nutrition policy to Zambia. Health Policy Plan. 2019;34(3):207-215. doi:10.1093/heapol/czz024
  26. Harris J, Drimie S, Roopnaraine T, Covic N. From coherence towards commitment: changes and challenges in Zambia's nutrition policy environment. Glob Food Sec. 2017;13:49-56. doi:10.1016/j.gfs.2017.02.006
  27. Li R, Hernandez-Villafuerte K, Towse A, Vlad I, Chalkidou K. Mapping priority setting in health in 17 countries across Asia, Latin America, and sub-Saharan Africa. Health Syst Reform. 2016;2(1):71-83. doi:10.1080/23288604.2015.1123338
  28. World Health Organization (WHO). Driving Commitment for Nutrition within the UN Decade of Action on Nutrition: Policy Brief. Geneva: WHO; 2018.
  29. Merenda PF. A guide to the proper use of factor analysis in the conduct and reporting of research: pitfalls to avoid. Meas Eval Couns Dev. 1997;30(3):156-164. doi:10.1080/07481756.1997.12068936
  30. Klemm RDW, Manohar S, Rajbhandary R, et al. Pathways from agriculture-to-nutrition: design and conduct of the national PoSHAN surveys of Nepal. J Food Secur. 2018;6(2):79-89. doi:10.12691/jfs-6-2-5
  31. Shrestha S, Thorne-Lyman AL, Manohar S, et al. Pre-earthquake national patterns of preschool child undernutrition and household food insecurity in Nepal in 2013 and 2014. Asia Pac J Clin Nutr. 2018;27(3):624-637. doi:10.6133/apjcn.092017.04
  32. UNICEF TWBG. Capacity Building To Strengthen Local Government and Community Participation in Multisectoral Nutrition Programs in Nepal. Multisectoral Nutrition Programs in Nepal.  Accessed March 6, 2020. Published May 2013.
  33. Jolliffe IT, Cadima J. Principal component analysis: a review and recent developments. Philos Trans A Math Phys Eng Sci. 2016;374(2065):20150202. doi:10.1098/rsta.2015.0202
  34. Antony GM, Rao KV. A composite index to explain variations in poverty, health, nutritional status and standard of living: use of multivariate statistical methods. Public Health. 2007;121(8):578-587. doi:10.1016/j.puhe.2006.10.018
  35. Tavakol M, Dennick R. Making sense of Cronbach's alpha. Int J Med Educ. 2011;2:53-55. doi:10.5116/ijme.4dfb.8dfd
  36. Panayides P. Coefficient alpha: interpret with caution. Eur J Psychol. 2013;9(4):687-696. doi:10.5964/ejop.v9i4.653
  37. Hooper D, Coughlan J, Mullen M. Structural equation modelling: guidelines for determining model fit. Electron J Bus Res Methods. 2008;6(1):53-60.
  38. Hu L, Bentler PM. Fit indices in covariance structure modeling: sensitivity to underparameterized model misspecification. Psychol Methods. 1998;3(4):424-453.
Volume 11, Issue 3
March 2022
Pages 362-373
  • Receive Date: 13 November 2019
  • Revise Date: 08 July 2020
  • Accept Date: 14 July 2020
  • First Publish Date: 01 March 2022